>> Steve: PEOPLE ARE LIVING LONGER, AND OFTEN BETTER, THANKS IN PART TO MEDICINE AND
PHARMACEUTICAL TREATMENTS FOR CONDITIONS THAT MIGHT HAVE ONCE BEEN CRIPPLING.
THAT CAN ALSO RESULT IN PEOPLE TAKING MANY DIFFERENT MEDS ALL AT ONCE.
AND THAT'S WHERE PROBLEMS CAN CROP UP.
WITH US NOW TO EXPLAIN, IN THE NATION'S CAPITAL: DR. ROHIT GANDHI, HE'S AN
EMERGENCY PHYSICIAN AND CLINICIAN RESEARCHER AT THE MONTFORT HOSPITAL, RIGHT NEAR
DOWNTOWN OTTAWA.
NOT ONLY IS HE APPEARING ON THIS PROGRAM FOR THE FIRST TIME, THIS IS HIS FIRST TIME ON TELEVISION
EVER.
SO DR. GANDHI, IT'S GREAT TO HAVE YOU HERE.
HOW ARE YOU DOING?
>> Dr. Rohit Gandhi: THANK YOU SO MUCH.
THANKS FOR THE WARM WELCOME.
I'M DOING WELL.
HOW ARE YOU?
>> Steve: I'M TERRIFIC, THANK YOU.
WE'LL MAKE THIS AS PLEASANT AN EXPERIENCE AS POSSIBLE, OKAY?
>> THANK YOU.
>> Steve: LET'S START WITH THIS: POLYPHARMACY.
HOW WOULD YOU DEFINE IT?
>> SO I THINK POLYPHARMACY IS VERY CLASSICALLY DESCRIBED AS AN INDIVIDUAL WHO IS ON FIVE OR
MORE MEDICATIONS ON A DAILY BASIS.
BUT THAT THINKING HAS SHIFTED A LITTLE BIT TO BE LESS ABOUT THE NUMBER OF MEDICATIONS AND A BIT
MORE ABOUT WHETHER THE MEDICATIONS YOU TAKE ARE ACTUALLY CAUSING YOU MORE HARM
THAN BENEFIT.
>> Steve: SURE.
AND HOW PREVALENT WOULD YOU SAY THAT PHENOMENON IS?
>> WELL, I THINK IT'S SOMETHING THAT AFFECTS CANADIANS GREATLY AND A LOT OF OTHER WEALTHY
NATIONS AS WELL.
OUR CITIZENS AGED 65 AND OLDER ARE ON AN AVERAGE OF SEVEN DIFFERENT CLASSES OF MEDICATION,
WHICH IS ACTUALLY QUITE SUBSTANTIAL, AND THAT BECOMES AN ISSUE IN TERMS OF POLYPHARMACY
AS WE KNOW THAT EACH ADDITIONAL DRUG WE TAKE AS AN INDIVIDUAL INCREASES OUR RISK FOR ADVERSE
EVENTS.
SO THIS PROBLEM I THINK AS WE GROW THE NUMBER OF MEDICATIONS AVAILABLE TO US IN TERMS OF
PHARMACEUTICAL OPTIONS BECOMES QUITE AN ISSUE HERE IN CANADA.
>> Steve: LET'S JUST SORT OF FIGURE OUT HOW THIS HAPPENS.
I GUESS OBVIOUSLY AT SOME POINT YOU'RE ON ONE DRUG AND THEN ANOTHER AND ANOTHER AND ANOTHER
AND SUDDENLY YOU'RE ON FIVE OR SIX.
I MEAN, HOW DOES THAT HAPPEN?
>> YEAH.
WELL, REALLY, THERE'S A LOT OF DIFFERENT REASONS AND I THINK A LOT OF DIFFERENT PLAYERS
INVOLVED IN CREATING THAT PROBLEM OF POLYPHARMACY.
A LOT OF CARE CAN BE FRACTIONATED AT TIMES.
PATIENTS DON'T HAVE A PRIMARY CARE PHYSICIAN SO THEY'RE SEEKING CARE FROM OTHER
PROVIDERS.
AND WHEN YOU HAVE THAT TYPE OF MEDICINE THAT'S BEING EMPLOYED, YOU END UP ON MORE MEDICATIONS
THAN MIGHT BE BENEFICIAL FOR YOU.
EVEN PATIENTS WHO DO HAVE A FAMILY PHYSICIAN BUT HAVE SPECIALISTS INVOLVED IN THEIR
CARE WHO ARE FOCUSED ON ONE SYSTEM OR ONE CHRONIC DISEASE END UP BECOMING VICTIMS OF
POLYPHARMACY BECAUSE OF ALL THE PLAYERS INVOLVED, WHICH AT TIMES CAN BE BENEFICIAL, BUT AS WE AGE
AND AS WE CONTINUE TO ADD MEDICATIONS AND RE-PRESCRIBE THEM WITHOUT THAT THOUGHTFUL ACT
OF DE-PRESCRIBING, WE END UP WITH A LOT OF MEDICATIONS ON BOARD.
>> Steve: WELL, I GET WHAT YOU'RE SAYING, BUT IF EACH MEDICATION THAT A PERSON IS
TAKING IS DESIGNED TO TACKLE SOME DIFFICULTY THE PATIENT IS HAVING AND THEY ALL WORK
REASONABLY WELL TOGETHER, WHAT'S THE PROBLEM?
>> WELL, THAT'S THE REAL QUESTION: DO THEY WORK REASONABLY WELL TOGETHER?
A LOT OF STUDIES THAT ARE DONE ON MEDICATIONS AND THEIR USE FOR TREATING A DISEASE ARE VERY
TAILORED TO THAT SPECIFIC DISEASE AND THAT MEDICATION AND THAT SETTING.
WE DON'T OFTEN STUDY HOW MEDICATIONS INTERACT WITH EACH OTHER.
AND I THINK THAT'S ONE OF THE SOURCES OF THE PROBLEM.
THE OTHER PART TO THAT IS, WHEN WE START A MEDICATION FOR A CERTAIN CONDITION OR THERE'S A
BENEFIT AT THE TIME, THAT DOESN'T NECESSARILY MEAN IT HOLDS THROUGH THROUGHOUT YOUR
LIFE.
AS I MENTIONED, YOU MAY START SOMETHING FOR, LET'S SAY, YOUR HIGH BLOOD PRESSURE AND IT MAY
BE HELPFUL TO HAVE TARGETED CONTROL OF BLOOD PRESSURE AT A CERTAIN AGE IN YOUR LIFE.
BUT AS WE AGE AND OUR PHYSIOLOGY CHANGES SO WE ADD MORE MEDICATIONS, AS WE ALLUDED TO
EARLIER, THE EFFECTIVENESS OF THAT MEDICATION MIGHT NOT BE THE SAME.
THE NEED TO TREAT AGGRESSIVELY MIGHT NOT BE THE SAME.
AND WE END UP WITH POTENTIALLY A MEDICATION THAT WAS HELPING US AT ONE POINT BUT MAYBE NOW IS
CAUSING US MORE HARM.
>> Steve: ALL RIGHT.
YOU'RE AN E.R. DOC, RIGHT?
>> CORRECT.
>> Steve: SO TELL US HOW THIS SORT OF PLAYS OUT IN YOUR PERSONAL EXPERIENCE WHEN YOU'RE
WORKING IN THE EMERGENCY ROOM?
>> SURE.
WELL, I MEAN, IT'S NOT UNCOMMON FOR US TO SEE A PATIENT IN AN ACUTE SETTING GRAB THEIR FILES
AND GO THROUGH A LIST OF MEDICATIONS THAT'S 10 PAGES LONG, OR WE HAVE A PATIENT THAT
SORT OF COMES IN WITH THEIR ZIPLOC BAG COMPLETE WITH PILLS, OLD, NEW, EXPIRED.
AND SO THAT'S A VERY VISIBLE PART OF POLYPHARMACY.
BUT THE PATIENTS WE END UP ADMITTING TO HOSPITAL, THE ONES THAT JUST CAN'T GO HOME, ABOUT
HALF OF THEM ARE ON AT LEAST TEN MEDICATIONS, AND WE KNOW THAT INCREASES YOUR RISK OF HAVING AN
ADVERSE DRUG EVENT, SO A SIDE EFFECT OF YOUR MEDICATIONS.
AND IT'S QUITE SURPRISING.
I THINK BEING ON 10 DRUGS INCREASES YOUR RISK ABOUT FIVE TIMES OF BEING ADMITTED FOR AN
ADVERSE DRUG EVENT.
SO IN MY DAILY PRACTICE, I'M SEEING A LOT OF POLYPHARMACY, A LOT OF MEDICATIONS THAT ARE
UNNECESSARY AND ARE PROBABLY LEADING IN AN UNRECOGNIZED WAY TO ADMISSIONS TO HOSPITAL DUE TO
THESE SIDE EFFECTS.
>> Steve: DR. GANDHI, LET ME JUST MAKE SURE I'VE GOT THIS RIGHT.
TEN MEDICATIONS EVERY DAY?
>> EVERY DAY.
>> Steve: MULTIPLE TIMES A DAY?
>> YEAH.
THIS IS A PROBLEM THAT IS NOT JUST ABOUT TAKING TEN MEDICATIONS A DAY AND ALL THE
POLYPHARMACY, IT'S, AS YOU MENTIONED, JUST UNDERSTANDING HOW TO TAKE THEM, WHEN TO TAKE
THEM.
COMPLYING WITH THEM.
PEOPLE EVEN GET FULL FROM HAVING TEN MEDICATIONS FOR BREAKFAST.
SO IT IS TEN PER DAY.
>> Steve: YOU MIGHT HAVE A PATIENT, FOR EXAMPLE, WHO IS TAKING 40 DIFFERENT TABLETS A
DAY FOR A VARIETY OF DIFFERENT THINGS?
>> YES, EXACTLY.
IT'S NOT JUST THE NUMBER, IT'S THE NUMBER OF TABLETS AS WELL, RIGHT?
SO THAT'S QUITE RIGHT, STEVE.
>> Steve: THAT'S ASTONISHING.
HOW OFTEN DO YOU FIND A SITUATION WHERE SOMEBODY COMES IN AND, I DON'T KNOW, LET'S SAY
THEY'VE GOT A PARENT IN THEIR 80s, SO THEY'RE IN THEIR, WHATEVER, 40s, 50s, 60s,
AND YOU THE DOCTOR SAYS TO THE CHILD OF THE PERSON WHO NEEDS TREATMENT, "OKAY, WHAT'S YOUR
MOM OR DAD ON?"
AND THEY GIVE YOU THIS QUIZZICAL LOOK LIKE, "UM, I DON'T KNOW."
HOW OFTEN DOES THAT HAPPEN?
>> YEAH.
I MEAN, THAT IS A PROBLEM THAT I THINK WE SEE ALL THE TIME.
EVEN PEOPLE ON THREE OR FOUR MEDICATIONS.
MY PARENTS AS WELL.
I ASK THEM WHAT THEY'RE ON.
AND IT'S DIFFICULT.
AND I THINK IT BECOMES DIFFICULT FOR CLINICIANS AS WELL BECAUSE RIGHT NOW IN CANADA WE DON'T
REALLY HAVE A GREAT REPOSITORY TO UNDERSTAND WHAT MEDICATIONS OUR PATIENTS ARE REALLY ON AND
WHERE THEY COME FROM.
SO WHEN WE SPEAK TO THEIR LOVED ONES WHO ARE TRYING TO RECONCILE THAT FOR THEM, IT'S
OVERWHELMING.
AND WE REALLY APPRECIATE SOME OF THOSE FAMILIES WHO ACTUALLY HAVE A LIST IN FRONT OF THEM.
SO IN THE RARE CASES, WE REALLY DO GET A NICE LIST AND PEOPLE ARE VERY MUCH INVOLVED.
BUT IT'S HARD TO BLAME THE FAMILY BECAUSE IT'S A VERY DIFFICULT TASK TO NOT HAVE A
MEDICAL BACKGROUND AND MANAGE SO MANY MEDICATIONS FOR A LOVED ONE.
>> Steve: SURE, BUT AS LONG AS WE'RE ON THE TOPIC, ANYBODY WATCHING THIS, FIND OUT WHAT
YOUR FOLKS ARE ON AND MAKE A LIST.
THAT'S JUST COMMON SENSE.
SO IF THEY GET INTO TROUBLE, YOU CAN GIVE THE DOCTOR GOOD ADVICE AND GOOD INFORMATION.
>> YEAH.
I THINK THAT'S A GREAT PIECE OF ADVICE, STEVE.
IT'S VERY UNDER-RECOGNIZED HOW IMPORTANT IT IS TO HAVE A GOOD MEDICAL RECORD OF MEDICATIONS
COMING IN TO HOSPITAL.
>> Steve: ALL RIGHT THEN.
WE'VE GOT THIS CIRCUMSTANCE HERE WHERE SOME PEOPLE ARE ON A GREAT NUMBER OF MEDICATIONS NUMEROUS
TIMES A DAY AND -- LET'S FIGURE OUT IF THIS DOES BECOME A PROBLEM, WHAT GUYS LIKE YOU
INTEND TO DO ABOUT IT.
THERE'S A TERM CALLED DE-PRESCRIBING.
WHAT IS THAT?
>> SO DE-PRESCRIBING IS A FANCY TERM TO HAVE WHAT WE CALL A PRESCRIPTION CHECKUP.
TO REMOVE MEDICATIONS THAT ARE UNNECESSARY, THAT AREN'T PROVIDING ANY BENEFIT, AND ARE
POTENTIALLY COMPOUNDING AND PROVIDING HARM.
SO IT'S REALLY THE ACTIVE ACT, BEFORE WE GET TO THE HOSPITAL OR ICU, WHERE WE'RE TRYING OUR BEST
TO REMOVE MEDICATIONS THAT ARE UNNECESSARY AND SIMPLIFY THINGS FOR OUR PATIENTS, WHILE KEEPING
THE QUALITY OF THEIR CARE AT A VERY HIGH STANDARD.
>> Steve: HOW DO YOU KNOW IF THE DRUGS ARE UNNECESSARY?
>> IT'S A GREAT QUESTION, AND IT'S PROBABLY A VERY COMPLEX ANSWER BECAUSE EVERYONE IS VERY
DIFFERENT, AND DRUGS, LIKE I MENTIONED, ARE BENEFICIAL AT ONE TIME IN YOUR LIFE, BUT LATER IN
LIFE, THEY MAY NOT BE SO.
AND THE INTERACTIONS AREN'T ALWAYS STUDIED.
NOW, TO REALLY UNDERSTAND, YOU KNOW, IF A DRUG IS UNNECESSARY, THERE'S A LOT OF CRITERIA THAT
ARE STARTING TO CREEP UP NOW.
WE'VE HAD LISTS FOR YEARS.
SOME OF THEM LIKE THE BEERS CRITERIA, WHICH SORT OF INDICATES WE PRESCRIBE THESE
DRUGS OUT OF HABIT A LOT OF THE TIME, BUT THE INDICATION ISN'T ALWAYS THERE.
WE TALK A LOT ABOUT THE NUMBER OF PATIENTS WE NEED TO TREAT -- IT'S CALLED THE NUMBER NEEDED TO
TREAT WHICH SORT OF SHOWS HOW MUCH PATIENTS DO WE NEED TO GIVE THIS PARTICULAR DRUG TO BEFORE
WE SEE ONE PERSON HAVING A BENEFIT.
WHICH IS REALLY INTERESTING.
BUT ON THE FLIP SIDE THERE'S ALSO THE NUMBER NEEDED TO HARM.
AND THAT MEANS HOW MANY TIMES DO WE GIVE THIS MEDICATION BEFORE ONE PERSON HAS A BAD EVENT OR AN
ADVERSE OUTCOME.
AND REALLY WEIGHING THESE TWO THINGS IS THE FIRST STEP IN HELPING UNDERSTAND WHETHER OR
NOT THIS DRUG IS ACTUALLY DOING US ANY HARM AND WHETHER OR NOT THE BENEFIT IS OUTWEIGHING THAT.
>> Steve: WELL, LET'S FIGURE OUT HOW TO GET OUT OF THIS PICKLE THEN.
NO DOUBT IT'S HAPPENING, THIS OVERPRESCRIBING, BECAUSE DOCTORS DO IT OR PATIENTS DEMAND IT OR
PHARMACISTS GO ALONG WITH IT.
SO OF THOSE THREE, WHO IS MOST RESPONSIBLE FOR SORT OF TURNING THIS VEHICLE AROUND?
>> YEAH.
WELL, I WOULD HAVE TO ARGUE THAT ALL THREE OF THESE PARTIES -- AND PROBABLY OTHER HEALTH CARE
PRACTITIONERS -- ARE INVOLVED IN THIS PROBLEM.
AND I THINK THE SOLUTION, IF IT DOESN'T COME FROM ALL THREE PARTIES, I THINK THAT THAT'S
GOING TO BE THE ONLY REAL WAY THAT WE'RE GOING TO GET A REAL GOOD HEADWAY ON REDUCING
POLYPHARMACY.
I THINK FROM THE PATIENT PERSPECTIVE, IT'S VERY IMPORTANT TO BE AN ADVOCATE FOR YOUR OWN
HEALTH.
I MEAN, PHYSICIANS ARE STRETCHED THIN.
THERE'S LOTS OF COMPETING INTERESTS.
AND AS A PATIENT, I THINK IT'S IMPORTANT THAT WE TAKE OUR HEALTH CARE, WE UNDERSTAND OUR
HEALTH CARE, AND WE DO THINGS LIKE YOU SUGGESTED, MAKING A LIST OF MEDICATIONS, HAVING THAT
AVAILABLE.
BUT REALLY TO START THE CONVERSATION WITH YOUR FAMILY PHYSICIAN.
TO GO IN AND ASK MAYBE FOR AN APPOINTMENT JUST ABOUT DE-PRESCRIBING.
I THINK HAVING THAT AS A FIRST STEP WILL GO A LONG WAY.
BUT CERTAINLY THE FAMILY PHYSICIAN HAS A ROLE.
THEY HAVE A ROLE IN PREVENTING THESE ADVERSE EVENTS AND GOING THROUGH MEDICATIONS, TO ACTUALLY
HELP OUR PATIENTS UNDERSTAND WITH TIME, IF THEY STILL NEED TO BE ON THEM.
AND I THINK THAT'S A VISIT THAT'S VERY MUCH WORTH HAVING.
AND ON THE OTHER REALM OF PHARMACEUTICAL, WE GET A LOT OF INFORMATION FROM PHARMACEUTICAL
COMPANIES ON HOW TO START DRUGS AND HOW TO GIVE THEM AND WHEN TO GIVE THEM.
BUT WE DON'T HAVE A LOT OF INFORMATION FROM THEM ON WHEN TO STOP THEM OR HOW TO STOP THEM.
AND I THINK THE ONUS THERE ALSO LIES WITH THAT TYPE OF INDUSTRY TO HELP OUR PHYSICIANS AND OUR
PATIENTS DE-PRESCRIBE.
>> Steve: NOW, THAT'S A GREAT POINT.
SO YOU THINK THAT THERE'S THE POSSIBILITY THAT DOCTORS DON'T REALIZE THEY'RE OVERPRESCRIBING
SIMPLY BECAUSE THEY PUT A PATIENT ON THE MEDS BUT THEN THEY DON'T EVER TELL THE
PATIENT, "OH, INCIDENTALLY, YOU DON'T NECESSARILY HAVE TO TAKE THIS FOR YOUR WHOLE LIFE."
THAT'S AN ISSUE, EH?
>> IT IS AN ISSUE.
AND I THINK AT TIMES, YOU KNOW -- PRESCRIPTIONS EXPIRE, RIGHT?
YOU GO BACK AND RENEW YOUR PRESCRIPTION EVERY THREE MONTHS OR SIX MONTHS AND I THINK THAT'S
AN IMPORTANT TASK AND IT SORT OF BECOMES SOMETHING THAT WE DO ROUTINELY.
BUT I THINK WHAT WE NEED TO DO, AS YOU SORT OF ALLUDED TO, IS TO REALLY AFTER A CERTAIN NUMBER OF
YEARS HAVE CHECK-INS OR REMINDERS THAT WE REALLY NEED TO REVISIT WHETHER THIS MEDICATION
WORKS.
I THINK THAT PATIENTS NEED TO ASK THEIR PHYSICIANS, HOW LONG DO I NEED TO BE ON THIS FOR AND
CAN WE TALK ABOUT THIS IN TWO YEARS OR THREE YEARS OR WHATEVER INTERVAL IS NECESSARY FOR THAT
PARTICULAR DISEASE PROCESS AND MEDICATION.
>> Steve: IN WHICH CASE, LET'S FINISH UP ON THIS.
PATIENTS GET MEDS FROM A VARIETY OF DIFFERENT PLACES, YOU CAN GET MEDS AT A WALK-IN CLINIC, YOU
CAN GET THEM FROM YOUR GP, YOU CAN GET THEM FROM A SPECIALIST.
AGAIN, ALL THESE PLAYERS HAVE A ROLE TO PLAY, PRESUMABLY, IN THIS DRAMA THAT YOU'RE
DESCRIBING FOR US.
DO YOU SEE A -- DO YOU SEE A QUICK AND DIRTY SOLUTION TO TURNING THIS THING AROUND?
>> WELL, I WISH I DID.
AND TO COMPOUND THE PROBLEM, THERE'S ALSO OVER-THE-COUNTER MEDICATIONS.
SO IT'S NOT JUST FROM PRESCRIBERS.
IT'S PATIENTS THEMSELVES THAT MAY TAKE AN OVER-THE-COUNTER MEDICATION THAT MAYBE HAS LITTLE
HARM BUT COMPOUNDED WITH YOUR TEN MEDICATIONS CAN DO A LOT.
SO IN TERMS OF A QUICK AND EASY SOLUTION, THERE PROBABLY ISN'T ONE.
I THINK WE NEED TO, FIRST, HAVE A SYSTEM IN PLACE WHERE WE CAN ACCESS PATIENT MEDICATION
INFORMATION IN A VERY UNIFORM WAY.
SO ALL PROVIDERS CAN SEE THAT AND ACCESS THAT, WHICH DOESN'T EXIST TODAY.
BUT I THINK, YOU KNOW, PUTTING ON THE RADAR PRESCRIBING AN OVERUSE OF MEDICATIONS ON
PATIENTS' AND PHYSICIANS' RADAR IS IMPORTANT AND HAVING THE TOOLS TO EDUCATE THEM TO
DE-PRESCRIBE, WHICH WE KNOW IS TIME SENSITIVE, TIME-CONSUMING, AND COMPLEX PROCESS WOULD REALLY
HELP.
A LOT OF MY PARTICULAR RESEARCH THAT I DO IN THE HOSPITAL HAS TO DO WITH PROVIDING PHYSICIANS
WITH INDIVIDUALIZED DATA ON THEIR PERFORMANCE AND ACTUALLY ALLOWING PHYSICIANS TO USE DATA
COMPARED AGAINST THEIR PEERS WHO PRACTICE IN THE VERY SAME SETTING AS THEM TO REALLY
UNDERSTAND, YOU KNOW, THROUGH AUDIT AND FEEDBACK HOW MUCH, LET'S SAY, EACH OF THEIR
PRESCRIPTIONS ON AVERAGE ARE PER PATIENT THEY HAVE AND PROVIDING THAT INFORMATION IN CONJUNCTION
WITH EDUCATION IS PROBABLY WHERE I THINK WE'RE GOING TO SEE THE MARK MOVE A LITTLE BIT.
BECAUSE WE KNOW THAT EDUCATION ALONE AND INFORMATION ALONE DOESN'T REALLY CHANGE BEHAVIOUR
IN A LOT OF DIFFERENT STUDIES AND CASES IN MEDICINE, AND WE NEED TO COMPLEMENT THAT WITH
OTHER THINGS LIKE AUDIT AND FEEDBACK AND UNDERSTANDING REALLY THE MOTIVATION ON WHY YOU
NEED TO CHANGE AND WE NEED TO HELP OUR PATIENTS TO DO SO.
>> Steve: WELL, HAVING SAID THAT, LET'S HOPE WE'VE DONE A LITTLE PIECE OF THAT EDUCATIONAL
PART OF THIS PUZZLE HERE TONIGHT ON TVO.
DR. ROHIT GANDHI FROM THE MONTFORT HOSPITAL IN OTTAWA, I WANT TO NOT ONLY THANK YOU FOR
BEING WITH US ON TVO TONIGHT BUT I ALSO WANT TO TELL YOU, YOU WERE EXCELLENT!
FIRST TIME ON TELEVISION AND YOU WERE TERRIFIC, SO THANK YOU, AND I LOOK FORWARD TO SPEAKING TO
YOU AGAIN ABOUT WHATEVER YOU'RE INTERESTED IN AS IT RELATES TO OUR HEALTH CARE SYSTEM.
>> OF COURSE.
THANKS A LOT FOR HAVING ME, STEVE. I APPRECIATE IT.