Covid-19 & Bridges: UCSF SOM Town Hall for students

hello everyone welcome and thank you for joining us and apologies for evening into your evening but I do want to thank you for taking the time to join us I know not everyone could and for that we are recording this session now and it will be available later on on the on the web probably with a streaming format and we’ll be posting that for those who again weren’t able to make it I’m joined here by by Dean Lucy and Dean power and before we get started I would like to hand over to the Lucy for some introductory comments Thank You Dean Davis and hello to all of you I’m very happy that you took the time to join this Town Hall and I’m only sorry that we can’t be there in person to talk with you one-to-one but but you know why that is we’re actually in the Medical Education Command room that we’ve been meeting every day for the past seven days and we’re practicing good social distancing so so that’s why we’re here and you are where you are hopefully also practicing social distancing I want to start by talking a little bit about how I across the duration of my career have dealt with a number of different epidemics and crises because I think it will give you some information that you could perhaps use in the way in which you’re focusing on this particular scenario here this pandemic Hoban 19 it is important to recognize that we know how stressful a time this is to be in medical school to be particularly in the clinical years in medical school so it’s unusual and it’s extraordinary but it’s not an isolated event I think in the medical profession all of us get used for the idea that these things are going to happen periodically and they require a set of competencies that you need to learn and we need to help you master so that you can be the type of physician who can respond on the frontlines as many of your faculty and colleagues are doing already so many of you know that I started my career here at UCSF as a resident and chief resident during the HIV epidemic that was my first epidemic response but I’ve had a number of other ones as well that most of you probably aren’t you aware aren’t aware of I was a internal medicine residency program director in Washington DC and responsible for the hospital response to the 9/11 attacks on the Pentagon and then the subsequent anthrax attacks at the post office in DC and then I moved to Ohio and as an education D and program director there was responsible for participating in the response to the stars epidemic as well as the h1n1 flu in all of these situations my job was to protect and support students and residents and also to personally provide direct care for patients who were at risk of or struggling with the diseases that were in epidemic or the crises that were weren’t facing us and so I I want you to say when I when I tell you I know what you’re feeling I do know what you’re feeling I’ve been where you are before and I think the learnings I and others of your Dean’s have had will will help you hopefully that’s what we’re intending to share today our purpose in holding this meeting is really three things one is to perverse first to provide you with factual information about kovat 19 so that you can know your cart in stemming the tide flattening the epidemiologic curve of this epidemic by adhering yourself to important Public Health response strategies secondly we want you to see yourself as informed trusted ambassadors for the truth we think that your neighbors your family your friends will be yearning for someone that they trust as a good person to help them really understand what’s hype and what’s truth in the in the national discourse and you can be incredibly important to both calm and also activate the community calm them when things are wrong but activate them in terms of getting them on board with social distancing and other Public Health interventions and the third thing we want to accomplish to date is to talk to you about the changes we’ve made as a school of medicine in the educational programs so that we can do our part as stewards of the public health response for the Cova 19 pandemic and do our part in flattening that epidemiologic curve that dr. Davis will talk more about in a few minutes thinking about this and thinking back on my experience I will say that it’s it’s fair to say that every day when physicians go to work they care for patients with infections and accept a certain risk of contagion it becomes kind of business as usual and all of you who have been in the hospital

know you’ve taken care of people with multi drug-resistant bacteria you’ve taken care of people in respiratory isolation you taking care of people with C difficile colitis all of which require you to continue to provide care using the best practices in infection control epidemics raise concerns though about this contagion risk that we voluntarily take on as physicians and physicians in training because of the inherent uncertainty about new pathogens we don’t really know fully what the biologic behavior of this new pathogen is we have some ideas but there’s still some unanswered question and we don’t currently have a definitive treatment and we don’t have a vaccine that we can use to mitigate some of the risks that providers take and and mitigate things like the hepatitis B vaccine or the influenza annual vaccine and so to me what this brings into into focus is the fact that when we talk about issues of professionalism and and concepts like altruism they’re with us every day but they’re kind of in the background they’re kind of an abstract concept that we know guides our decision-making but we don’t think about it dig in and day out until faced with an epidemic and then this comes like a laser focus for us every day we get up and we put on our clothes to go to work in the hospital and we think to yourself wow I’m walking into a place where we’re concerned about a patient suffering from a disease that’s a pandemic across the world now and so and so I think that putting this issue of professionalism right at the forefront adds cognitive burden and emotional burden to the work that we’re doing every day and and my experience in the past I’ve dealt with this really understanding the power of community and the power of first getting a lot of information so I know what my risk is and let the risk is to the people around me and second talking to my colleagues and then talking again and talking some more not just to actually share information and brainstorm about solutions but to also share some of the emotional burden because when one person is down another person can genuinely step in and lift them up and I hope you’ll be finding that is true with your peers as well as with your Dean’s and with your faculty so the other thing I thought about and reflecting back to my own experience with past crises and epidemic is that that there’s always two questions that physicians and physicians and training are called upon to answer in this and the first comes from family and friends who basically say something like I don’t know how you do it or why are you doing it or why are you as a medical student not just packing up and leaving and going back to school some other time and the answer that I’ve come at is truly I do this because this is the work this is what I trained for them what you have been training for and the expertise that you need to develop so that you can be a doctor who can be on the front lines of caring for patients when they need us most and caring for communities when they are most fearful like in the midst of an epidemic I think it’s important in answering this question not only to say this is the work but I feel confident as you should that the faculty at UCSF are the best people in the nation and probably in the world for you to be learning from in terms of how to protect yourself and to provide compassionate patient-centered care for our patients and to end to launch and continuously improve system-wide initiatives both at our institution and in our communities to stave off future transmission of this epidemic the second question doesn’t come from outside of you it comes from inside of you and that’s that voice that’s sort of when you get up in the morning and you start to put on your white coat sort of says I’m I’m afraid and what do I do about this I’m worried what do I do about this and um again working with colleagues is super important in this environment and sharing these fears and getting people to talk about but I also think it’s really important to reach down and tap into that empathy that we selected you for that Dean Massey who is here one of the earlier town halls saw in you when you applied to medical school with all of your incredible academic honors just like everyone else but we recognized that you had a special spark in serving patients and the communities and that was why we wanted you to train here with us at the UCSF in the UCSF way it’s important to to when you tap into that empathy for others and their fear that you realize that courage is not just about being fearless hers is actually about having fear but acting despite it and when I feel called upon to do that I try and look for someone else in the environment who’s worse off than me and in this environment I think

we can say safely that our patients are more fearful than we are for good reason they already are fearful about the condition that brought them to the hospital some of them will be concerns about Koba 19 but many will be diabetic ketoacidosis or acute myocardial infarctions or asthma exacerbations and they’re already fearful because of the vulnerability that that illness has provided to them and on top of that they worry about coming into a healthcare system where they know there may be patients who also are struggling with this pandemic virus and so think about your ability as a student your the privilege that you have to spend some extra time with patients who are not those struggling with Cova 19 because we do want to protect you from providing direct care for patients with a high suspicion of Kovach 19 but there are many others who you can actually spend additional time with make sure their concerns are addressed I’m an advocate them on rows and in doing so put aside your fear to sort of alleviate the fears of patients who are probably more vulnerable than you feel at any given moment the second group I like to sort of think about with real intention because I think they’re often overlooked in situations like this is the people who are on the front lines and don’t have the luxury of being able to work remotely or talk remotely these are frontline nurses respiratory therapists patient care aides frontline faculty and clinicians but also the people who make our institution work the environmental services workers food services workers and and even the greeters at the begat the front desk of the hospital and so I’m think too about what it’s like to be in their shoes without options and if you have the opportunity say a kind word thank them for what they’re doing and again try and set aside your fears so that you can work with intention and generosity towards those others I’m gonna turn it over to dr. Davis now who’s going to talk not only as your curriculum dean but as a specialist in infectious diseases about the Cova 19 by virus I believe we’ll be joined by being King at the end of the session who’s currently on a command conversation but wanted to have the opportunity to talk with you as well dr. Davis Thank You Lucy alright so a one process thing so we will be able to take questions if you could add those to the chat window and especially start them with a question mark our dear doe Quin Tran Taylor has volunteered to take all of your questions and aggregate them and gather them into some some common themes and then we will be able to answer those at the end of presentation we will try to get to all of those that be that we have time for our agenda for today is a little bit of a kovat update and then really thinking about then why do we need to change the curriculum and what will those changes be and what can we do to help prepare for that so as st.lucie mentioned I I do occasionally participate in my role as an infectious diseases faculty member here as well so I thought it might be good to bring at least a little bit of additional information here we will also be thinking about introducing a more about Kovan for those who are in career launch into coda coming up as well as an intro to career launch for those who are just starting from your launch and working into into F s and F – for those who are in F – so for many of you though small flashback to the PhD so coronavirus is one of the causes of the common cold and there are different types of coronavirus and and some of them are particularly more pathogenic and certainly hit more on the lower respiratory tract I show a picture of one of those here on the Left which is which has some of the standard structure of a corona virus this is actually from the New England Journal of Medicine in 2003 when we had SARS and so Sarris was also a corona virus and in fact it is very closely related to the current one which is called SARS coronavirus – I show the right picture here which is from a recent science article being able to say that this is a structure of of the corona virus the krona Byers – that is actually bound to its primary receptor to get into human cells which

is which is the ACE receptor – and it interacts with with a protease domain in there I showed this primarily to just say that there’s a lot of science going on this was done by Chinese researchers early on as the the epidemic was unfolding to say that you know there’s some druggable targets there people are working really hard to try to make some advances against this pandemic and there’s a reason people are working so this right now and that’s because of its magnitude so I for those who haven’t followed this is the Johns Hopkins website that real-time tracks cases as they are are being reported from different municipalities and countries and and in particular also I will mention someone did bring up to my attention after the first presentation there are by the way a couple of websites that are screenshotting this and putting this on their websites like coronavirus map dot-com or something that are actually malware sites another type of high risk but the idea is that the Hopkins website is is safe and I guess I’ll draw your attention here to the number in in the upper left which is one hundred and twenty six thousand cases confirmed and forty six hundred deaths and they sort of upper right this was in the lower left you’ll see this was from 11:30 last night which is when I was working on this talk and and then as I woke up and checked akin at 6:30 this morning we had already moved to one hundred and twenty seven point eight thousand total confirmed so by about fifteen hundred and the total deaths had actually gone up by almost a hundred and so that’s in the span of eight hours or so so just giving you a sense of how rapidly this is moving so so this is important this is an example of a good old epidemiologic curve and so looking at an outbreak and what actually happens the blue bars are the curve that pertains to what was happening in China itself and you can see that the disease there seems to be waning and that’s a great thing in no small part probably due to all of the measures that were put in place in China including things like social distancing and the bars in orange represent what’s happening everywhere else and you can tell there that we do not seem to be going down and is current as of yesterday so what’s happening here in the United States again I go to the CDC for most of their numbers to see see where we’re at and as most of you who’ve been following the news are aware the primary sites of activity and the where the disease has has really settled is in Washington State around Seattle in here in California and in New York and there are other cases that clearly have been reported and and there is human to human transmission going on in those states as well if we look at our epidemiologic curve in the United States it looks more like this do not be fooled by what you see after that sort of March second or third point there as the graph illustrates these are illnesses that began probably prior to this or after this time reported that they began before what happened they reported and will we will likely catch up with this over time so what do we know about the disease in terms of some of its effects and some of the other epidemiology much of what we know comes from the reporting that we had in China where they have had extensive experience with the disease and and so I just I’m showing a few graphs of this also generated primarily by Johns Hopkins looking first at the what is the spectrum of infection itself and luckily the majority of infections are mild again 80 percent or so or mild only about five percent requiring intensive care the bulk of people recover so that’s another good good sign again the 3.5 percent who don’t we’ll get to in a second in terms of risk factors for bad outcomes so for people who died the mortality rate is actually much higher for those who are advanced in age so clearly elevated for those who are over 60 over 70 over 80 and those with existing conditions so you know here specifically cardiovascular disease diabetes and chronic breast Kotori disease as examples of predisposing conditions for us for

mortality how contagious and deadly is this so if we put that in that kind of two-by-two so on the left is a graph where on the x axis you have the average number of people infected by each sick person that’s an R value there and and that speaks to how contagious viruses and on the y axis is the percent who died the case fatality rate and so if you look at this covin 19 or the SARS coronavirus 2 is not surprisingly not far from the original stars you can see there and from the Spanish flu itself so you can see it lies within that box and there’s an error bar there so on the right that’s because the case fatality rate actually depends on the country so again in China where there’s been a lot of experience here the case fatality rate seems to be around 3.9 percent in Italy which is currently having a huge outbreak the case fatality rate is up to six point two percent here in the United States it seems to be closer to the number found in China which is for us we point one percent but you can see again they’re depending on the number of cases the fatality rates have changed dramatically I mentioned Italy and for those who have not had a chance to see what’s going on there I would strongly encourage you to do some reading about that to see where things could be going in particular this is an article that was was posted yesterday by one of the writers in the Atlantic who is actually a medical ethicists and was his stationed in Italy and witnessing a lot of what’s going on there Italy had gone within the span of three weeks from 200 serious cases to 2002 now over 12,000 and and in particular it really is overwhelming their their health care system especially ICU beds ventilators etc and people are making very very difficult decisions about triaging and so I found that the the close of the article and the exportation was really was really important asking all of us here in the States the political leaders heads of business and private associations and everyone of us to work together to accomplish two things to radically expand the capacity of the country’s intensive care units and to start engaging in extreme forms of social distancing cancel everything in now the emphasis is the authors so that gets us to a little bit of why change and why do we need to do some of this again going back to what is now all over the internet Twitter and its own meme is the concept of the flattening of an epidemiologic curve so on the left is the is the standard model in the in red the usual epidemiologic curve you see a incidence or you see a number of cases being reported in a given time period and that Rises and then eventually falls as the outbreak ends and if we Institute mechanisms that decrease the forward transmission of infection something like social distancing that can flatten the curve and that’s shown in green which means that that that the number of cases being reported on in any one given period of time is lower than than if it had been left to its own devices and as a consequence that actually can also extend the time period over which an infection can happen there also is as shown here in blue the concept that if one lifts interventions such as removes social distancing there can be a resurgence and these are not just theoretical concepts shown on the right our actual epidemiologic curves related to social distancing interventions here in the United States during the Spanish flu in 1980 and if we look at Philadelphia where there was a delay of around five months or so before social distancing was employed you see through the standard peak whereas if you look at st. Louis where these social distancing measures were taken immediately you see that same concept of a flattening of that particular curve so and why is that important again it’s not the area under the curve it’s actually most important what’s most important is this blue line here the concept that the number of cases that comes out in a day which is in theory directly proportional to the number of severe cases that you would get in a day really can run up against the capacity of the healthcare system

and if you exceed the capacity of the healthcare system that’s when you get to see things like what’s happening in Italy right now and so so really our goal is to do everything we can to ensure that we do not overwhelm the healthcare system because that’s what we’re going to have to make some really really tough choices so summarizing why change number one this is a serious disease number two we are all at risk of infection understanding full well that we may have different risks of complications from this infection and for some those risks are are much lower but we are all at risk of infection and therefore risk of passing this forward and so for the safety of ourselves each other and for the greater community we should each and every one of us do what we can to stop the forward transmission of infection and our addition arm our individual and collective adherence to these kinds of measures can make a difference so I mentioned an R factor before I not to get to I D nerdy right but it’s pretty so but but that our number I talked about that that reproductive number we know is is influenced by different discrete factors including things like the number of contacts per day the more people you’re in contact with if you are infectious the more infections that can happen that’s where social distancing self quarantine come into play at the same time the probability of transmitting an infection per contact is a roll is is a factor here and that’s why in the hospital we do things like wearing our personal protective equipment or PPE we wash our hands because that decreases the chances that for any given contact that we will transmit the infection there’s also the infectious period that’s a factor here and we can do things there like contact tracing to decrease a latent period or starting timely treatment when treatment is a available and then there’s population susceptibility so our goal of course is to reduce population susceptibility and vaccination would be a great way to do that so so those are important important concepts there and we can make a difference by affecting that our number so back to the the curricular domain what are the changes going to be and I hope I’m sure many people have reached email fatigue there have been a lot of emails have been going around and we have certainly contributed to some of that I do hope that you get a chance to read read the emails that we’re sending there are some concepts contained within that and I will try to summarize as best I can what’s happening here so effective Monday this coming Monday March 16th all classroom and lab based instruction will move to remote or distance learning for all phases our patients and and members of the public including things like standardized patients who are on campus really only for our educational purposes that has been suspended again because we can’t really justify exposing patients and members of the public to a possible increased risk by coming to a health system when when they have no other reason except for our education essential activities so things like security exams so that includes for those who are on in f2 shelf exams and the like will still be happening on campus and that is permitted for groups less than 25 clinical activities again for those of you on f2 and career launch clinical activities remain there because you are essential members of those clinical teams you are providing care you will have the ability in fact to provide some types of care that members of your team will not be able to while they are attending to other things and it’s important to know that campus will remain open so though we are making these changes the curriculum is not shutting down the campus is not shutting in the curriculum continues cannabis will remain open resources are available extracurricular activities they’re organized here will be suspend and then what can what can we do so first is preparing for remote learning so there will be some things that you will be doing well they and many of you have been doing remote learning obviously a lot of people are used to seeing online lectures and things of that nature we will be trying some new things not just online lectures there may be more zoom meetings especially for small groups and things of that nature so just making sure that technology is up-to-date and reliable when you’re having a an important soom meeting is not the time to find out that wherever you’re at that

the internet is not as robust as you might hope practicing or dry running sessions first remember that remote learning in general can be more flexible but as many of you probably experienced when watching online videos it can be more time-consuming not everyone absorbs information quite the same way and that may not be the easiest way for some and so it can be more time-consuming remembering that process during meetings especially online when you’re having a zoom meeting is incredibly important as I’m sure many people have seen the YouTube videos and whatnot about the conference calls and things of that nature so again just focusing on process at a time like this especially in f1 but I think for everyone when there is an increased amount of activity that is happening remotely and you’re doing more social distancing it can be a little isolating so I would ask that you invest a little extra time in the check-in when you’re doing that with your small groups just check on each other see how everyone’s doing it’s it’s good to connect with people and and again zoom is not always the optimal way to to connect but it’s what we do have in some waves now and and so I would encourage you to lean into that and then take advantage of you know virtual office hours Q&A sessions things of that nature again most non-essential meetings have been moved to zoom type meetings and so and so taking advantage of virtual office hours or other things is a really good idea and then I had here is one of the shares so the information for those who were in f2 so FX + f2 which already had remote capabilities will now move to remote again so there will not be an in-person attendance option for that clerkship night actives are in between so we are going to give her chip directors the opportunity to if they have very small groups and have the ability to ensure that social distancing is appropriate and just so everyone is grounded in the same definitions here we are defining social distancing as basically arms with the part or approximately six feet apart from each other and that’s based on the fact that that this coronavirus like many others is spread primarily five droplets and those typically travel about a 3-foot radius around us so so six feet is considered to be pretty much more safe and so so if they can ensure that and ensure that the the premises are appropriately cleaned etc and up to CDC standards then then they can proceed with with their clerkship didactics I will tell you all now that that we may have to migrate to remote and or other pre-recorded sessions because if the if this pandemic continues to progress and take more time and an effort from our faculty they may be pulled to give time primarily to patient care so we will have to be flexible with and a reminder to to everyone here that you are not to be providing direct care for patients with known or suspected koban 19 for the career launch students again I think we primarily have 4b students here for those who are who are oh so close to to graduation there may be some 40 students here but for for those who are 4b remember that we will work with you if sites close on short notice so there are some sites already that have been overwhelmed by the number of number of patients presenting respiratory disease and have even started running short on personal protective equipment and so they have actually requested that no learners be in their environment and so and that can be an incredibly short notice so we will appreciate your flexibility up front and we will work with you the primary goal here is so that your graduation is not in jeopardy and so we will work very hard on that and I would ask that that you please be in touch on email including even after after match day for updates not only about match but other events that are happening as well we will have to take those as a as it goes but right now we are planning about a one month period out and so we’re updating that every week or two to see where we’re at and again as many of you who have been following the news have seen things can change really on a daily basis so at this point I will hand things over to Dean lose you to make

some more closing comments and then we will see if we can hear if not I’m going to turn it over to Dean can just make one observation that I think is helpful do you think about as you’re talking with your friends and family and colleagues the way we manage risk in the community in terms of infection is through social distancing so not only being three six feet away from everyone but also minimize your participation in big crowds you know staying away from anyone who’s sick the way we manage infections and contagion risk and the clinical environment is through infection control and so it’s it’s obviously when you think about it there’s no way that you can be three feet away from a patient you’re taking care of robotis of what their illness what the illnesses that they have that has landed in a hospital or in the clinic so so just be aware that as clinical students you are living in two different environments one where social distancing is is the way to go and the other where decreasing risk for infection control is the right way to do things and so without I’m gonna invite Sam is going to apparently help Dean King now so we will switch to the Q & A I just won’t make a couple just one comments one is we are very committed to making sure that your curriculum continues in the way that it needs to continue so that you develop this competencies we need you to have to be UCSF physicians that being said this is actually a situation where we will expect that there will be some glitches and we hope that everyone can understand people are working as hard as they can there your faculty your direct course directors to staff or trip directors so be a little bit forgiving and patient with us we’ll get it right please give us advice if you find some things that you think could be better the other thing I want you to realize is if the faculty who are teaching you are also working hard to keep our health systems functioning there’s an incredible surge of patients that we expect there will be more so they’re either actually providing care for patients themselves and extra patients in that or working to redesign our local institutional systems or our public health systems you may have seen some of them even on CNN and many of the media shows and working in the government so if you have the opportunity in the inclination acknowledging that you know this is a hard time for them that they’re working hard and you appreciate their engagement with you would be I think really priceless in terms of helping manage their morale it’s not your primary responsibility but if you have the time and effort to do that I think it would go a long way everyone needs to be supported in situations like this and the faculty are no different and then lastly as I said earlier this is a expected part of being a physician it doesn’t mean it’s easy so if you need some extra support please reach out to us through either email or through the student experience hotline contact us by email if you have concerns your ideas don’t hesitate to let us know what questions you have what support you need and what thoughts you have about how helping us and the others in the environment do the very best job we can with with your education so with that I’m going to turn it over to DQ is she ready to do some questions for us or exam I think you might be ready now okay I think we should go to the questions that are online I can see many of them I just wanted to add a couple comments in a way similar to Katherine doesn’t know it turns out I’m in that high-risk group so that means I’m pol and I’ve been in medicine for a long time and part my early part of my career I spent working with drug resistant TV we just spread basically very similar to the way this virus is spread one of the experiences I had in the 20 years I worked there was that none of the health care workers well in the 20 years I was there two health care workers got sick from tuberculosis this is what I was working with drug-resistant TB and the reason they got sick is because they did not they absolutely broke protocol and they were involved in the patients in ways that was inappropriate but everybody else who actually did what they’re supposed to do never contracted the disease and in fact my wife was a high school high school teacher and she because she converted her PPD and thankfully and all this time I never did and her exposure was to someone she didn’t know had TV in her class and because I was

working with TV and knowing it and expecting it and been doing all of the right things I think I was important to protect myself from that so my message to you is this is this is a serious problem you you have to now take it seriously it doesn’t it may at times not feel that way but as a medical expert you should you should take it seriously you should not panic cause panic is not useful and how do you get it people call people speaking to you directly they sneeze on you they spit on you they laugh in you’re within your area or they sing for example those are examples of how air drop with airborne droplets above or our air made airborne and the bars is in those air blowing droplets but most part those droplets will fall to the ground so if you stay three to six feet away certainly six feet away there’s also there’s virtually little chance except if you touch something now that was that someone to sneeze on and you put your hand to your face or mouth you can get it so practicing really good hygiene taking this very seriously and teaching others in your community to do it I think is is important the other thing I that I want to reiterate it if you get sick you are sick and you should assume you’re infected until otherwise the proven otherwise and we’ll talk later about testing the we are now beginning in the next day or so we will ramp up we are capable of ramping up to do a lot more testing the testing will be done on people who have the highest risk but but I think pretty soon we’ll be able to test more and more people so that if you are if you are certainly if you have any symptoms you will be able to get a test within a day so to prove whether you have it or not and the symptoms are fever and dry cough and fatigue you usually don’t usually don’t get everything but those things should actually make you make you worry that you may have it and you should just assume you do until you just proven otherwise so anyway I think that we are here to help you we realize that this is challenging and we should stay in as few locations as possible um if you know you know the social distancing is really important in places where it’s done rigorously the epidemic has diminished so so take that part take that part seriously but thank you all for all that you’re doing I know that this is trying this is a moving target we’re working as rapidly and can to address all your questions concerns and make sure that your education continues but thank you to Kazim Lucy and Dean Davis and the other people who have been working day and night to try to make sure that we do the best we can thank you to being Lucy and to Dean keen for being here and for comments and again thank you to all of you for for your patience for everything in these sort of uncertain times and remember we’re here reach out to us and let us know if there if there are questions or if there things we can do