Normal vs Healthy: Why Your Labs Look Fine but You Still Feel Awful

I'm nervous. I think we're live. We are live. But I'm still a little nervous. If you're here in the first 10 seconds, I'm pretty through my shirt. Okay, Dr. Rose, how was your day? It was great. It was great. How was your day, Leah? It was good. It was awesome, like every day, all the time. Um If you're just joining, hi. Welcome to the Med Matrix Podcast, Med Matrix Method Podcast. Mess up in the first 5 seconds of me introducing. My name is Leah. You don't usually see me. I'm on the back end, um but I am the media marketing director here at Med Matrix. Pulling the strings, answering your comments, posting the videos. That's me. So, I've have the wonderful opportunity to be on this podcast with Dr. Rose. Future, don't I look like I'm blushing? I'm turning a little red. Um and I'm super excited to be here. Um Dr. Rose, would you like to give an introduction before we jump in? I would, yes. Um my name is Dr. Sasha Rose. I am a naturopathic doctor, a licensed acupuncturist. Um I've been practicing for over 20 years, and I am one of the lead providers here at Med Matrix. I am really excited to be talking with Leah today. As she mentioned, she's usually the one behind the scenes running the show, um doing pretty much 90% of the work. And I am excited for her to be on the other side of the camera tonight. I don't know how excited she is, but I'm I am excited. I have a lot to live up to, Dr. Rose and Colleen usually. They they run with this, and they run with it well. So, I've got a lot to live up to. Um so, before we get started, today is um we're going to be talking about the care gap between what's normal and what's healthy. Why sometimes your labs will come back as fine, the numbers will come back as fine. The reason you went to the doctor is because you don't feel fine. So this is a pretty common experience, especially in traditional medical care and and I'm sure at least one time in our lives everybody can relate to it. So we're going to be diving into that, but before we get started, this podcast is for educational purposes only. We are so willing and and would love to give you medical advice, but you would have to be a patient. So if you're interested in becoming a patient, if you're not a patient already, visit our website, you can book a discovery call. And yeah, learn about becoming a patient. Let's get started. All right. So again, we hear it all the time, my labs are normal, but I feel absolutely terrible. This happens so often. Dr. Rose, why does this happen? Yeah, so I would say the majority of my patients coming in can relate to that statement that I'm told my labs are normal, but I do not feel normal, I feel awful. Um It's yeah, it's just one of the most common sentiments and um I don't think it's just the people coming in to see us. I think this is somewhat universal. Um And the big thing that we like to talk about and a differ what we like to differentiate between is normal labs does not always mean optimal for you as an individual. So the labs are designed to detect disease, but not to detect dysfunction that happens early, right? So, it's basically um um around disease but not some of the symptoms and even signs that can happen before labs are technically out of range. And so, it's fairly common for um somebody for a body to be having a hard time, to be struggling, and we'll get into the most common symptoms, but um for the body to be struggling long before, and I'm I'm not meaning months, I'm meaning years, long before kind of your labs come back as abnormal. And so, yeah, it's just I guess somewhat sadly a a very common experience that you're not getting that kind of confirmation from the lab work. It's not proof that something's wrong, and so, you know you don't feel like yourself, you know you aren't something isn't right, but you're told, "Actually, everything is fine. You are You are fine." And that's just a That's just a hard experience to have. Incredibly disheartening. Been there. Um like everyone else, I'm sure. Um I know you mentioned that like the ranges are different, too. The ranges in between labs, like can you elaborate on that? Cuz I'm not the best person to talk about it. I'm just going to butcher, I guess, what those like ranges are and why it happens that way. So, can you explain them? Yeah, so ranges on a like on a lab on lab results, um and what what that What is Again, what does normal mean? Where do these ranges actually come from? Um and you're not alone. I think most people probably don't understand it, and we just kind of take it for granted that it's accurate, that range, whatever that is. Um so basically one one important thing is is that and I know this from working with multiple labs that reference ranges vary. So the reference range that there's not a universal reference range for any specific test. There's there's you know in gen there's like they're generally somewhat similar but there are there are fluctuations um and I'll give an example later on. That's something that came up today with one of my um patients that kind of showed how it can skew a little it can be skewed a little bit to the right or to the left. Um but basically the reference ranges are simply based on population averages and that population is going to include both healthy and unhealthy individuals. So um sometimes those wide ranges are going to you know include people that are supposedly healthy. They don't actually have a disease but those are the people that there is going to be an early dysfunction and yet that's considered normal because they are included in that statistical reference range. So again it's like what is normal mean? It does not mean optimal um and you know we here at MedMatrix at most functional medicine practices we really are striving for optimal optimal uh well-being, optimal health, optimal prevention and that really is not the same thing as a showing as your number is showing up as normal on routine blood work. So it doesn't normal doesn't mean things are functioning ideally. It doesn't you know it it really varies test to test and I will give some specific examples, but um sometimes depending on a test, it's like the the the range is more narrow than that again that wide range that's kind of including people with you know, some people with a disease, some people who are considered normal, but actually we know they're pretty much at a level of dysfunction. And then other tests, it's more our optimal is going to be we want it higher or we want it lower. Interesting. So, when you I guess are talking about the different ranges and they do change if they're based off of the averages, right? So, if they're constantly changing averages and ranges, then how are we I guess how are you and we can go more into like specific signals, you said specific ranges for different um illnesses and different diseases and different like warning signs, symptoms, but how are we able to know within these ranges or how are you able to know and treat people within these ranges when when the lab I guess won't tell you itself? Like you just have to know what an optimal number is or like how would you do that? Yeah, so I think maybe at this point in terms of enable to answer what would be optimal, like what's you know, what's what's what's normal someone's within range, but they're not but they're in in my opinion from a functional medicine provider's perspective, it's not normal. I think maybe if we start talking about specific examples, that might kind of help clarify things a little bit. So, one of the most common I guess um differences of opinion or a good example, I guess would be looking at a thyroid panel. And there's one um specific test it's a thyroid stimulating hormone or a TSH, and that's pretty much the only test that's used to detect thyroid a thyroid imbalance, like hypothyroidism, which is a sluggish or under-functioning thyroid thyroid gland, or hyperthyroidism, which is overactive. So, thyroid stimulating hormone is kind of the most common test that's run to first detect an imbalance, but then also um if somebody's been diagnosed with most commonly hypothyroidism, it help to manage the medication, right? Medication management. So, TSH on a normal the normal reference range of TSH is Again, this can vary a little bit, but it's usually like 0.5 to 4.5 or 0.5 to 5. So, if your TSH comes back anywhere within that range, you know, not all, some providers are going to basically say you're good, things are fine. You either uh don't have hypothyroidism, it's fine, or you're on the right medication, we don't need to adjust your medication, you know, you're you're good. We have a much more narrow window when it comes to TSH in terms of what we consider to be optimal for TSH. So, we like to see it between 0.75 and two. Again, it varies per individual. We That's just one test in our in our kind of complete thyroid panel. We are doing other numbers, and that's kind of We're going to look at all of that to see if Again, does the medication need to be adjusted, do other things need to happen, but I think that TSH is a really good example of um you know, someone could have low thyroid function, and we could maybe call it like borderline hypothyroidism, but conventional medicine would say you're fine, we don't need to do anything, you know, that's not why you're tired, that's not why you have a hard time losing weight, that's not why your hair is falling out. Interesting. That's a little off This is a little off of the show notes, like off from the show notes, but why? Why is that? Why do you think that patients come in, they say, "Hey, even though my labs are back and they look fine based on the lab, they're in range, I'm on this medication, but I still feel absolutely terrible." Why do you think the doctor says, "Well, there's nothing I can do if you're in range?" So, it's very localized to conventional medicine. Well, I wouldn't say localized to conventional medicine, I would say we are an outlier of this in functional medicine. So, why would you say that is? Why are we the outlier or why Why in conventional medicine are they saying that you're fine? Why when a patient when a when you are confronted with a patient, well, not you specifically, but when a conventional medicine doctor is confronted with a patient who says, "Hey, I know my labs look fine, I know I'm on this medicine, but I still feel horrible." And the doctor says, "Well, you know, all this is fine, there's nothing I can do for you." Why do you think that is? So, it kind of, you know, um What So, somebody comes into their doctor, their lab their numbers with is within normal, patient still isn't feel any better, doctor says, "You're on the right dose, see you later." Um and it happens all the time, um especially around thyroid conditions. And I think a lot I think it's a number of things. It's comes back to some topics that we have, um discussed on other episodes of this podcast before, which is the influence of insurance and in conventional medicine and that, you know, insurance will often, you know, pay for certain labs, certain medications only if the lab values are at a certain place. So, um they might not pay for, I don't know, a different medication if things are normal. They might not pay for an advanced more thorough thyroid panel if that TSH is within normal. So, sometimes the providers' hands are kind of tied. Um the other thing is the limitation of a 5-minute, 7-minute office visit. And so, there's not a lot of time to do more than you're fine, here's a here's a refill on your medication. Um and we all know that fatigue there's a lot that can be that can contribute to fatigue. So, yes, it might be that they're not their thyroid is not being optimally supported. It also might be that there's an issue with sleep. And there's no time in that visit, there's no room in that very short conversation to discuss to dig into, why are you tired? Maybe they're maybe what they're eating is really not an optimal way to eat for that person. There's really no time for that conversation. So, maybe their cortisol is just right. There's so many reasons why somebody's fatigued. Low vitamin D, low B12, low iron, like all these things that, you know, are going to very often contribute. And um because of the model and these short visits and these insurance constraints, it's super, super common for for people to feel dismissed, not heard, not given the answers that they're looking for um to these kind of debilitating symptoms. Yeah. What what are some of those symptoms besides I know then about fatigue, we talked about things that go into fatigue, but what are some more common symptoms that you see when labs are coming back as normal? Um so chronic fatigue, um a lot of brain fog, um which can show up as difficulty with word recall. It can be um a little bit of the um I'm not sure where I left my keys. Um that that can be brain fog. Uh a lot of the like a cog you know it's it's often cognitive. Um either weight gain or or difficulty losing weight. Um I mentioned sleep. Uh that's a big one. People either I would say it's more common at least in the patients that I'm seeing, people will often be able to fall asleep, but they they wake up frequently or they wake up between 1:00 and 4:00 a.m. Um so sub you know sometimes it's quantity, sometimes it's quality of sleep. Um a lot of digestive issues. Uh and that's another one where you're not going to your standard blood work is not going to pick up digestive issues. There's not a whole lot of labs that primary care will order. They're depending on what's going on with digestion, they might order a stool sample, they might want to rule out, you know, um like a parasite. They but mostly they're going to refer you to to gastroenterology on that one. Um and then the mood, you know, mood changes. So irritability, depression, anxiety. That's a we see a lot of that and I would say those very common symptoms, chronic, right? Where people are dealing with this for years usually, and those are the ones that are I would say in some ways conventional medicine has the hardest time um providing answers to. Yeah. The I guess circling back to like the limitations of insurance, um what are some more of these tests like this gut test that or this like biome test, um do you think are not run like the thyroid test? Things like that. Yeah, so a lot of these are kind of I mean that a complete thyroid test would not be considered advanced, but it's not it's not run it's not it's not standard to have a full thyroid panel run. Some of these other tests that we use in functional medicine to help us get to root causes um would include what's like a comprehensive diagnostic stool analysis. There's different labs that run different ones, but um yes, what does that lab test uh tell us? It tells us the health of somebody's microbiome. It tells us whether there's a parasite. We have a lot of people coming and asking about parasites. So it will rule out or rule in um the presence of both parasites and parasitic eggs. Um yeast, fungal, candida overgrowth uh some vi- the most common viral uh gut pathogens and then um a lot of really important in- like inflammatory and gut health markers. So so some things that people may not have heard of, but they give us a sense of how well is somebody breaking down fat, absorbing fat. Um do they have a reaction to gluten like a sensitivity, not just celiac, not an allergy, but even a sensitivity. Um what is the level of inflammation and um so it's it's very comprehensive. It does not take the place of a colonoscopy, but But also provides a lot of info or an endoscopy, so endoscopy being an upper GI, colonoscopy being a lower GI scope. Um I'm referring out for those all the time. These stool tests do not take the place of those scopes, but they also provide uh the results provide a lot of information that you're not going to get on those more standard um diagnostic tests. Wait, that's so interesting. What kind of markers would you be looking for for like oh, you're not celiac, but you could be you could have a sensitivity to gluten. What are some of these markers? So it's an anti-gliadin IgA, like an immunoglobulin. Basically, it's like if you have certain um antibodies circulating to gliadin, which is the protein in gluten. And again, if you go to an allergist or if you get if you get tested for celiac, that's a yes or no. That's a yes or no, you have celiac. And that's a true allergy, that's a specific part of the immune system. The vast majority of people do not have an allergy to gluten. They don't have celiac, but a fair number of people will have a sensitivity to it. And so they will have all sorts of gut issues, all sorts of inflammatory signs throughout the body, but they've been again, they've been told you're fine, you can eat as much wheat as you want, you don't have celiac. That is so interesting. I guess the same thing would apply to dairy, too, right? Because dairy is pretty inflammatory. It can be inflammatory for people. I don't have a test on that. I mean, we have other panels, other advanced panels that are like food sensitivity panels. This stool test does not have a specific marker looking for sensitivity to dairy. That is so interesting. Wow. Um okay, so let's I guess transition more into like the mental state of somebody who is going through all these tests, they're going back and forth to doctors, they're doing everything they're supposed to do, seeing the specialist, paying the co-pays, which we all hate and dread and have nightmares about. Um and they still feel terrible. What toll does that take on somebody not only, you know, physically as they're going through all these symptoms and and still experiencing all these symptoms, but mentally as well? Yeah, I mean, it can be really um somebody who's been trying, somebody's been going to the doctor, maybe they've been even referred to some of these other specialists, whether it's neurology, cardiology, rheumatol- you know, they've done all the things, including primary care, and everybody keeps telling them the same thing that everything looks fine, and it it's demoral- I mean, I guess at minimum, it's demoralizing, right? They feel they feel dismissed, they feel frustrated. Um as you mentioned, they're often spending money on co-pays, they're spending money on gas, especially now, price of gas, um and time. You know, people are taking time off from work, they're getting you know, babysitters um to watch their kids so they can do these visits. They're Maybe they're taking care of an aging parent, they have to have somebody watch the parent so they can go to these visits. It's it's a lot. Um and they're just feel like what they're presenting to that to their doctor is that it's not enough to be taken seriously, you know, and that it's a little I mean, I you know, feeling gaslit would be summarizing it, I think, in one in one word. Um saying, "Well, you know, maybe I really am fine and I am just making this up. It is Maybe like it is all in my head." Um and unfortunately, because of the way the system is right now and that people are often dismissed or feel dismissed and um things are kind of there's no intervention, there's no nothing is really done, no action is taken, that it there's a big delay in when they actually do receive a diagnosis and an even longer delay to appropriate treatment. So, during that whole time, somebody's fatigue, they're not sleeping well, they're maybe in some level of physical pain and they're the you know, the as we mentioned, maybe mood, you know, there's a depression, there's anxiety, there's both. They're they're day their daily life, the quality of daily life just kind of continues to go down and that has like a snowball effect, right? Like you don't feel good, you're not going to exercise. You're not going to exercise, you're going to gain weight. You're you're going to get more depressed, you're going to get more anxious. You know, it's everything's connected. You're not going to have energy to um shop, you know, regularly for healthy food. You're not certainly not going to have time to cook and eat well and so you then you're doing takeout and you're doing more processed food which increases inflammation which makes you feel worse, etc., etc. Um you so you know, I'm making some general statements here um but I think there's a term that I think is important which is like medical trauma. And sometimes there's extreme examples of medical trauma where people were like blatantly mistreated um or had, you know, at some point in their life, maybe childhood, had a series of pretty intense surgeries or interventions and there's that level of medical trauma. But I think that there's I think it's also medical trauma when you've gone from doctor to doctor or you keep going back to your um to your doctor and you're continually dismissed. I think there's of course going to be a level of distrust for doctors in general, for prescribers in general. And I see a lot of people come in pretty wary, right? Like they're a little bit like I haven't been helped yet. I don't know if you can help me. I've been told that it's all in my head. I don't know if you can help me. I've been just given an antidepressant or told to have a glass of wine and relax. I'm not sure you're going to be any different. Well, I really like the word gaslight. Mhm. I like that word in general, but I I like the the usage of it because really when you go to the doctor and they they do tell you there's nothing we can do for you, like you're fine, you do feel directly and personally gaslit by this doctor. When in reality, you're right, it is completely the system that there's it's the system that's speaking through this doctor, yet we instead are I guess framed not to mistrust the system, but we're framed to mistrust this doctor and the medical care because of their constraints. Right. So I think gaslight, not only is it a great word to use, but it's misdirected at how we feel. And I think that's I'm saying we because again, we've all been there. We've all been there, yep. I think that's really interesting. Um so how do we I guess in functional medicine approach this differently? Like what what makes an experience with functional medicine just I guess a totally different experience than what you're used to? Yeah, so So medicine does take a pretty different approach to um um I guess lab ranges to one what labs that we the the the level of uh comprehension to labs that we order like the amount of labs the just kind of what we want to be looking at and um also what we are going for with the results. So I think we talked I think we kind of spelled out optimal versus normal, but we're also ideally starting right off the bat with a very comprehensive panel. And so as discussed a full thyroid panel um you know a what's called as a complete blood count which is looking at your white blood cells, your red blood cells. It's looking at hematocrit and hemoglobin. And then a comprehensive metabolic panel which is going to be your liver enzymes, your kidney health, your fasting blood sugar. We're also looking at insulin not just that fasting glucose. So we're looking at your insulin levels so that here's another example of you know kind of picking up the very beginning stages of insulin resistance when you're still fall within normal, right? Your insulin is still normal which is somewhere between two and 20 for example, but if I see anybody with insulin that's over 10 honestly, but certainly over 15, I'm considering that borderline insulin resistance. And that we you know again in terms of practicing proactive, practicing preventive medicine like that's a great test to be able to catch that that slightly elevated borderline level years before somebody comes back and they're actually diabetic. Um we do a hemoglobin A1C just on the topic of blood sugar on everybody, and that's a that's a shows us a 3-month average of your blood sugar. And we're catching people when they're in the early stages of pre-diabetes. People aren't going to feel this. They're not going to have symptoms. Um and there's a lot of people that that's, you know, unless somebody's overweight and maybe over a certain age, conventional medicine is not running a hemoglobin A1C on most people. And we're catching people I'm catching a lot of people who are pre-diabetic and had no idea. And so it's a real incentive to make some lifestyle changes. Like nobody wants to, you know, end up with type 2 diabetes. And so it's a There's a That's a really good example. Um So we're looking at overall patterns. You know, I'm looking at um And so the in in that comprehensive test that we start with right off the bat, we're looking at micronutrient levels. So I'm looking at magnesium. I'm looking at your vitamin D. I'm looking at B12. I'm not just looking at iron. I'm looking at ferritin, which is the storage of iron. And that, in my opinion, is a better indicator of, again, borderline anemia compared to just your hemoglobin and hematocrit or just your iron. Somebody's fatigued, you have to look at all of those numbers. And so we're putting it all together. And so again, somebody's not technically they don't technically have iron deficiency anemia, but they're extremely fatigued and um their ferritin is at a 10, which is normal, but we really like to see ferritin close to 50. This is This is a female that's like a female reference range. It's a little bit um different for for men. So looking at patterns, looking at, you know, putting together what somebody's coming in with, what they're what they're presenting with symptom-wise, sign-wise, history-wise, medications, and then I'm I'm looking in their labs and I have enough different markers to kind of pick up patterns, themes, and kind of piecing it together. And so, uh do I then need Do I think it's something going on with their gut? Do I think it's something going on with their hormones? You know, we're looking at testosterone levels, estrogen levels, progesterone levels, cortisol. Uh we're looking at kind of all of those and based on what's going on, do I think that your fatigue really is about your sleep? We really need to focus on your sleep. Is it that there's a metabolic issue and there's a lot of inflammation going on? Where is that coming from? Is that coming from the gut? And so, it's very holistic. It's very personalized. It's not the same It's never the same conversation with with the same You know, I mean, everybody has a has a different picture and so we're treating each person very um uniquely. And I guess that ties into root cause, right? Like you're not treating each individual symptom, you're looking for how do you get rid of all of them in one go. Exactly. Exactly. one stone. Did you make that one up? No, I read it somewhere. Oh, that's good. That's a good one to repeat. Um yes, so we are fundamentally practicing root cause medicine. And so, yes, piecing the health history, what their symptoms are now, what medications they're currently taking, um and trying to stay away from what I call band-aid medicine, where oh, I see this lab is abnormal on your test results, I'm going to give you this medication. I'll see you in 6 months. Um and um uh Hold on, I have one technical question to ask you. Do I need to change out the battery on this camera? I don't think so. You look fine. I I'm not recording anymore. Oh. Damn. Okay, that's okay. Okay. Um I guess the storage is full. But Okay. Did we press record on the camera? Should we just What do you want me to do here? To all the nine people who are on this live right now, I deeply and sincerely apologize. I'm I've missed a step in all my nerves. Okay. Um Dr. Rose, if you could lean up Yeah, and turn this on. Click that button. It's on. No, I didn't click record. On the side. Um You know I'm not techy. It's okay. Um Everything's okay. Uh Okay, well I thought this was a great podcast. Well, actually Dr. Rose, um do you want to Do you know Do you see on the side there's a red little button on the side of the camera? And we can go through like a case study. Um do you want our behind-the-scenes person to come help me? Yes. Okay. Why don't we keep talking while that's happening? Yeah. Um, there's just a little button on the side of the camera. You just have to press record. Oh, see I can't see that from here. Yeah, guys. Sorry everyone. I'm so incredibly sorry. This is This is I think we're good. I think we're back on track. We're back. We're so back. Um, okay. So, I guess my final thought um, and this is a little off topic, but it's not really off topic is I heard that if you're breaking out Mhm. you could just have very low vitamin D. You'd just be very, very low in vitamin D and I think that is a great, I guess idea or not idea, but a great display of root cause medicine and how if you went to a dermatologist, if you went to an aesthetician, then you wouldn't really and you go through all of the products and the treatments and the you know, you wouldn't know. But, if you got labs tested and really you're just lacking vitamin D, I think that's an incredibly like It's a good Yeah. Um Yeah. I mean, I think that's a good example of there's so many different reasons why somebody can have acne, right? Um, but that's not something that's going to be checked if you go to primary care or to dermatology if they're not going to they're not going to make that connection. So, it can definitely contribute. I would say, you know, I don't know what percentage of people coming in have have you know, a fair amount have actual vitamin D deficiency and the vast majority of people have sub optimal levels of vitamin D. And so, it can definitely be a contributing factor. All right. Yeah. So, um unless you would like to share a case study, Dr. Rose. Um case studies are tough sometimes cuz it's I mean this is I think we've kind of made it pretty clear that this is like nine out of 10 people coming in have had this experience, right? Most people No, I mean most people do. I would say 9.99. Yes. So, I would I mean I could probably bring up, you know, any one of my patients and this was kind of their initial feeling. Um I would say not to give a specific example, but it's just one of the most rewarding parts of this job that um because as I mentioned people will come in understandably somewhat wary, right? And somewhat distrustful. And I do I have people who have not been to a doctor in 10 years or at least around here they can't get a doctor. Um and there's a certain level of distrust and um they come in not really being sure what they're getting themselves into. And it's very rewarding to kind of explain a lot of what we've talked about today and to go over like how the visit's going to work and what my goals are in working with them and a little bit of like optimal versus normal and to have the time and the space. Our first visit is 60 minutes. Our follow-ups are 30. Like it's unheard of for people to have that kind of time and attention in a visit. And that's just my time with them. That doesn't include like the time when they're are their their blood work done or their time with the assistants um the medical assistant. So, um there's just something inherently therapeutic just in that visit and in it's almost I hope kind of the opposite of feeling gaslit. And so, for people to have a medical experience where they feel validated, they feel heard, um and I'm like, "No, you're not making this up. It's not in your head. They're really We really do need to optimize hormones, metabolism, nutrient levels, etc." Um that's validating and so, it's very rewarding. And I get to see it every day. Aw. Um unless there's anything else you'd like to add? I think that's No, I just think it's a really important conversation, a really important topic. Um you know, normal versus healthy and um yeah, I think it's I think it's just information that, you know, ideally can be kind of shared um to a more and more of a broad audience. You're 100% correct and at least you have taught me and the doctors here have taught me, providers, provider assistants have taught me that you don't have to settle for normal. And that we shouldn't be settling for normal and that's what we're sold, especially in health care. That's right. So, thank you everybody for joining. Um remember that this is not medical advice. If you would like medical advice, it's for educational purposes only. If you'd like medical advice, please visit our site and book a discovery call. Um this is a huge conversation that we are going to have 1 million more times because we need to have it 1 million more times until it is standardized and it is applied in all medicine. Um Dr. Rose, thank you so much for joining today and thank you everyone for bearing with me as Hey, good job. Thank you everybody. Bye.