Blog, Chirosecure Live Event December 26, 2022

Initial Treatment Plan – Mark Studin DC

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Hi, I’m Dr. Mark Studin and I, first I’d like to thank ChiroSecure for giving me the platform to share this information with. I’m usually very excited to be in this venue and share, but today is just incredibly special for me because I really get to attack a lot of different, Subjects that are germane and timely to our profession.

So let’s go right to the slides and let’s get started. We have a lot to cover today. We’re gonna talk today about initial chiropractic treatment plans and frequency protocols. Three times a week, twice a week, once a week, daily, 12 visits. What’s my initial treatment plan? It’s not quite as simple as that, but there are rules and it.

Quite as simple as that. But before we get to the treatment plans, we have to understand that we have to look at a definitive diagnosis. Now, today we’re going to discuss issues related to pain. , we’re not gonna talk about what people call maintenance care or wellness care or ongoing care. We’re gonna talk about pain because that’s the common denominator in every chiropractic practice in the country.

That is the absolute common denominator. Everyone treats a patient with pain. So when you have the patient in your office, you have to initially triage, you have to create a diagnosis. Then a prognosis, then a treatment plan, which must be reflected in your documentation before you treat the patient. Now, a diagnosis is an identification of a disease.

Via examination or let’s word pathology, whether it be connective tissue pathology, which is ligaments and muscles strength sprain, whether it’s osseous, pathology, these are the things we need to figure out first. So remember then you get to the prognosis following the diagnosis. It’s the predict.

Of its course and then treatment. Can I get the patient well, and I have to know that before I come up with a treatment plan or the treatment plan. Let me reflect, let me rephrase that. You have to do the prognosis, which then. Ends up into your treatment plan, and if you can’t help them, your treatment plan might be referral to a surgeon, referral to this, referral to that.

That’s your treatment plan. Before you treat and before you treat is the critical answer. You have to know what you are treating, and I have to tell you, in my formative years, I would just adjust patients and just adjust them and not know any different and I got in trouble for that. It cost me dearly and I did have problems.

So let me share with you. Mark students mantra, which I’ve been saying since 2006. If you don’t know, don’t guess. If you don’t know, don’t guess. Patient and I’ve had this conversation with doctors through the years. Doctor a patient’s coming in and they come to me and they say, patient has radiating pain down their arm.

And by the way, I teach in three different chiropractic colleges at various levels, and two medical schools at various levels. And I’m giving you what’s an academic standard. I’m giving you licensure board standards, I’m giving you carrier standards, and I’m giving you a patient centered standard and patient centered.

Comes from actually it’s called The best practice treatment comes from sace up in Canada back in the late nineties. Three things, the evidence in the literature, the doctor’s experience, and the patient’s feedback. Here’s you ready? Here it is. If you don’t know, don’t guess. Just don’t guess. And doctors often come to me and say, I have patients with pain radiating down their arm.

What’d you do? I adjust. , what are you treating? The pain radiating down the arm? No. What’s causing the pain radiating down the arm? What are you treating? Subluxation. Okay. How do you know that? because that pain radiating down the arm. No. You keep going back to the symptom. What’s the cause? Or I’ll say biome, or they’ll say Spinus rotation.

Or vertebral rotation. If they don’t like to use the word subluxation. Okay. Or biomechanical failure. I don’t care what the word is. What are you treating? What’s causing the pain? , what component, if you’re using the word subluxation, is it myo pathology, histopathology, kinesio, pathology, pathophysiology, histopathology.

Which one of those things are causing that? And by the way, those five segments of subluxation complex are from Leonard Faye, who’s still alive out in la. I spoke to Leonard a few weeks ago, and we are all of him a tremendous set of gratitude. But I want you to know what was all Hypothe. It’s all hypotheses.

Leonard had no definitive answers when he came up with that. But as time moved on, the evidence in literature started to show that. So at the end of the day, I said, how do you know what’s there? And the answer is, and we went in circles, pain, subluxation, pain, biomechanical failure, pain rotation. How do you know if you don’t look, have you taken an x-ray?

Is there an os? Misalignment. Is there a spondylothesis? If it’s in the lumbar spine, is it a tumor? Is it a herniated disc? You don’t know. You’re guessing you don’t know. And if you don’t know, you don’t touch simple. Don’t know. Don’t touch. Because the answer is that if you do, you can hurt somebody. And you know what?

Not knowing, putting a bag over your head hurts all of. It hurts the reputation of chiropractic. I can, I work with hundreds and hundreds of neurosurgeons, orthopedic surgeons, pain management doctors, er doctors from coast to coast. I teach gosh, I, I’ve taught them in 39 different states, something like that.

And every single time they see, they came from the chiropractor and now the person has a herniated disc, which I don’t believe to be totally true. I think there was an underlying. , which the chiropractor didn’t diagnose and then exacerbated. So that’s my personal belief. And I don’t have a specific case to bring out, but they’ll say they went to the chiropractor, it didn’t work.

The person had a tumor, the person had a myelopathy, the person had this. Why didn’t they diagnose it before they treated? And it hurts our reputation. And reputation drives referrals, folks. Reputation drives referrals and never forget that you wanna get more referrals, increase your reputation. A dear friend of mine is a marketing consultant for orthodontists, and he’s probably one of the most successful in the country at it.

He’s in an airplane, he’s in a different city presenting teaching. He teaches up at a Tufts University Dental School in Boston. Guy’s incredible. , you know what? You know what his entire business is about? Building the reputation of an orthodontist. Build it to the general dentist, build it to the public because those are the referral sources.

Guess what? Our utilization is stuck. Is stuck at 7%. Some people say, Tim, I think that’s inflammatory. We’ve been stuck there since I’ve been in the game since 1981. I’m in my 42nd year of doing this. , we’re stuck at that same level of utilization. So what I’ve done is I’ve worked with academia to build collaborative requirements between chiropractic and medical academia.

And right now we’ve put in about 1,000,600 thousand additional referrals into chiropractic practices at 49 states. So the answer is, I know it works. I watch it work, I watch it every day, work in different offices. But what happens is when you. Guess, and someone gets hurt or they don’t get better and you don’t have a definitive diagnosis, and they go to the ortho, neuro neurosurgeon, pain management doctor, urgent care clinic, primary care.

Guess who it hurts, not just you. It hurts everybody. And you know what? You should never ever treat someone without knowing what the cause is. Hard rule. So we have two kinds of pain with radiation. Now that can be caused by a myelopathic finding or radicular pain where you have arms, legs, flanks to chest, intermittent lancinating, electrical burning again, which can cause that radiculopathy motor.

If you have motor weakness, sensory weakness, paraesthesia diminish reflexes worse with axial loading. What’s causing all of those things? What’s causing it to. I know I can get the I’m gonna adjust. I’m gonna adjust. I know I can get the I’m gonna put a genie rub on ’em. I’m gonna do joint mobs.

I’m gonna put E-stim. None of those things are gonna help, by the way. They’re gonna help them feel better temporarily. It’s not gonna get to the cause of the problem, especially if you don’t know what it is. But then you can have the second kind of pain. , pain without radiation. None of these things going on zip, not ailish.

No matter what language you put it in here you have localized pain, just localized. So if you are having localized pain without radiation, or pain with radiation and these things occurring why? It goes back to what I said before. If you don’t know, don’t guess. You need a definitive diagnoses. And by the way, what does that have to do with initial treatment plans?

The answer is everything. Everything. Because you have to be, your treatment plan has to be legally defensible because if it’s not, it could cause you your money, your license, or your freedom. And I’ve seen doctors lose all. , you know what happens when you get in trouble? How many doctors do you know that have been taken down for a RICO case or have been charged with even a criminal charge by hurting someone, by causing significant issues?

Probably nobody. I know a lot of people, if you were sued for Rico, who’d you tell? Nobody? Zero. You’ll only tell them when you saw 40 new patients last month, and you probably lied about that. I’m the father confessor. Mark, what do I do? How do I get outta trouble? I have one standard answer call a criminal defense lawyer.

That’s my answer. I told someone that says yesterday, they call me Christmas morning, they were served the day before. What do I do? What do I do? Call a criminal defense lawyer. It’s the only answer and I hear it all too often, not because. You are nece necessarily hurting someone. You might be delaying necessary care.

You might have gone have a pathology that went undiagnosed. You are responsible for all of that. And it’s not a question to practice outta fear. Just follow the rules. If you don’t know, don’t guess. Diagnosis first, prognosis second, treatment plan. Third simple. So therefore, no matter what you’ve got going on, The commonality of treatment within chiropractic is a high velocity, low amplitude thrust, a chiropractic spinal adjustment.

That’s what all of us are taught and hopefully all of us are doing. I don’t care if you are doing physical therapy, what we call adjunctive therapy, joint mobilizations, arthro, arthrokinematic movements. Heat stem laser. This, I don’t care what you’re doing, okay, but if you are doing a high velocity, low amplitude thrust, a chiropractic spinal adjustment, and if I had time, I would go through again, which I’ve done in the past.

The mechanism of the chiropractic adjustment, it’s fascinating. It’s all in the evidence, all in the literature has to do with the brain and central sensitization, which I’m not gonna get into right now. But if this is what you’re doing, you’ve gotta be careful. You’ve gotta be careful and make sure you do it right.

And by the way, I didn’t put a reference. And from here forward, we’re gonna start to see a lot of references. I didn’t reference the fact that the wrong vector can be dangerous to the human spine. The wrong vector of thrust is critical. . Remember, in school we did physiology. You go inferior to superior, inferior, left to right?

All those things are important. All those things you’ve learned are critical. So here’s what most of, most, everyone relies on. Palpation motion or static palpation, and that’s an. . Why? Let’s read right from the evidence in the literature. Palpatory studies re palpatory tests studied regardless of the studied condition, demonstrated low reliability, and were invalid or unreliable.

By the way, you’re gonna see me turning this way. I’m working on multiple screens. I’m reading off the other side cuz that’s in my mouses and should not be used to arrive at a diagnosis, treatment plan, or assess prog progress. Motion palpation is poor. It’s failed for inter and inter rate reliability.

It’s not my opinion. It’s right from the evidence in the literature and there’s a lot more studies than this. There is a lot. So if you’re looking at, so here’s the next one. I look at range of motion. You know what folks? Range of motion is a problem. You wanna know why range of motion is a problem because you’re looking for hypomobility.

Hypomobility is not the problem. Hypermobility is the problem. Hypomobility is usually muscle spasticity unless you have osseous fusion or an osseous locking mechanism based upon an anomaly, which happens rarely. The majority of the, your motion palpation showing decreased range of motion. Number one is muscle spasticity.

Number two, it’s global. You’re looking at C1 through T1 in the cervical spine. I’ve got a cervical up here. You’re looking at the whole motion and it could say 45 degrees, normal inflection. What if. What if you have fusion at C 56 and it still shows normal inflection 45 degrees? That means the other segments have moved too much.

To compensate for the one moving too little, showing normal, but yet you’re calling that a normal study. And how could you have normal, when one segment is fused, one motor unit, two bones is fused, how could you have that? You can’t. It’s not possible. The issue is too much movement, that’s the problem. And not globally segmentally, because that means the connective tissue is.

The ligaments have torn. You have connective tissue pathology, and when you have a ligament that tears according to Hauser, which I don’t have up on the screen today, according to Hauser Al one’s tissue tears, it wound repairs, it doesn’t heal the wound repairs with a different grade of. . So studies have shown that once tissues have damaged, they remain.

And that’s right from the evidence in the literature, they remain non-functional for the rest of that person’s life because collagen and elastin and the ligament are only replaced with collagen because you have the fibroblasts and the liga. Which during puberty, they’re producing more collagen and elastin.

The ligaments growing. When you hit puberty and it stops, those fibroblasts become dormant. They don’t go away. Those dormant fiberglass stay there until there’s tissue damage and when there’s tissue damage, now you only have collagen. There’s no longer elastin. And even a spinal disc, which is a ligament that connects bone to bone is I believe 95%.

No, I apologize. It’s 75% collagen, 25% elastin, where an elbow, and I don’t have the exact number, but for academic purposes, I’ll say 50 50 collagen and elastin. But now when a joint has more collagen replacing elastin, the joint starts. Hes now, you would think you would aase and decrease the range of motion.

No. The tissue tore, literally tore. It’s a secondary strain sprain. Primary is overstretching fibers pop. Secondary is partial tear. Tertiary is avulsion. We don’t get the avulsions. We’ll get primary, mostly secondary. So when you have that secondary strain sprain, it’s gonna leave healing. and now that’s gonna fill in with collagen.

It’s not gonna knit tight together and like stitching it together? No, it’s gonna fill in that healing gap and lay down collagen and it’s gonna wound repair. I’m not gonna use the word heal because healing implies it’s going back to normal tissue. It wound repairs. with internal adhesions, permanently giving excess space or excess range of motion, and therein lies a specific problem.

That’s an issue with range of motion. You should be looking for too much. You can’t tell this when you look at palpation, either motion or static, but chiropractic is safe. According to Whedon, at Allen 2015, they studied 6,669,603 test subjects and it shows, and by the way, that account for 24 million visits, no mechanism by which is spinal manipulation to chiropractic.

Induces injury into normal tissue has been identified. Zero Zippity, Dodo none but herein lies another problem. Normal healthy tissue. Injured spine versus healthy spine. How many people come to you with a healthy spine versus an injured spine? Most people come to you with injured. and they’re not a healthy spine.

If it was healthy, why would they be in pain? Why would they have dysfunction or functional losses? Why? We know that it’s relatively safe in a healthy spine, but you have to identify that injured spine and therein lies the issue. How do you do that? Let’s look at diagnosing and anatomical versus biomechanical pathology, and what does this have to do, by the way, with treatment?

everything. We’re leading up to that in a moment. Everything. Now, let’s look at anatomical, which is on your left side. You could choose unwisely. Which is one of our political organizations. Pick that up from the American Board of Internal Medicine, which is a dangerous place to be and creates a public health risk.

And I mean that sincerely because they only want you to image for red flags. Fracture, tumor infection, that’s it. Fracture, tumor infection. Now they got that for the American Board of Internal Medicine Providers. Who based upon the evidence in the literature, I think out of Harvard, failed to diag actually, they diagnosed non-specific back pain approximately 95% of the time.

Non-specific means there’s no anatomical cause they don’t know what to do with it. They have no clue and they failed. I think it was a 75% failing rate in competency in musculoskeletal medicine. So here you are, people creating. A profound platform with no success in spine, no education in spine, coming up with a policy, and then our political organization has chose to follow that.

Now, I want you to know right now, blue Cross Blue Shield across the country. He’s trying to limit your ability to take x-rays in the first 28 days of of care. And I don’t have the facts yet. I hopefully will soon. And I think this program choose unwisely as I call it, might be the genesis for that to the detriment of our patients and our practitioners.

But then again, we wanna look at an anatomical and biomechanical pathological diagnoses. You’re ruling out fracture, tumor infection, connective tissue path. Ligaments. You can do that through imaging and biomechanical pathology. You know what you’re treating. You are not guessing. Let’s look at some of the issues.

You ready? This was incidental anatomical pathology, fanon offices in the last three months of this recording, cuz I just put it out there. Look at this spawning. Can you imagine? Putting this person in a side posture. This person had mild cervical pain. He’s got a clay shovel as fracture. This guy can’t be treated in your office, and I wouldn’t wanna adjust until this.

Does it really have any sequela on the rest of this point? Probably not, but I don’t want to be treating someone with a fracture. Look at these nets all over the spine. They’re actually, they’re all over the place. And I saw the CAT scan. It’s a lot worse than this. But this look at these lucencies.

this is all Mets from, I think this person had kidney cancer. I don’t wanna treat this patient. Can you imagine putting ’em on their side and look at this. This is Paget’s disease. , this person had minimal low back pain. And look at this one. This is eagle syndrome. Calcification. I believe it’s the hyoid bone.

I’m not gonna do a rotary on this person in this cervical spine. Look here. Secondary. Okay. The thyroid and the hyoid. This is all calcifications. These are not normal findings. This grossly changes my diagnosis, prognosis, and treatment plan, which is only a small portion. Of what I’m looking to do now, there is technology out there.

One such piece of technology is called inverter, which will take a spine and instead of motion palpating, it’ll give you a roadmap of which way the spine is. Processes are rotating. And it’s a hundred percent correct every single time the evidence in the literature is overwhelming. And I forgot to put that citation up here.

And it’ll also tell you to adjust superior to inferior to superior, and it’ll give you other issues such as angular deviation translation. We don’t really have time to get in this, but what you’re doing is you’re getting a road map. There’s no guessing, but let’s look at the additional benefits of doing.

An x-ray to come up with a definitive diagnosis, you’re gonna get paid because now the carriers are gonna say, what are you treating? I’m treating this, which is now demonstrable. This is patho biomechanics. It’s biomechanically, patho pathological, and there’s an I C D for a biomechanic pathology. You can also get paid for long-term care because you can repeat an x-ray.

Now let’s take the radiation issue off the table very quickly. And this is according to Tobi. I didn’t cite the reference for this. Tobi said that you need a hundred milli serves of X-ray of radiation in one sitting, cuz it’s not cumulative to have less than one in 100,000 negative. To have less than one in 100,000 disease process show up from radiation or radiation, one in 100,000.

So to get to the one in 100,000, you need to take. 56.6 lumbar x-rays at one sitting. You need to take a hundred thoracic x-rays and 5,000 cervical x-rays in one sitting to reach that number, and that’s absurd. No one’s gonna take. 5,000 cervical x-rays or 56 lumbar x-rays in any given sitting and radiation is not cumulative.

So there’s, it’s the sky isn’t falling folks, and this is all over its evidence, all over the literature. But you can get paid for long-term care to show the persistence of these lesions. And what we’re starting to see in lawsuits in RICO suits across the country is the carriers are going after doctors for predetermined treatment.

Based upon range of motion muscle testing. They’ve got an answer for that too. There’s no answer and I’m told formally there’s no answer for this. This is proof positive. So it does a whole lot of things. It tells you where to adjust, when to adjust, when you’ve reached mmi, get paid for long-term care, and it prevents lawsuits because it makes it the , and there’s a lot of things out there you can use.

Even an x-ray that you’re marking up yourself will do the. The other thing you need to learn from an X-ray is ADI Ilan Dental instability. This subverted does that also, but if it’s three millimeters or more, it’s unstable and this is very unstable. This patient, this was a patient done two days before this recording, so three millimeters is unstable and you should strongly consider altering your treatment plan.

if you’ve got an instability with the a d I joint, the Adi interval, you got thelan dental or the transverse ligament up there. You’ve got perhaps a myriad of other ligaments in that area. Ligament, the nuke. A bunch of other things that you’ve gotta be concerned about. You might want to alter your treatment plan significantly.

Don’t be doing a cervical or especially an upper cervical adjustment, and you might possibly want to co-manage that with an MD special. , the doctor who did this sent it right out to a neurosurgeon, and the neurosurgeon said, you’re the only chiropractor that ever did this, and then ever referred to me and recognized it most adjust and then hurt the patient.

They end up coming to me after, you are the guy I wanna work with. And he started sending him he just sent this out two days ago, but he said, I’m gonna start sending you a lot of cases. because you are the guy I wanna work with because it’s evident, it’s demonstrable, it’s evidence-based, and you are working with your, you’re collaborating.

And you’re working within the healthcare system, you’re not fighting it, you’re working with it. And guess what? They see? 99% of the patients we see, 7%. You want to keep fighting for 70? You want to tap into that 99, and this is through a posture of clinical excellence. No advertising, no marketing, no fancy dinners, no holiday gifts, only because you’re a damn good doctor and you’ve understood diagnosis first, prognosis second, treatment plan.

Third, then. Initial treatment plan, get a co-manage with an MD specialist and get a surgical consultation. Does this person need surgery? Probably not. , but you know what? I want a written clearance from this surgeon saying not chiropractic is indicated because he has no experience in chiropractic. I want him to say Conservative care is clinically indicated.

That protects my butt. It protects my patient, builds relationships. It’s good for chiropractic. And we go all the way back to the beginning. We’re gonna go all the way back. Here we go right there. That’s where we’re. The band comes off the head, the band-aids come off, and all of a sudden everyone’s getting referrals.

And that to me folks, is what it’s about. Let’s look at chiropractic as primary spine care providers versus medical manager. According to Daytona and Al, over 96% of chiropractic patients with spine related. Stated they were health compare with these statistics of medicine, which persisted about 95% diagnosing non-specific low back pain.

So here we are helping 96% of the people they’re helping only five per, they’re only diagnosing 5%, which is the fractured tumor infection. They don’t know what to do with the rest. So you wanna build that reputation and the relationship because we’re helping these. When we look at evolving protocols and evolving protocols are key, as the evidence evolved in every healing discipline, so to treatment protocol protocols with large enough cohorts, a cohort as a sample size to further confirm the efficacy of care in determining the necessity of initial x-rays, the American College of Radi.

That is the holy grail in medicine to determine imaging, all imaging, CAT scan, x-ray, mri PET scan, tomo grams, whatever it is. They’re the industry standard and the and the gold standard for everyone. It says they had deemed initial imaging of radiograph of the. With or without rec radiculopathy.

This is usually appropriate, which is, it is their strongest recommendation. Removing any controversy on standard of care. You have medicine, putting it back in at a high level when our political organizations who are supposed to be protecting you are take, are working hard against you to take it out.

It’s absurd. But now we go to the next step about treatment. Let’s talk about treatment frequencies and by the. This is something I teach in chiropractic, academia, in the classroom. This is something I teach as a clinical instructor for the State University of New York at Buffalo Jacob School of Medicine and Biomedical Sciences.

Office of continuing medical Education. I have to put the whole thing in there that I’m teaching around the country for medical education and I’m teaching chiropractors this, and I’m teaching medical doctors this because not to be chiropractors to how to refer to a medical doctor. And it’s long that I’m gonna read it.

So bear with me Wayland al. Report it. That an appropriate standard of care is multimodal treatment, inclusive of a chiropractic spinal adjustment and manipulation for three times per week for four weeks. In the acute and chronic patient treatment may be initially provided more frequently and tapered as the patient approaches, so that’s a chiropractic spinal adjustment, multimodal in the beginning.

Heat stand, laser, thx, whatever you need to do, continuing treatment should be pred. On the demonstrate, on the demonstration of improvement in functional capacity, and not only a temporary reduction in complaints they have to get back to function. A small population of patients with chronic pain with more complex problems may be, may require ongoing care after a plateau and subjective and functional status of good.

Patients with severe pain scale seven to 10 and don’t gimme a scale of one to 10. It’s zero to 10 and it’s the visual analog scale. Go to Mr. Google. Print out the visual analog scale picture of the smiley faces laminated. Put it on every wall in your office to refer to that will protect your butt.

Patients with severe pain greater than seven 10 and findings consistent with moderate to severe functional limitations may warrant daily treatment for up to a week to manage pain and approved functions. Hey, . I did that when I practiced. I’m gonna see you every day for the first week. They’re acute. You can only do a little over a long period of time, go home and icep patients with more complex presentations.

Sufficient significant comorbidities. Chronic neck associated disorders or whiplash associated disorders might require longer periods to demonstrate subjective, objective, or functional. That’s a protocol, folks, and this is your reference. Three times a week is not 12 visits. I don’t know where the heck, oh, I’m gonna see you for 12 visits, Mrs.

Jones. No. It’s three times a week for four weeks, and then a reevaluation. It’s not 12 visits. That can be three months. How do you know how many visits it’s gonna take? You don’t have a Ouija border or crystal. It’s three times a week, and then a reevaluation. You wanna see ’em daily in the three times a week, that’s fine.

You wanna see them twice a week, that’s fine. But in four weeks you’re doing a reevaluation, non-negotiable. This is a legally defensible posture. And it will help your patient. I don’t have time to get into why three times a week is important from a physiological perspective of how you’re retraining the muscles, the ligaments attended, you’re working with Central sensitization with pacinian corpus, your crip receptors, your refin corpus, your stretch receptors, your GOGI tendon organs, which are also, those are all mechanical receptors and the no receptors, the free nerve endings, which pick up the environment around those joints.

All of those are mechanical receptors and some appropriate receptors which feed. Lateral horn up the spinal thalamic tract through the per ductal gray area into the thes ping pongs around the brain, goes fer often to disparate areas for compensation and helps your body. It takes time to do that while you’re creating biomechanical homeostasis.

There’s the answer and the reasons, but three times a week is not 12 visits. So folks, I. That takes us to the end of our time. I really enjoyed putting this together. It’s taken me about, God, about 12 years to put this information together. I had a whole different program and two hours before this I said, I don’t wanna do this.

What I had, I wanted to do this, it was. Needed in the industry and it’s needed by you. So again, I’d like to thank ChiroSecure for giving me the platform to sharing this information. And I look so forward to doing this with you the next time we do it in a few months and we’ll just keep doing it and we’ll hit every subject hopefully that our hot button issues in our prevent, in our profession to help you practice better, help more patients and and enjoy.

Thank you so much. Have a great day.