Child Study Center Grand Rounds 01.04.2022

January 10, 2022

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Looking to 2022 and Beyond the Pandemic

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00:00So thanks everyone for joining and I am.
00:04I'm was really hoping that we could
00:06be together at least in hybrid mode,
00:08but I'm very glad that we can be together
00:11as we have learned our this time virtually.
00:16This is the beginning of our the new Year.
00:20None of our academic year,
00:21but the new year. So first,
00:24let me wish everyone a happy New Year and I
00:27really hope that you had a chance for some.
00:31Rest and relaxation in this this year.
00:35I know that last year,
00:36in December 2020, 2020,
00:40our holidays were much changed by COVID,
00:44so I do hope that you had a
00:46chance to be together.
00:47Perhaps this year with
00:48more family and friends.
00:50And that always this time the holiday
00:53break is always a time of reflection
00:56and sometimes resolutions and I'll
00:58return to that theme in a bit.
01:01But I'm just really glad that you're
01:02back and and hope that we could
01:05be in a in a more hybrid mode.
01:07But really glad that you're back.
01:10I think what none of us anticipated,
01:12quite frankly,
01:13is that where we would be is
01:17664 days since March the 12th.
01:21With the coronavirus with Covin 19
01:24really still dominating the new
01:27year and it's just important for
01:29us to acknowledge that that we are
01:32that we are back in a completely
01:34virtual mode for a few weeks.
01:36And that that this is a part of our reality.
01:40And it is also a part of reality
01:43that we are 664 days and I don't
01:46know if the counting has been helpful
01:49but but that's where we are.
01:52I wanted to begin today before talking
01:55about the department specifically,
01:58given that Omicron has so much
02:01dominated our last few weeks to give
02:05you just a sense of the current
02:08reality that we are in.
02:10And 1st to say that as of yesterday,
02:12as of yesterday and y'all,
02:13New Haven Hospital,
02:15just across the street from the department,
02:18the inpatient census was 338.
02:23And that was actually a dramatic
02:25increase from just a week ago a week ago.
02:27Monday, 143% increase.
02:32For a bit of context, on April 21st,
02:352020,
02:35when we were in the middle of the
02:38first surge, the first peak was at 450.
02:43In our second surge,
02:44the second peak was just a year ago
02:47on December the 8th and it was 241
02:50and we've already surpassed that.
02:53So this is a new and dramatic surge.
02:58The ICU and just the all New Haven
03:01Hospital is at 60 with 30 in
03:04intubated and on ventilators there's
03:06an 89% occupancy rate in Yale,
03:08New Haven which means that the
03:11hospital is actually extraordinarily
03:12stressed for beds and you're full which
03:15means that there are many patients
03:17sitting in the Ed waiting for beds.
03:19It's a tremendously high number
03:21and we are feeling that in the
03:23behavioral health world as well.
03:25And across the state,
03:27there are more than 800 patients hospitalized
03:30with about 70% of those unvaccinated.
03:35Now I'm going to show you one more
03:37reality and I understand that I'm really
03:39starting out with the kind that starkness.
03:42But I want the context in which we are,
03:45why we have gone virtual and why
03:48I'm a crime continues to haunt us.
03:52So the other current reality is
03:54that we are in vaccine plus booster
03:56plus mask are incredibly important,
03:58but we are seeing more breakthrough
04:01infections and so this graph
04:03right here is from Yale,
04:04New Haven Health and showing the
04:06rate of breakthrough infections.
04:08Now going around 20 to 25%,
04:11which was higher than before.
04:14On the other hand,
04:16the news is good in the sense that with
04:19vaccine plus booster it's a milder disease,
04:22but much more contagious.
04:25And then finally the positivity
04:26rate in our state is climbing.
04:28We are now about 20% as of yesterday
04:3421.5% sorry, we just go back a bit.
04:37So these are the stark realities
04:39of where we are in this moment.
04:41On January the 4th on why, again,
04:44we've gone to complete virtual.
04:46And one of the realities is that for a
04:48few more weeks than I would have hoped,
04:51and that I certainly would have
04:52hoped in 2022,
04:54we'll be dealing with continued uncertainty.
04:58I'm going to talk about how I'm very,
05:00very proud and the fact that we
05:02have all done this before and
05:04we're learning a lot of skills.
05:06And there is a bit of positivity
05:09in the landscape.
05:11Continue perhaps reasons for optimism that
05:14this particular surge won't last as long.
05:17That it's not as virulent.
05:19That we're increasing immunity
05:21across our communities and we have
05:24learned a tremendous amount which
05:26I'm going to continue to address.
05:29But that's the reality and why we're virtual,
05:32completely virtual,
05:32and why all of a sudden you're
05:35seeing more communications about
05:37Omicron coming from the department,
05:39and the various precautions
05:40that we need to take.
05:44We are as reality, though very
05:47likely going to move to an endemic.
05:50And I just want to make that point not
05:53so much from an infectious disease POV.
05:56But from a how we think about adapting to
05:59that and an endemic compared to a pandemic
06:02is that there is transmission still,
06:05but the number of cases remains relatively
06:08constant and present around the world.
06:10We're not there yet.
06:12We're still very much in pandemic stage.
06:15But there's no question.
06:16I think that COVID and many infectious
06:19disease experts talk about it,
06:21that COVID will be endemic,
06:23and it will be a part of our daily lives.
06:27And we will learn to adjust to it.
06:30So we will learn to live with COVID.
06:32We will learn to make adjustments.
06:34For example our workplace environment.
06:36We may have masks regularly
06:39wearing them in different settings.
06:41And I know currently we've changed
06:43some of them at or we the CDC and
06:46others have changed some of the
06:48mask requirements or suggestions,
06:49but will continue to be created
06:53in our mask wearing.
06:55It's likely that in public spaces we will
06:58continue to have masks and continue to
07:00think about how we are in public spaces,
07:03and very likely that there will continue
07:06to be this kind of push pull between
07:09variants and vaccines variants and vaccines.
07:12But coronavirus has really changed
07:14the way we work, and I suspect that
07:18that will be that will continue.
07:20And we'll talk about that a bit more.
07:22But remote work I think,
07:24will be a widely accepted across
07:27the world and across our community.
07:30Some of the advantages is it will
07:32actually help us find talent.
07:34We'll be able.
07:34Just as Kieran said,
07:36that he's been able to actually convert grand
07:38rounds over this next few weeks to virtual,
07:41and we'll have a speaker from London.
07:43We'll be able actually to access
07:45people in new and in new ways.
07:48Not so new 'cause it's been 600
07:51and however many days will continue
07:53to have virtual learning will even
07:55start to use virtual reality that
07:58will enhance our abilities to work.
08:00Across geographical locations and of course,
08:04telemedicine.
08:07But I want to also return to
08:10reflection to that third that third
08:13panel in my welcoming you back.
08:16And I have this quote here not
08:19actually to emphasize any particular
08:22religious tradition over the holiday
08:24break that we've just come through.
08:26But actually to the last
08:28phrase within this quote.
08:30It unveils the extraordinary
08:32that are hurried,
08:33our hurried and conceal and neglect.
08:37Because I think that's what has
08:39happened with the pandemic that we
08:41need to continue to remind ourselves.
08:44That we have lived and are living just as I
08:47began this talk deeply in reactionary mode.
08:52And in a hurried, pressured,
08:54stressed reactionary mode.
08:57And what that I think is
09:00the unintended effect.
09:01It's been very effective in many ways,
09:04but the unintended effect is it is not
09:07permitted us or sometimes concealed all
09:10the extraordinary things that everyone
09:13of you in this virtual room have done.
09:16You've cared for families,
09:18your own families.
09:20You care for the children coming to see us.
09:22You kept research programs going.
09:24You kept training programs going.
09:25We have been innovative.
09:27We have found new solutions and we have
09:31actually held together as a community
09:33and I'll continue to emphasize that.
09:36But I really hope that we regardless again
09:39of religious tradition but that we can
09:41take the spirit of this holiday break.
09:44To continue to reflect on the
09:47extraordinary that we have been through
09:50and that we are continuing to be in.
09:53And continuing to support one another in.
09:57I also want to return to
09:59the themes of September.
10:01It's only been a few months since
10:02September when we were actually talking
10:04about the state of the department then,
10:07and I wanted to remind you that in
10:10September we needed to acknowledge
10:12what we were going through while
10:15at the same time pushing forward.
10:17And in September we had a theme about
10:20acknowledging that there were many things
10:22going on in our hearts that were not
10:25necessarily expressly and explicitly stated.
10:27That is our collective loss
10:30that there have been many,
10:31many losses and not just to people,
10:34not just of loved ones and friends,
10:36but many losses for the
10:38department for our community,
10:39for the medical school to school,
10:41New Haven, and the nation,
10:43and the world.
10:44And that within that that we are
10:47in a collective continue to still
10:49be in a collective mourning,
10:51and everyone is extraordinarily tired.
10:55And I know that you are,
10:56and I know that we were even just
10:59before everyone got on virtually.
11:00Having extraordinarily long sighs of oh,
11:03not again. Didn't we do this in January 2021?
11:09But the other theme of September,
11:11which continues to be if not louder
11:14now as the importance of our coming
11:17together in the importance of gratitude.
11:20Gratitude for these moments together,
11:22whether they're virtual,
11:23hybrid,
11:24even those brief moments of in
11:27person waving across the room.
11:29The month that all the people that come
11:32into 350 George to support our practice.
11:34Security group that's there.
11:36That's everyone coming in to keep
11:38research. Going.
11:39Our gratitude for all that we're
11:42doing together. 'cause again,
11:44that is what holds us together.
11:47So it's really customary at this
11:49time in January to talk about
11:51the state of the department.
11:52So here's what I think the state of the
11:55department is and we can stop right there.
11:57But the state of the department
11:59is that we're doing well, though I
12:02think we're considerably stressed by COVID.
12:04We have some challenges.
12:06What I'll talk about,
12:07and we're in the midst of tremendous,
12:10tremendous change.
12:12Part of it brought on by COVID,
12:14part of it brought on by the change
12:16that we were already involved in when
12:18this pandemic in March 12th began.
12:22Customarily at this time one
12:24talks about accomplishments.
12:26You talk about the what I'm
12:29going to talk some about what,
12:31but I'm also going to talk
12:33about how and process,
12:34and I think some of that
12:36process that we're involved in,
12:37especially around culture and climate,
12:40that it is really important that
12:42we intend to. And again,
12:43it is a balance between the two.
12:47And so here's where we'll go.
12:50I want to do just a very
12:53short department snapshot.
12:54I want to touch touch a bit on
12:57carrying forward what I think we
12:59have learned during Kovid and what
13:01we need to continue to adapt to.
13:03To spend some time on the surge in
13:05mental health needs because that surge
13:06in child behavioral health needs is
13:08impacting every mission in this department,
13:11not just our clinical.
13:13It's impacting everything,
13:14climate and culture which
13:16relates to recruiting,
13:18developing and growing our our community.
13:21And then finally,
13:22where we're going.
13:23So that's in a nutshell,
13:25where we will go.
13:28So short department snapshots.
13:32Now some of these slides you have seen
13:34are some of you in different settings.
13:36Have seen one of the things I have
13:39actually learned not only during COVID,
13:41but over this course of time as as
13:44your chair is that communication,
13:47communication, communication that there
13:50is a virtue and repetition because it
13:52actually brings out additional points.
13:55But I want to remind you first about the
13:59structure of how we sit as a department.
14:02So we as the CHILD Study Center from
14:04one of the 19 clinical departments
14:06and the School of Medicine,
14:08the School of Medicine is in Yale University.
14:12But the other piece that also gives
14:14us another system within is that we
14:16our clinical practice is a part of
14:19the Yale Medicine clinical practice.
14:21Which is a part of the clinical
14:23efforts of the School of Medicine.
14:25So we are nested in that way,
14:28but we also have a relationship
14:30with the hospital,
14:31which is a totally different system,
14:34and the Yale New Haven Children's Hospital is
14:36a part of the Yale New Haven Health system.
14:38Across across the state of Connecticut.
14:41Two different systems.
14:43We collaborate.
14:44We care for patients in the hospital.
14:48We go back and forth.
14:49We do research.
14:50We have education, but two different systems,
14:53great advantages, great advantages to
14:55being a part of this large system.
14:58Great benefits.
14:58We could spend a lot of time talking about.
15:01The actual individual benefits
15:04are linked to resources,
15:06but it also has a constraint in some
15:08degrees of agreement of which decisions are.
15:12Hours in which decisions are
15:14a part of the system.
15:16Keep that in mind.
15:18And here is the state of the department
15:20in a glance in terms of who we are and
15:23and a number of you have seen this before,
15:25but I just want to keep
15:28emphasizing that we're big.
15:30We're about 520 people.
15:31If you if you include our voluntary
15:35faculty or community faculty as well.
15:38We are we are a large department and
15:41we were growing pretty rapidly pre
15:44COVID and are continuing to grow not
15:47so rapidly at this point as is true of
15:50every department across the medical school.
15:52You can see the distribution
15:54in terms of gender and race,
15:57but we are actually a pretty big department.
16:00One thing to call attention to here
16:03in terms of assistant associated
16:05full professors is that we are also
16:08a bit of an aging department and we
16:11need to work considerably on growing
16:13our number of assistant professors
16:15and many of our assistant professors
16:18are many of our clinical faculty
16:20are assistant professors and live
16:22in this 102 here.
16:26Financially,
16:26I'm not going to go through all of this,
16:28but I just want to give
16:29you a by the numbers link.
16:31Look at the department.
16:33Our annual budget is about
16:3546.1 million right here,
16:36but there is a difference.
16:38A delta here that's covered
16:41actually by Yale Medicine.
16:42We'll get to that in a bit.
16:46Everyone in our grant world has been
16:48extraordinarily busy and fiscal.
16:49Year 21, we had 120 proposals
16:53submitted and we have a number 172
16:55active awards across the department.
16:58Just think of them and I don't actually have
17:01to remind you of the amount of work that
17:04that reflects on all levels of individual.
17:07Principal investigators,
17:08your teams our business office.
17:11Everyone looking at our annual
17:14buildings and patient care,
17:16you can see the the between the inpatient our
17:19hospital based services and our outpatient.
17:22We bill about 13 million.
17:25But you look at what we collect.
17:28And not going to perseverate on that.
17:31Many of you have heard me say before
17:33that that delta has nothing to do
17:36with the considerable amount of
17:38effort that people are putting in,
17:40but has to do with the structural
17:43nature of behavioral health and the
17:45reimbursement will come back to that.
17:48And then you see here the volume of patients.
17:50Then this number will actually
17:51be higher now if we bring in the
17:54current or the current months,
17:55I'll show you a bit more about that,
17:57but we do. A tremendous amount of work.
18:01And if you're curious about these,
18:03this particular age range or
18:05this particular length of stay,
18:07so we have a tradition actually
18:09of caring for families,
18:10especially families with developmental
18:12disabilities well into adulthood,
18:14and for following them across the lifespan.
18:19Sources of income for the department.
18:21I just want to show you this again
18:24to remind you that nearly 1/4 of
18:27our actual revenue that we very much
18:29depend on is from Gibson Endowments,
18:32so that's why we focus so much on our
18:35child Study Center Associates and on
18:38on bringing in and being sure that
18:40we are good stewards to the donors
18:42of the department and then nearly
18:4560% from our grants and contracts.
18:48One other kind of financial piece
18:51just to show you.
18:53Is the finances by mission now
18:55a number of you have heard this,
18:56but I can't emphasize it enough.
18:59That, in contrast to every
19:01other clinical department.
19:02We actually cover our education and
19:06research missions through our endowments,
19:09our grants, our gifts.
19:10Every other department does
19:12it in the reverse,
19:13the clinical revenue goes to support that,
19:16but the nature of behavioral health
19:18means that that's not possible.
19:20So far in the clinical side,
19:22we have a 7.1 million unfunded gap
19:25that is supported by Yale Medicine,
19:29and 90% of those expenses
19:32are made up of salaries.
19:35So it's really important this is
19:38actually the structural issue in
19:41behavioral health that I want to
19:43continue to bring everyone into in
19:45your roles as members of the faculty.
19:47Your roles is in training with us as
19:50our members of our Community and as
19:52members of the greater community,
19:54and to help you be advocates for this issue.
20:01So let's go forward to carrying forward
20:04what we've learned during copin.
20:07Just to to talk about that briefly.
20:111st, I'm actually not going to talk
20:14about the various technical things.
20:16I'm gonna talk about what
20:17we have actually learned.
20:18I think from these 22 months psychologically.
20:22No surprise that we've learned
20:24that things change unexpectedly,
20:26just like in the last few weeks.
20:29But I can't emphasize enough.
20:32But we've also learned that as a community,
20:34we're adaptable and we can be flexible.
20:37Back to that quote that I
20:40gave you from from about the.
20:42Her edness keeping us from talking
20:45or seeing the extraordinary.
20:47There's been an extraordinary examples of
20:50tremendous adaptability across our missions,
20:52and by education and research on the
20:55clinical through all of this and
20:57enormous flexibility peeping at people,
20:59being able to turn on a dime to do what
21:02they have are here and committed to doing.
21:05I think we should celebrate that,
21:07but I also think we need to be reflective
21:09of what made it possible for us to do that.
21:12So that we don't lose that capacity
21:14when we come back, whatever,
21:17come back means.
21:19I think we've learned also that we need
21:22to be extraordinarily intentional about
21:23holding our community together as strong
21:26as our Community as a department was,
21:29it does not stay together when
21:31we are simply apart and virtual.
21:33And with this degree of stress.
21:36It takes intentionality and I again
21:39celebrate and I'm grateful for how many
21:42good ideas have come out to actually
21:44hold us together from small gatherings
21:47when we can gather to tusum book hours,
21:512 coffees zoom,
21:53we need to be intentional to
21:54continue to hold us together.
21:58We've also learned that we can actually
22:00be accepting and we can work together
22:03to make change to move forward even when
22:05we're in the middle of uncertainty.
22:07But we need to again think
22:10about how we've done that.
22:12And what we've learned is that we people
22:15have learned to work in different ways.
22:18They've learned the possibilities
22:19of working from home,
22:21so we now need going forward to
22:24understand and accept individual needs.
22:26While at the same time having
22:29expectations and best practices
22:31that we can share as a community.
22:33And finally,
22:34we can absolutely never communicate enough.
22:37As I said earlier, I was.
22:38I was learning this before,
22:40but I have learned this tremendously
22:43that we have a tremendous amount to say.
22:46There's always more to say,
22:47and there is tremendous virtue in
22:50repeating it across different modalities.
22:55So what do I think our new working
22:57environment will look like?
22:58Best is a crystal ball, can tell is.
23:00I think we will likely once we get past all
23:04mycron I'll continue the hybrid grand rounds.
23:07There are tremendous advantages to this
23:09'cause we can invite speakers from all
23:11over the world who can join us remotely.
23:14Easier for them cost effective,
23:17tremendous ways of sharing ideas.
23:21I think we'll actually start to use virtual
23:24interviews for faculty and fellows,
23:26which which actually levels the playing
23:28field in case someone either can't
23:30afford to come or the cost is just
23:33too high to bring them for interviews.
23:35Initial virtual interviews truly
23:38levels the playing field.
23:40I think we'll continue to use the
23:42virtual platform for faculty meetings,
23:44but be smart about it and so
23:46it's more participatory.
23:47Obviously hybrid Tele health.
23:49And I hope that people across
23:52your various groups will also can
23:54begin to use hybrid participation,
23:57even when we can be in person and
23:59again be really smart about how
24:02to make everyone feel included.
24:04And finally we need to have be very
24:06thoughtful about work schedules that
24:08allow some time for working from home.
24:10The world has changed and that
24:13is where we are.
24:15And to the point of communication,
24:17I just really need to celebrate and
24:19talk really gratefully to our new.
24:22Let me emphasize full-time
24:24communications officer Krista Krista
24:27hit the ground running in November.
24:30I'm sure for Krista it feels
24:32like it's been a Millennium,
24:34but it's been a wonderful two months,
24:36and Krista has already, as you know,
24:38very much up the game of the insider.
24:41And it's coming out regularly
24:42has put out an associates.
24:44Newsletter is building a
24:47communication strategy.
24:48A regular communications calendar,
24:50and is very open to input from everyone,
24:53but I think Krista Krista's presence
24:55is going to greatly add to a number
24:57of these things that I'm going to
24:59talk about later, but just has truly,
25:02truly already shifted the gain in these
25:04two months. So thank you, Krista.
25:09But to use a metaphor,
25:11we are in a continually evolving situation.
25:13Just just recently, Dean Brown in a
25:17meeting with the chairs was talking
25:19about how this metaphor was one that
25:22she had come to not like at all.
25:24But it is the fact of our reality
25:26and I just want to remind us though
25:29about our capacity for adapting and
25:31flexibility and staying in touch
25:33because we are in an evolving situation.
25:39So let's turn to the behavioral health surge.
25:42And in many ways this graphic
25:45does not accurately represent it,
25:46because it suggests that a physical
25:48health crisis ends in wave one.
25:50You have an economic crisis and
25:52then a mental health crisis.
25:54This would actually be better represented
25:56by waves that are the lighter blue
25:58is still with the darker blue.
26:00'cause obviously we're in
26:02different surges from the virus.
26:04But it is true that this particular
26:08pandemic has not caused a surge
26:11or this behavioral health surge,
26:13although it certainly has
26:15added tremendous stress,
26:16but that we are in the middle of if you will,
26:19a mental health be child
26:21behavioral health pandemic.
26:23So let me just give you some information.
26:29Reports of this started even well over
26:32now a year ago in the summer of 2021,
26:37and these are just a few of the
26:39headlines that Amanda Lowell gather.
26:41But it's been as you know,
26:44the American Academy of Pediatrics.
26:47American Academy of Pediatrics
26:49and our own society.
26:52A camp has declared a national emergency
26:55in child and adolescent mental health.
26:58Noting, as did the surgeon General recently,
27:01noting that there are
27:03increasing numbers of cases,
27:05there's increasing need
27:07and a workforce shortage.
27:09And just in the last week and actually
27:12just this morning and the New York Times,
27:152 editorials on not only children's
27:19behavioral health needs,
27:21but the tremendous tremendous stresses
27:23that families across the country
27:26are experiencing and what people are
27:29calling a crisis for American children.
27:32Now let me say one thing about this kind
27:34of reporting and those kind of data.
27:36And then I'll show you data from us locally.
27:40Creating a sense of urgency by these kinds
27:43of headlines is only as effective as if,
27:46as when we propose solutions to it.
27:50So I am incredibly pleased that this
27:54has been gaining national attention
27:56and people are talking about this,
27:58and it is now.
28:00It is now a headline issue that there
28:02is a child behavioral health crisis.
28:05But I would say that there was a child
28:08behavioral health crisis before the pandemic.
28:11There was already a fractured
28:13delivery system before the pandemic.
28:15And what the pandemic has shown
28:18is how fractured it is,
28:19and we're creating a sense of urgency
28:22now about that great framing strategy.
28:24But the thing that has to go hand
28:27in hand is to create solutions,
28:29and that's what I hope that is our
28:31responsibility, and we do well.
28:34What does it look like for us?
28:37So these actually are this.
28:38These are data from Aaron who
28:40actually show our requests for
28:42clinical services from July 2019.
28:45So about a little more than six months
28:47before the pandemic before we went out
28:50and March to the end of November 2021.
28:54And I want you to note right
28:57here in January 20. This peak.
29:00So referrals for some unexplainable reason
29:03had a peak right there in January 2020.
29:06I don't think it's so inexplicable.
29:08I think things were starting to
29:10to go on the upswing for a whole
29:13host of non pandemic reasons.
29:15Then here's the pandemic tremendous drop.
29:18And then you can see the steady
29:21steady increase ever since.
29:23So basically at this point we take.
29:26This is the that January peak
29:28showing you that something was
29:30happening before the pandemic.
29:32But if you look now with pre
29:34pandemic way out here in 1819 we
29:37had about 150 referrals per month.
29:41Now we're averaging about 250 referrals
29:44per month, and that's an average.
29:47So there are months where that's more peaked.
29:50Make sure your data from our
29:53hospital side of things now.
29:55Our hospital colleagues operate on a
29:57fiscal year that begins in October.
30:00So these data from 2022 is fiscal year
30:032022, starting in October 2021
30:07and basically covering 3 months.
30:10That's what you want to hold in mind.
30:142022, three months compared to right here.
30:172021 a full fiscal year.
30:19And three months in the Ed and
30:22I short presentation here,
30:24a fiscal year 2022.
30:26There's already been 600 visits
30:28for child behavioral health needs.
30:31There have been 239 and
30:33missions in that period of time,
30:36and these borders means the number
30:39of children sitting in the Ed waiting
30:42for a bed waiting for admission.
30:44And just look at the difference
30:46here between 2021-2022.
30:50And the number of hours that
30:52those children have been sitting
30:55waiting cumulatively.
30:56I will add the lighter to show
30:59UED visits and the light light
31:02blue line is October,
31:03November,
31:04December so you can see this
31:06peak compared to the other years
31:09and then in missions right here.
31:14So this has been a tremendous,
31:17tremendous behavioral health surge.
31:18But the other point at the bottom of
31:21the slide is again borders border hours.
31:24If you take those as a proxy of need,
31:26have really been on the
31:28rise since fiscal year 17.
31:30But the pandemic has.
31:32Perhaps widen the fracture,
31:35but certainly shown us the fracture.
31:38And those are the two points I wanted
31:40that I already called your attention to.
31:43So what we're seeing is referrals or
31:46dramatically increasing across services.
31:48There's an increase in anxiety,
31:50depression, suicidal ideations,
31:52eating disorders.
31:54There's a tremendously greater severity that
31:56requires more intensive and longer treatment,
31:58so it's not just that there's more children,
32:00they're actually sicker.
32:02They need more help,
32:04so they're staying in treatment longer.
32:07Then there's fewer programs that
32:09are available if you think about
32:11continuum of care and getting
32:12children back into the community.
32:14And there's a huge workforce shortage.
32:17So it looks like this increased referrals,
32:19greater severity, longer time,
32:21and treatment,
32:22fewer openings longer wait time
32:24than the system becomes backlogged.
32:27Which is exactly what we're what,
32:29not only we are seeing,
32:31but you are all experiencing.
32:36So it's a behavioralhealth
32:38kind of perfect storm.
32:40And how do we do it?
32:41How are we meeting this surge?
32:42We're trying to add resources
32:44to the emergency room
32:45restricting our catchment areas.
32:47Working with Yale Medicine and Yale
32:49New Haven for additional support,
32:51but also advocating with our
32:53state colleagues to think
32:55about a continuum of care.
32:57More support on the prevention
32:59side for pediatricians for school
33:02based services as well as support
33:04for intensive outpatient programs.
33:06And outpatient services,
33:08and also how do we develop
33:10this workforce in a way that
33:13is sustainable and all entices
33:14people to come into the field.
33:20If you're going to be talking to anyone
33:23really, even your colleagues in the center,
33:26your colleagues in the School of Medicine,
33:28your neighbors here are some key
33:30points that I want you to keep in mind.
33:33This is not a single solution.
33:36This is not a.
33:38More beds, more emergency services.
33:41More acts. This is a continuum.
33:44Think about how children get into the system.
33:47And think about how they get out
33:49of the system and the system.
33:50In this case, is all the services
33:53that we provide here in the middle.
33:55Think about it as a continuum and continue
33:58to advocate that it is a continuum.
34:01The second point to make.
34:03If you were going to do it is that's
34:05the one I've already been making.
34:06Is that behavioral health referrals
34:08were already on the rise?
34:10This is not a simple pandemic caused issue.
34:14That this tremendous stresses of the pandemic
34:17certainly have highlighted the issue,
34:19but they were already on the rise.
34:22And perhaps one point
34:24that is maybe more subtle.
34:26Is that workforce shortages are just much
34:29more than getting more people to the field.
34:31They're actually about making a field
34:33that is better reimbursed for services.
34:35So remember that that we build nearly
34:3913 million and we collect about 6.
34:43That's a structural built-in issue about
34:46reimbursement for child behavioral health.
34:48Which makes it really hard.
34:51Unless you're a part of that nested
34:53system that I showed you really hard
34:56to build and sustain a practice.
34:58Parody for support for behavioral health
35:00services is what we need to be pushing.
35:05So let me go back to this point
35:07that I showed you and let me just
35:09actually show you the reality here.
35:11Not to be depressing.
35:12But that for each dollar of clinical revenue
35:15and a number of you have seen this before.
35:18It cost us a dollar and a half
35:21and expenses because again,
35:22of the low reimbursement rates.
35:26So here's a metaphor for you to use.
35:28Let me let me just pause right here though.
35:31Is that what?
35:32We've increasing the clinical
35:34volume is not the answer.
35:35Regulating it,
35:36and all these things are things we're doing.
35:39Working on philanthropy.
35:40Trying to increase the self pay.
35:43Working toward more contracts.
35:45Advocating with our health system and
35:47Yale Medicine colleagues for more.
35:49Support all of those things.
35:51But here's some metaphor.
35:54And this is the metaphor that
35:55I want you to think about,
35:57that I want us to be able to use.
35:59So if you think about the
36:00bucket of needs over here,
36:01and you think about a A balance
36:04beam with a fulcrum in the middle,
36:06the child behavioral health
36:07and family needs are huge,
36:09and they're pulling that weight
36:11down and they come from a whole
36:14host of issues and resources.
36:15Don't meet the needs,
36:17and so there's an imbalance.
36:20One solution is obviously to do prevention.
36:24To decrease that light blue bucket by
36:27access mental health school based programs,
36:30controlling the waitlist
36:32controlling catchment.
36:33The latter, I would say,
36:34is a reactionary solution.
36:36The top one is a more sustained 1.
36:40The other is to increase the
36:42resources so you again try to bring
36:44it a bit more balanced and you
36:46increase the resources by having
36:48number of people delivering care,
36:49increasing the funding networks
36:52and contracts. With the 3rd way.
36:55The 3rd way where we as a department
36:58can make a huge difference
37:00is to move the fulcrum.
37:04And when you move the fulcrum,
37:05you do things like thinking
37:07about different payer models.
37:08You link physical and child,
37:10be physical and behavioral health
37:11so that you're talking about one.
37:13You talk about parity,
37:15you invest in a continuum of services,
37:17and then when you move the fulcrum.
37:20You can do a lot more with actually the
37:22same potentially resources that you have.
37:27So that is actually the reason that
37:29we are engaged with a number of.
37:30You have participated already in this
37:33consultation around with Wellspring
37:34Consulting around building a child.
37:36Behavioral Health policy consortium.
37:40And we're asking Wellspring to
37:41help us talk about how we can bring
37:44individuals across the university
37:45that are folks on child behavioral
37:48health around this hub idea.
37:49How can we more effectively disseminate what
37:53we know to actually work collaboratively
37:56with policymakers and with agencies to
37:58impact the delivery of these services?
38:00How can we use ourselves and our
38:03resources to move the fulcrum?
38:05And that is what we need to do.
38:10But at the same time,
38:11with all of those data that I've
38:12showed you about where we're at
38:13in the behavioral health search,
38:14who I most also concerned about,
38:16besides the families coming
38:18to us is us is all of you.
38:21And these are data that look about health
38:24care workers that includes behavioral
38:26health and what they report now about
38:29their own health in the pandemic.
38:33And you can see that nearly
38:34half in a national survey.
38:37Nearly half report that their
38:39mental health has gotten worse.
38:41And a third report.
38:43These other impacts on other aspects of
38:46physical health, work, life, finances, etc.
38:49So that worries me a lot.
38:53Which brings me then to culture and climate.
38:55And how do we begin to address our
38:58climate and our department culture?
39:00How do we begin to address
39:02even more intentionally?
39:03What makes us us?
39:05And we've done a lot of talking
39:07about purposes and values,
39:08but I want to highlight
39:10these two things in red.
39:12That how do we begin to even more
39:15in the and the words that all
39:17of us say whatever programs were
39:20leading to exemplify the values
39:22that we have for this culture?
39:25And how do we put into place
39:27some organizational practices
39:29and processes that will help us
39:31actually move the culture forward?
39:35So I'm very grateful to Tara
39:36for for creating this slide.
39:38In developing this slide.
39:39This is totally her work and
39:42the work of her committee,
39:43but showing us that culture
39:45change is a process.
39:47It's a process that we are starting
39:49some work and rest restorative practice
39:53with our colleague Jasmine Davis
39:54whom you've had a chance to meet.
39:56We're starting work around racial
39:58equity training with Ingrid Kennedy and
40:01the search team and that this kind of work.
40:04Actually begins to create us as a
40:06professional learning community
40:07that we are learning from each
40:09other and we are making changes,
40:10learning how those changes
40:12work that leads us to change,
40:14which then gets us back into more training.
40:17What is really,
40:18really important about this besides
40:20the fact that this represents a
40:22tremendous amount of work by Tara
40:24and her team and and everyone else?
40:27But what's really important is
40:29that we need engagement in this
40:32activity and these activities across.
40:34All the departments. This is our culture.
40:37This is our community.
40:40And we all need to be engaged in this
40:43change as a part we're all weary.
40:45We're all impacting the pandemic.
40:48This is important change for
40:50us to be involved in.
40:52So here's some upcoming events,
40:55again with Ingrid and her team.
40:56Just so you have those dates.
40:58And in the spirit of communicate,
41:00communicate, communicate,
41:00we will send these dates out for everyone.
41:04But just so you have them,
41:05you can see there's one coming up in January,
41:07then February and April and May.
41:10But again,
41:11we are need this together and
41:13we need full participation.
41:15Engagement is a key part of
41:18citizenship of this community,
41:19and our annual appraisal of
41:21how we're doing together.
41:23And I would just underscore
41:25that by our participation.
41:26We also send a message among
41:28all of us I support for the
41:30culture we want to build.
41:35Then there's an equity issue that
41:36I feel strongly about that we have
41:38to address in this upcoming year,
41:39and I hope that sooner in the year
41:42than later that we need to address
41:44the great inequity in our masters
41:47level and APRN clinicians in their
41:49starting salaries and in salaries that
41:51reflect their experience in the amount
41:54of time that they've been with us.
41:55So I'm in regular conversations
41:57with our Yale Medicine and Yale
42:00Hospital colleagues about doing
42:01that is high high priority.
42:03For me and continuing to work also on
42:06advocating for ways that same clinicians
42:10can progress academically as faculty.
42:15I wanna apart began culture change is
42:18continuing to think about how we develop.
42:20We recruit, we retain our faculty and how
42:24we do all of this together more seamlessly.
42:27And again, terrorist group is working
42:29on a number of components of this,
42:31but I just want to highlight a few.
42:35So one and our search is going forward.
42:38We're going to announce all positions
42:40or even internal opportunities
42:42for new responsibilities,
42:44and I hope you've noticed that we're trying
42:46to do that on the website more consistently,
42:49but we'll be very vigilant now that we have
42:51our new full-time communications officer.
42:53Did I mention Christmas presents?
42:56And then for new jobs we'll have
42:58postings and sites that I hope will
43:01reach more diverse candidates.
43:02We're working with Dean Lattimore.
43:04A standard interview review process,
43:07and, as I mentioned earlier,
43:08virtual options to improve people's
43:10ability to come for interviews.
43:13Unconscious bias training for everybody
43:16that participates in searches.
43:18And then in the spirit of being
43:20a learning community to try and
43:21learn from best practices,
43:22not only are at Yale,
43:24but in other places,
43:25and we're putting this in place.
43:27Some of these changes in the current
43:30internal search for new social work,
43:32direct training director position.
43:36Several areas of growth and recruitment that,
43:39while that we're that are happening,
43:41uh, largely because some of them,
43:42largely because of again pandemic
43:45and with a new physician scientist,
43:47office at Yale or clinician
43:48scientist in the medical school.
43:50We now have the opportunity to build
43:53up our cadre of clinician scientists.
43:55We're continuing to grow our embedded
43:58pediatric psychology program with Pediatrics,
44:01so making for more better delivery
44:03of services in pediatric in
44:06the context of pediatric care.
44:08As you saw from our hospital
44:10growth and behavioral health,
44:11we need to increase the depth of our
44:14hospital child behavioral health team.
44:17Eating disorders have dramatically
44:19increased with this on behavioral
44:21health surge and our hospital
44:23colleagues now are committed to
44:24building an eating disorders program,
44:26and I'm very pleased that Rebecca
44:28Comedy has brought her expertise
44:30and will help build that.
44:32And then finally,
44:33we're starting to see a freeze our
44:36run by thawing rather a thawing of
44:39the freeze on faculty positions,
44:41and clinically and opening up
44:44for replacing those positions.
44:46I've given a fair amount of
44:48sad news with the pandemic,
44:49so I just actually want to
44:51give you one bit of good news.
44:53And that is through our Yale Child Study
44:55Center Collaborative with scholastic,
44:57scholastic,
44:57and our partnership with Scholastic.
45:00They have very good relationships with
45:02the now outgoing First Lady of New York,
45:05Chirlane McCray.
45:05And Charlene did a tremendous
45:07amount of work on behavioral
45:09health delivery in schools in New
45:11York City on through her program.
45:14Thrive NYC.
45:16And so it's plastic has made a
45:18partnership with Charlene and Charlene
45:19will be coming to do some work in
45:21the collaborative beginning in March.
45:24I'm very looking very much forward
45:26to learning from her seeing what she
45:28did in New York and we we can borrow
45:31innovative ideas and she will also
45:33be working with Dean Latimore around
45:35some of his efforts in diversity,
45:37equity and inclusion.
45:41There are additional efforts though that I
45:43want to really point out around performing,
45:45assessing, developing and deploying.
45:49So here's from HANA.
45:51Darren Davids work on on creating a number
45:56of courses that I hope people will take
46:00advantage of around leadership development.
46:02Our leadership from the beginning
46:04course we are running again in January.
46:06Very grateful about pure coaching
46:08groups and grateful that four members
46:11of our faculty have now stepped up
46:13to be pure coaches to actually help
46:16people in development around these.
46:17These areas listed on the slide.
46:20We will have some career development
46:23workshops beginning in the spring
46:25around grant writing about negotiation,
46:27some aspects of leading.
46:30And then Barron is available for
46:33ongoing consultation and support.
46:34Again about lab development etc
46:37and just always to remind people
46:40about the Faculty Support fund.
46:43We'll have more leadership
46:45workshop opportunities.
46:46This has become a topic of
46:47discussion in the faculty meetings,
46:49and I'm hoping that in by the spring,
46:50if not a little earlier.
46:52We'll have some workshops on building
46:54a shared understanding of leadership
46:56styles and effective approaches.
46:58And for methods for defining
47:01our responsibilities and how we
47:03then talk about accountability.
47:05And finding and developing more
47:08opportunities for leadership
47:09across the department.
47:11Not just in this kind of hierarchical sense,
47:13but across the department.
47:17And this is something we
47:18brought up in September.
47:20The difference between
47:21mentorship and sponsorship.
47:23And I would just highlight that Tara's
47:25team again is working to really build
47:28out our mentoring and sponsoring plans.
47:30As is Dean Lattimore's office.
47:33And to emphasize that everybody,
47:35all of us have a responsibility
47:38for sponsorship for finding the
47:41career opportunities to help our
47:43colleagues in this Community.
47:45Just paying attention to time.
47:48I think what I'm going to do.
47:52I'm going to make one point about
47:54this slide and that is that there are
47:57a number of things that we need to
47:59be doing about improving onboarding.
48:01Again, Terrace Team is working on it.
48:05But I want to make .2 points right
48:08here on the last two bullets.
48:10Routine exit interviews are fine.
48:12I just would hope that we never have
48:14to do exit interviews 'cause I want
48:16to retain people, not have them leave.
48:19But we get into the practice,
48:21not just during annual assessments,
48:23but get into the practice of
48:24what we call stay interviews,
48:26what they eat with,
48:27what does everyone need to meet,
48:29the goals you have for being
48:30a member of this Community,
48:32whether it's your research goals?
48:34It's your clinical goals.
48:35What do you need?
48:36We shouldn't learn about that
48:38at the time of an exit.
48:40We should be thinking about it
48:42proactively as we go forward.
48:44And to that, how do we bring resources
48:47together to facilitate success?
48:48So I'm very grateful to Tom.
48:51I'll show you just this one
48:53example that Tom Fernandez brought
48:55together as many of you know,
48:57our researchers to ask what might they
49:00need to actually make their work better?
49:04More successful.
49:06And some of the things that came
49:08out are things that we can do.
49:09We can create a grant library.
49:11We can create a library of
49:14of sample IRB protocols.
49:16We can actually create a
49:18shared recruitment process.
49:19We just need to think through
49:21how how that would work best.
49:23There were some very innovative
49:25ideas about sharing lab equipment
49:28so that that one piece could be
49:30shared across data management.
49:32Can we actually share data
49:35processing data data folks?
49:37Can we create shared resources that unite?
49:40Our research groups,
49:41but at the same time just strengthen and
49:44allow people to do the work they need to do.
49:46So this is the kind of thing that
49:48we have in mind when I talk about
49:51sharing and and how we create
49:54these kinds of ways of uniting us.
49:58I'm gonna skip that and I'm actually
50:01gonna just briefly focus on this.
50:03That what you're going to be
50:05hearing over the next few weeks is
50:07bringing together some work groups,
50:10and I wanted to hand to highlight
50:12the difference between a standing
50:14committee and a work group.
50:16Work groups will be brought together
50:18to handle very specific issues.
50:19Disband their submit to work
50:22efficiently to provide an actionable
50:25plan that we can work on,
50:27and three of those will be
50:28around strategic goals.
50:29Onboarding, mentoring,
50:31and annual assessments,
50:33and stay tuned for more about that.
50:35But we're going to start using
50:37this work group strategy or
50:39ad hoc committee strategy.
50:42And I want to just conclude in the last
50:45few minutes just to briefly talk about
50:47how we update our strategic goals.
50:50So this just is a pretty I hope familiar
50:54kind of triangle about strategy and
50:57vision at the top mission values,
50:59goals and we've been working
51:01a lot in this blue box.
51:04We have our clearly our mission
51:06statement might need to be updated.
51:08Don't know, but we've been working
51:10a lot in this blue box as we think
51:13about what are the projects and
51:15strategic goal areas that we have.
51:19And these have been the ones for
51:20the last few years that we've had
51:23stress and development stress and
51:24its impact on ongoing development.
51:26And we've had strategic recruits
51:29in this area.
51:30Child behavioral health services.
51:31This is why we had the integrated
51:34practice at 3:50.
51:35George the the blue one here is quite
51:38frankly why we're in the middle of
51:42the consultation with Wellspring.
51:44But as she may remember from the faculty
51:46meeting a few back in late summer,
51:49we actually started talking about this
51:52before about how do we refresh it?
51:56And here are some of the ideas that
51:58came out and the ones with with
52:00Red Stars beside them are ones
52:01that actually were putting into
52:03place in one way or another,
52:05and that are actually already starting.
52:09And some of those ideas were programmatic,
52:11some were operational and
52:13some were cultural climate.
52:15But one of the things that was actually
52:18quite missing from this was more focused
52:20on what directions do we want to take.
52:23Some of our basic science research efforts.
52:27So to that I've asked Tom to put
52:30together one of these workgroups.
52:32To really focus on what are the
52:35strategic areas or goals in our research,
52:37what are the gaps?
52:39What are the things we need to strengthen
52:41and to report back to us in March?
52:44And we'll have parallel work groups on
52:46education in our clinical missions.
52:48And as we hear more from Wellspring,
52:50we'll probably have a work group on
52:52how we put all of that into place.
52:57I've said a lot.
52:59And what I want to do to conclude though.
53:04And is with a return to gratitude
53:07and thoughts about leading teams
53:09and service and stewardship.
53:12We've been through a lot and
53:14we're going through even more.
53:16And we will come out the other side.
53:20I can't express enough my gratitude
53:22to everyone in this virtual room to
53:24everyone that's not here at the time.
53:26I can't express my grant enough.
53:28My gratitude to all of you.
53:30For not just what you have done the what
53:34you've done, but how you've done it.
53:37You've done it with grace.
53:39You've done it with tremendous generosity
53:42and caring for not just the families,
53:45but for your colleagues.
53:47And I have seen great professionalism.
53:50I know we're going to come
53:52through this current surge.
53:53We've done it before.
53:54We've been adaptable and flexible and
53:56know we will will come through a bit more.
53:58Weary perhaps,
53:59but we will come through as a community
54:02working together to help others.
54:05And I thank you very much for that.
54:08I would also say that I am
54:11tremendously honored to be your chair.
54:13But I would want to emphasize that I
54:16don't do this work as your chair alone.
54:19We've discarded this discussions in the
54:21faculty meeting about the infrastructure
54:22of our department and organizational charts,
54:25etc.
54:25But what I really want to say is that I
54:29actually have a team that works side by side.
54:33And they helped me do the job and all of you
54:36in this virtual room helped me do this job.
54:39All of you,
54:41we're all working together.
54:43And we will focus on the organizational
54:45details in our future faculty meetings.
54:47We will focus on organizational
54:49details for the department.
54:51But I just want to say that I'm very grateful
54:53to this team for all the responsibility
54:56that they shoulder and working with me.
54:59And then to the final point,
55:00I want to make is about
55:03service and stewardship.
55:05We've also started in faculty meetings,
55:06discussions of different models
55:08of leadership and how we how we
55:11move from a very top down model.
55:14A very hierarchical model to one
55:16where the leader and the leaders
55:18serve the good of the team.
55:20The good of the community,
55:21and they're always thinking about
55:23how to steward all of our resources,
55:26our human resources,
55:28our financial resources,
55:29everything to steward it for the
55:31future and the next generation
55:33that will come after us.
55:35So that we can help everyone thrive.
55:38We're going to continue to
55:39build out that idea,
55:40and the faculty and we'll dive
55:42deeper in it over the next weeks
55:45to think about that particular
55:46way of leading what what's the
55:49most effective ways of leading.
55:51But I just really want to conclude now
55:53is saying that you have my commitment.
55:55And the commitment of that leadership
55:57team to serve and to steward.
56:00And the needs of our department as
56:02we steer through these next weeks
56:04with Omicron these next months.
56:06We've got a tremendously amount
56:08of good work ahead of us.
56:09We've got a lot of change ahead
56:11of us to make us a thriving,
56:13creative place for the next generation.
56:16And so I really appreciate again the
56:18opportunity to do it together to
56:20work with you and to work for you.
56:23So thank you very much and
56:25I'll stop sharing and.
56:27We can have some discussion.
56:28Thank you.
56:39Thank you so much, Linda.
56:40I think there was a couple of
56:43questions in the chat as well.
56:50I think a question of clarification from
56:53Megan Goslin about those MDI sessions.
56:55If they're a repeat of what has
56:57gone previously, or if they're
56:58they're new sessions coming up,
57:00maybe it's a question for Tara.
57:02They are repeat, but I'm sure there will be
57:04things added from being learned. Terrell,
57:06yeah, they they so each pair were
57:09offering them two per session
57:11so they build on one another.
57:14So we have the first one.
57:15So the next ones will sort
57:17of go a little bit deeper.
57:19So there are different content.
57:21To answer your question and you
57:23should plan on just attending one of
57:25each pair so in the fall excuse me,
57:27in the winter there's the
57:29January February dyad.
57:30So just one of them of each
57:32would be helpful in the same.
57:34In this, in the spring you
57:36don't have to attend all four.
57:38So I hope that answers.
57:42I see looking for other questions here.
57:46Carol, thank you for answering.
57:49Mendez question? About blinded applications
57:58that's it. OK, I'm very glad by the way too.
58:03I would just say that we had some open open
58:06office hours on the schedule last year.
58:08I'm glad to continue those
58:10that they would be helpful.
58:11Also, glad we will have time in the faculty
58:14meeting tomorrow for more discussion
58:15but but I'm glad to have anytime to
58:18discuss any of these ideas with you.
58:35Alright, but about yeah,
58:36about peer support services.
58:38Absolutely. I know Darren had to be
58:40in a training so that she's not here.
58:42But Yep, agree Larry. Just
58:44a thought. You know,
58:45for all of us you know we sometimes
58:48forget who's sitting right next
58:49to us who's really hurting and and
58:52just important and and you know.
58:54Very often they're just enough of
58:56us around 2:00 to be available,
58:58and you know a way to think
59:00about that together and to,
59:01you know, take care of each each
59:03other as we take care of others,
59:05and I've just gotten a lot and
59:07I've been talking with Dorothy's
59:09to be a lot about this.
59:11You know how we can be available
59:13for each other and for our
59:15colleagues who you know,
59:16in the Ed and other places,
59:17are really hurting?
59:20I mean not that you know really,
59:22it gets back to the point of we
59:24have to be intentional about holding
59:27or holding us together. Thank you.
59:35I have to say personally
59:36that I am really feeling the
59:38virtual environment right now,
59:40'cause otherwise we'd just be
59:41standing in the room and you know,
59:43talking back and forth and but.
59:46But I'm still glad that you're all here.
59:47Virtually that's great.
59:51And so many people still on the line
59:53exactly right. Glad to take any
59:56other thoughts on anything.
59:59Surprised you anything you'd
01:00:01like to have. More explicated
01:00:14OK. So Karen, you announced last week
01:00:17and last week you announced next week.
01:00:21Next week we'll have doctor Jenny Chung
01:00:23will be presenting to us virtually on
01:00:26how social status and non human primates
01:00:28can influence immune function health and
01:00:30well being with findings that are really
01:00:33relevant for for human research as well.
01:00:35And then I just like to thank you for really
01:00:37kicking off this grand rounds series of
01:00:39the New Year and with the sole brewing,
01:00:41but hopefully optimistic presentation.
01:00:44So thank you very much and I'd like to.
01:00:47I'm sure everyone on the call will
01:00:49join me in thanking you for giving
01:00:51such a compelling talk today.
01:00:52Thank you.
01:00:53You're welcome. I hope not too
01:00:56sobering. Ristic, realistic
01:00:58still, hopeful and optimistic exactly
01:01:00right, exactly right.
01:01:04OK. Thank you, thanks everybody.