YCSC State of the Department: Looking Ahead to 2024

January 09, 2024

Information

YCSC Grand Rounds January 9, 2024

Linda Mayes, MD
Arnold Gesell Professor of Child Psychiatry, Pediatrics and Psychology in the Yale Child Study Center; Chair, Child Study Center

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00:00Welcome to the first Grand Rounds of 2024.
00:03I hope your New Year is off to a good start,
00:07and on behalf of the entire
00:08Grand Rounds Committee,
00:09I think we'll hope for a happy,
00:10successful, but above all,
00:12a more peaceful year ahead.
00:14Now Doctor Mays has been very generous.
00:16She's given us a couple of moments to get
00:18us started with our Grand Rounds series,
00:20and we wanted to start with
00:22a few words of thanks.
00:23We wanted to start with gratitude.
00:25So our first word of thanks goes to you,
00:27the Child Study Center community.
00:29Thank you for supporting grand rounds.
00:31Thank you to everyone who's reached
00:33out with feedback about talks,
00:34invited speakers, suggested speakers.
00:36We really want to encourage more of that
00:39and Andrews will talk to you a little bit
00:41more about how you can get more involved.
00:43We want to make grand rounds
00:45the best that it can be.
00:46We wanted to contribute to the
00:48mission of the Child Studies Center,
00:49showcasing the best in clinical practice,
00:52cutting edge research and medical education.
00:54And to do so,
00:56we need your help.
00:58And the second word of thanks goes
00:59to our Grand Rounds Committee and we
01:02thought we would take this opportunity
01:04to introduce you to the committee.
01:06And so Andrews and I have the
01:08pleasure working with Julie Chilton,
01:10Mike Crowley,
01:10Tara Davila,
01:11Amanda Lowell and two of our newest
01:13members of our Grand Rounds committee,
01:15Jen Reyes and Sarah Sanchez Alonso.
01:18Sarah is doing some fantastic work
01:20looking at multimodal imaging
01:21and developmental neuroscience.
01:23And of course,
01:24Chen is doing wonderful work trying
01:26to assess the socio emotional quality
01:28of the early childcare environments.
01:30And so we're delighted to have
01:31them on board on the committee.
01:33These are the people that you need
01:34to reach out to if you want to give
01:37suggestions about grand rounds.
01:38And then our final word of thanks
01:40to Krista Marshizzo and to Una
01:42Casey for their tremendous support,
01:43without which grand rounds
01:45simply wouldn't happen.
01:46And so now I'll just ask Andreas to come up,
01:48just a moment to tell you how
01:49you can get more involved.
01:54I had three things to say,
01:55but we're such a well coordinated team
01:57that I only have two things to say because
01:59the you mentioned about suggestions.
02:01You can approach any one of us
02:03in the grand rounds committee,
02:04be it with a particular speaker
02:06you're interested in or a topic
02:08that you're interested in.
02:09We put a lot of work and effort as a
02:12committee to have a broad range of
02:15interests and topics and speakers
02:18and that leads to our schedule.
02:19We think we've put together a very
02:22nice rich schedule for the coming
02:23year and we invite you to tell
02:26you what's happening next week.
02:27It's going to be a very special one.
02:29We have Maya Adam from Stanford
02:31University who has been using
02:33cartoons and short animated videos
02:35to take messaging in healthcare,
02:38including mental healthcare around the globe.
02:40And many of these videos are
02:41done not in Hollywood,
02:42but in Africa and in the global South.
02:45So it's really important, interesting work.
02:48And my final point is about attendance.
02:49Thank you for being here.
02:51We love having you here in person,
02:53where you get coffee,
02:55and having you in Zoom where you don't
02:57get coffee, And wherever you are,
03:00we really encourage you to not only come,
03:03but to participate, to be active.
03:05There is no question that is a dumb question.
03:07Our speakers are here to teach us all,
03:10and whether you make your questions
03:12on the text or in person, it's great.
03:15And finally, as you heard,
03:18we have Cmes and CE us.
03:20Not this week, but usually we do.
03:22And thank you to Tara for her valiant
03:24effort in getting us to CEU Land.
03:27So without further ado, our chair, Linda.
03:28Sure.
03:35Thank you Andres and I also would
03:37echo gratitude for for so many,
03:39for all of you on Zoom and for all
03:42of you coming and let's get going.
03:45Let me just start.
03:47So first, I want to welcome
03:49everyone back from the winter break.
03:51However you celebrated the holidays,
03:53I hope that you've had a restful and
03:55really joyous time and most importantly,
03:57that you had a restorative time.
04:00As I've been reflecting on this
04:02particular time that we just came
04:04through and the meaning of the
04:06winter break over these these many,
04:09many centuries,
04:10I have some thoughts that I wanted to
04:13actually begin with that across cultures,
04:17this time of year,
04:19beginning with the winter solstice,
04:22actually represents a time of coming
04:24from darkness from the darkest day,
04:26which is December 21st,
04:28and then emerging into light.
04:31And really across cultures,
04:33people represent this time of year
04:37as a coming from dying into life,
04:40winter into spring, darkness into light.
04:44I think that is actually a
04:46really important metaphor for us.
04:49And the reason that I actually
04:50have the image of Stonehenge
04:53here is it turns out many,
04:56many centuries ago,
04:58somehow the people that put Stonehenge
05:01figured out the winter solstice.
05:03So the moment of the winter solstice,
05:05or at the time of the winter solstice,
05:07the sunset is actually reflected
05:09in the middle of the two stones,
05:12then the middle 2 stones.
05:13The sunset is centered there in the
05:16summer solstice.
05:17The sunrise is centered there.
05:20It's a remarkably enduring mystery of
05:23how centuries ago people figured this
05:26out and this particular metaphor of
05:29both mysteries and darkness into light.
05:31I think it's highly relevant
05:33to hear what we do,
05:35whether we do it in our clinical work,
05:37whether we do it in our research,
05:39whether we do it in our education,
05:41is we're trying to unpack mysteries.
05:44We're actually bringing people
05:45sometimes from the darkest moments
05:48of their life into some lightness
05:50by the clinical work that we do.
05:53We're bringing people who are in
05:55training from their moments of deep
05:58confusion perhaps into lighter moments
06:00and clarity and what they will do.
06:03So this metaphor of darkness into
06:05light in the winter solstice is one
06:07that I want us to hold in mind,
06:09and that I I really do hope you
06:11had a restorative break,
06:12but I also hope that you can
06:15begin to to get this idea of what
06:17we're moving into light.
06:19But the other piece I want to say
06:21about that is that we've also
06:24come through a pretty dark year,
06:26and we're saying goodbye to it.
06:28Actually, pretty dark year.
06:29A year that's been marked by the
06:32war in Ukraine,
06:32by the horrors of October 7th,
06:35by the war in Gaza,
06:37by unremitting climate change,
06:39the fires in Maui, the fires in Canada,
06:44earthquakes, political divisiveness,
06:46the hate that spreads across our country.
06:50But on December 30th,
06:53Nicholas Kristoff wrote an editorial,
06:57and the title of his editorial
06:58is this was a
06:59terrible year, but also maybe one
07:01of the best ones for humanity.
07:03And So what Kristoff reminds
07:05us is also important to this
07:07darkness and light metaphor.
07:09And that is that if we stay in
07:11the darkness, we stay paralyzed.
07:14If we remind ourself only of all the dark
07:16and terrible things that have happened,
07:19we actually stay paralyzed.
07:21But we need to balance,
07:23challenge and hope.
07:25And Kristoff actually remind us,
07:27I really do recommend this,
07:29that in 2023 there were remarkable reductions
07:32in infant mortality across the the world.
07:35There were there were reductions in
07:37children living in poverty across the world.
07:40Debilitating illnesses went down
07:42continue to go down in Illinois in
07:45incidents there were life altering new
07:47vaccines not just the COVID vaccine and
07:50there were changes in treatment for
07:52chronic conditions such as sickle cell.
07:54So this is what I want.
07:55Also,
07:56I realize the beginning in somewhat
07:58of a somber darkness into lightweight,
08:01but would actually like us to keep in
08:05mind managing this challenge between
08:08balancing challenges with optimism.
08:11So I'm going to come back to that metaphor,
08:13but here's where I'd like to go.
08:16First,
08:16I'd like to do some of the
08:18departmental snapshots,
08:19talk about our faculty and the
08:22overall community, our finances,
08:24and add something about the ABC's of
08:26fundraising and why in the world we do it.
08:28Though it may seem like an obvious
08:31question as to why we do it,
08:32remember I do this in September
08:35and do it in January.
08:37So I would like to ask the question
08:39of what's happened since September
08:42and give you an update on that.
08:44Come back to what are the systemic
08:46changes that are happening and the
08:48local changes that are happening,
08:50both of which we are involved in,
08:52one of which we have a bit more control over,
08:56Conclude with the question of what
08:58holds us together and then return
09:01to the theme of September,
09:03which is staying grounded amidst
09:06A tremendous amount of change.
09:08So the first part of the snapshot
09:11is what are we now?
09:13Well,
09:13now we are actually a community
09:16of almost 566 people.
09:17That made me actually quite a surprise.
09:21Over the times that I've been presenting,
09:23we've grown from 500 to 566.
09:26That includes all of our community,
09:29faculty, trainees, staff, etcetera.
09:32We're 185 faculty total.
09:34That does not include our community, faculty.
09:38And as a gender split across faculty,
09:43trainees and staff,
09:45we are typically more 3/4 women and then
09:48you can see the racial distribution across.
09:52We still have work to do to
09:54become a more diverse community,
09:56but we are getting there and
09:59glad to show you.
10:00Share these slides with you.
10:03I also want to do a closer look at
10:06promotion progress and this shows you
10:09Assistant to Associate to professors.
10:11We still have some work to do
10:13to even that out to make it a
10:15little bit more balanced across,
10:17but we're moving in the right direction
10:20in terms of our research track faculty.
10:22You can see the distribution there.
10:25And once again,
10:26we still need to be moving many of
10:29our associate research scientists more
10:31more aggressively moving them up.
10:35And then to remind you about
10:36our social work faculty,
10:38our instructor and assistant
10:40clinical professors,
10:40I always wanted to keep reminding
10:42us that we still need to make
10:44progression to the next level,
10:46but this is where we are.
10:48And there
10:51let me show you a bit about our finances.
10:55So this year, our fiscal year 23,
10:58we had a revenue of 52.2, 9 million,
11:03so that's a pretty sizable
11:05revenue and expenditures of 59.8.
11:07That gap is filled by Yale Medicine just
11:11to clarify that right now as you can see
11:16we have 169 grant proposal sent out,
11:18we have 142 active awards
11:21that's that's pretty remarkable,
11:23that's a lot of grants.
11:25And then our patient care,
11:26the Red Arrows demonstrate or show that
11:30while we have 12.1 million in billing,
11:33we only collect about 50% of that
11:36and that has nothing to do with
11:38in the inefficiencies.
11:40That actually has all to do with
11:42what I continue to talk about about
11:44the lack of parity and reimbursement
11:46for mental health services.
11:48We bill for what we should be paid,
11:51but what we collect is what the payers pay.
11:55So there you go,
11:57that's that's actually the profile.
12:00And then if you want to divide that
12:02between what you can see that actually
12:05our grants and contracts account for
12:07nearly half of our budget and then you
12:10can see the distribution that goes
12:12between contracts and other clinical sources,
12:15endowments,
12:16the income from the hospital patient care,
12:19we could do a lot to
12:21increase our clinical trials.
12:22Our clinical trials are a very,
12:24very, very small portion.
12:26We could certainly grow that,
12:28but I want to call your attention to
12:31the fact that our endowments plus gifts
12:33are now about a fifth of our total revenue.
12:37That is perhaps should have been the
12:39obvious answer for why we fundraise.
12:41But let me go into that just a little
12:44bit more in detail because I want
12:46what we've been showing and what
12:48I've shown to you here is basically
12:50what comes in and what goes out.
12:53But is there a question?
12:54And there should be a question of what
12:56are our reserves, what do we save.
12:59And so let me give you just a little bit
13:02on the ABC's for gifts and endowments.
13:05So when we get any gift,
13:07regardless of its size,
13:09it we ask these three questions.
13:13And initially off the top,
13:14there is a 12% assessment by
13:17the school on any gift.
13:19But the first gift question we ask is,
13:22does the donor want this to be an endowment,
13:25which means that it pays in perpetuity.
13:28So on $1,000,000 gift in perpetuity,
13:32we would get around 35 to $40,000
13:36a year and as that amount grows,
13:39because it's invested,
13:40you will get more.
13:42Or does the donor want it to
13:44be in current use,
13:45that is that you spend it down.
13:48We also then ask does the donor want
13:51it to go to an individual faculty
13:53project or to the department?
13:56And then the third question is
13:58this unrestricted that it can be
14:00used for any purpose broadly,
14:02child mental health being broadly or does
14:06it have to be restricted and targeted?
14:09Those are the three questions
14:11we ask about any gift
14:13that comes in with from our
14:15associates or our non associates.
14:18And then I want to show you actually
14:20the balances then that we have
14:22on current use and endowment.
14:24And fundamentally you can reduce this
14:27slide to This is why we fundraise.
14:30So in the department I'm showing you
14:33across fiscal year 21 through 23 and
14:36the end of parentheses for fiscal year
14:3823 is the percent that are restricted
14:41that is can only be used for one very,
14:44very specific purpose.
14:45So for the department,
14:47we have about 6% unrestricted,
14:50but we are incredibly fortunate
14:53that among the balances that are
14:57overall overseen by the faculty,
14:59we have nearly 70% unrestricted,
15:01which means that the faculty overseeing
15:04those things have great flexibility
15:07in being able to do what they do.
15:09That is really good.
15:11And that's why unrestricted gifts to
15:14the faculty or the department give
15:16us absolutely the most flexibility
15:19and that's why we fundraise and
15:21that's why we try to fundraise
15:24for unrestricted gifts.
15:25I am very glad to go through any
15:27of these things in more detail,
15:29but I wanted to,
15:30to give you that perspective
15:34now to go to the progress since September.
15:36And I'm going to cover each of these areas.
15:39I'm going to put clinical services
15:41and the last one because there's a
15:43number of things that will bring us
15:45back home to the themes of September.
15:47And remember, our theme of September
15:50was staying grounded amidst a lot of
15:52change and I will come back to that.
15:55So first to turn to organization and culture.
15:58Climate has been a lot happening,
16:01a lot happening since September of 2023.
16:04We've been continuing to work with Ingrid
16:07Kennedy of Cirque and we were very,
16:09very fortunate that Ingrid and pursuing
16:12an advanced degree decided to make the
16:15Child Study Center her case study.
16:18And so she's created a really nice
16:20document we'll be glad to share with
16:22you about service leadership and the
16:24progress we've made in the center,
16:26but also the things we need to do.
16:29And shown on the slide is one of
16:31her our infographics,
16:32but very glad to share that with you.
16:35Darren has brought together a wonderful
16:38leadership blog and I hope you will.
16:40If you haven't already listened or
16:42read the interview with Doctor Comer,
16:44I hope you will because it is a beautiful,
16:46beautiful statement not only about
16:48his career but about how he thinks
16:51about mentoring and leadership.
16:53And then we have our new leadership
16:55series which we inaugurated on
16:56October 30th with Pam Sutton Wallace
16:58from The Health System.
17:00Darren, being our second speaker,
17:02I mean, I hope you've noticed the subtle,
17:05maybe not so subtle Trojan Horse
17:07posters around that are to get this
17:10idea that leadership is not just me.
17:12Leadership are the skills are in all
17:15of us and that we really are thinking
17:18about this idea of service leadership,
17:20our responsibility to bring everyone along.
17:24Coming up in the leadership lecture series,
17:27we'll actually be the CEO of Gaylord
17:31Specialty Healthcare in February
17:33and then we'll be very grateful to
17:35have NI Addy from the Dean's office
17:38and Psychiatry in April.
17:40Other activities in this in this space,
17:44we'll have two leadership workshops from
17:47Cirque on 17th and 24th and Krista's been
17:51sending out announcements about that.
17:56Hold on, let me get the pointer
17:58back to where it should be.
18:00Tara is continuing her Friday focus
18:02sessions and having really a lot
18:04of people come, which is great,
18:06really delighted about that.
18:08And then the final update to look
18:11ahead is Amanda Calhoun has brought
18:13together a clinical case conference
18:16on clinical services for Black Youth.
18:19Very excited about that.
18:21We have over 100 people signed up for
18:24in person for next Tuesday the 16th.
18:26And so stay tuned,
18:28but this is really an important
18:30event for us and an important
18:32event to continue to push these
18:34discussions of diversity
18:38and these are just the goals
18:40that we shared in September.
18:42What I'd like to point out on a
18:46particular one is this one and I'd like
18:49to engage your your thinking on this.
18:52It's something of great concern for us as
18:54we advocate not only for the post grads,
18:57for for everyone coming in a
18:59junior position to our community.
19:02So here's the here's the issue.
19:05You may have seen that New Haven
19:08and Connecticut has become one of
19:11the most expensive places to live.
19:14Rents in New Haven are now quite
19:17out of proportion,
19:17and you can see how they relate
19:19to the national average.
19:21For Connecticut,
19:23this has created an equity issue
19:27so that individuals that might have
19:30support from their families or might
19:33have made a savings can choose to come,
19:36but those who don't,
19:38it's really hard for them to
19:41live in New Haven.
19:42At the same time, we're trying
19:45to advocate for raising stipends,
19:47which we need, which we have done,
19:49but we can't raise stipends to
19:52keep up with this rent escalation.
19:56This impacts post docs,
19:57it impacts pre docs, It impacts us across.
20:01It also impacts retention.
20:03We're having these conversations
20:05centrally with Central Campus and
20:07we're having these conversations
20:09here in the medical school.
20:11Are there things that we can do?
20:13Can we partner, for example,
20:16with landlords in New Haven
20:18to offer subsidized rent?
20:20Are there things that we can do
20:22to address this because it is an
20:24equity issue and it is impacting
20:26recruitment and retention,
20:28not just for us parenthetically
20:30but across the school.
20:33The other thing that I want to raise is
20:36that I am sure if you're reading the
20:38newspapers or reading and listening,
20:40you are aware that there is a national
20:44push about DEIV agendas and initiatives.
20:48These are just four head headlines
20:52taken only from the New York Times.
20:54If you got across, there are many, many more.
20:58I have these here that I want
21:01to reassure our community.
21:03I want to be aware of this.
21:05I want all of us to be aware
21:07of this national discourse,
21:09but also to reassure our community that
21:11we are not moving away from this agenda.
21:13We are continuing this agenda,
21:16but it behooves us to be aware of what
21:19the currents of the discourse are.
21:22But just to remind you that climate
21:25and culture is vital to us.
21:27Culture is what I think the values
21:29that we hold about equitable rent
21:32is an equitable issue about an
21:35inclusive culture,
21:35and the climate is what we do
21:38that reflects those values.
21:40And so all the trainings that
21:42I've just brought forward that
21:44are happening and have happened
21:46are devoted to that agenda,
21:47to create and to inculcate a culture
21:51of respect and inclusion which
21:53over time creates climate change.
21:56We're sticking to the course,
21:58but do be aware of the national
22:00discourse that is pushing increasingly
22:02and pushing us to be thought
22:07so. Our research mission,
22:09we could actually spend the
22:10rest of the time on this.
22:12It is so productive and so, so full.
22:15But I just want to give you a
22:17sampling that is probably about 10%
22:20of what's happened since September.
22:22I mean literally about 10% of
22:25what's happened since September.
22:26And I apologize for not including 100,
22:29but I just want to give you a sample that
22:32as you can see there have been books.
22:34There have been a number of really
22:38distinguished awards from Kasha to ****
22:39Aslan, Chris Cipriano, Uche, Jessica.
22:44And then there have been a high
22:47impact papers that are coming
22:48from all of our research groups.
22:51It would go on several slides,
22:53but this is really,
22:54it's really important to know
22:56that that and then grants,
22:57I haven't even put the grants on that.
23:00Our research is thriving
23:01and we're doing very,
23:02very well.
23:04These are some of the areas that
23:07in September we focused on as
23:10goals for this academic year
23:11and they're all moving forward.
23:13I want especially to call out the
23:16series that Kareem and Soraya have
23:18brought together for research and
23:20progress because I think that's
23:21another way of trying to integrate
23:23both our clinical and research
23:26activities and also just to make two
23:29points around the subject recruitment
23:31and the strengthening the base.
23:34We have a collaboration very
23:35productive now that Tom and Yong
23:37Sung have brought together between
23:39the Yale Center for Clinical
23:40Investigation and the J DAT team.
23:42And J DAT, if you in case you didn't know,
23:45stands for Joint Data Analytics team.
23:49And they have actually now made
23:51it possible for or going to make
23:53it possible for us to recruit
23:55subjects through my chart.
23:56That may not sound earth shattering,
23:59but it actually is earth shattering
24:02because there has heretofore been a
24:05resistance to recruiting subjects with
24:07behavioral health needs through my chart.
24:10So now we will be able
24:11to recruit through them,
24:12which is really a remarkable
24:15and important achievement.
24:17I also wanted to remind you just
24:20click through this that we have a
24:23strategic profile that tries to
24:26integrate our clinical and research
24:28and policy education efforts
24:30in these particular areas.
24:32And around this particular,
24:34this Oval shows the other themes
24:36of the child Study Center,
24:37our focus on normative development,
24:39translational science etcetera.
24:43But these are our areas,
24:44neurodevelopment and disorders,
24:46movement regulation disorders,
24:48mood and emotion regulation,
24:50trauma,
24:51HealthEquity and HealthEquity
24:53services that broadly define our
24:56research portfolio and how we
24:58integrate across the clinical.
25:00I think we're deeply in need actually
25:03to think about where are the gaps,
25:05there are some gaps and where
25:07are the gaps in this profile and
25:09what are the ways that we can
25:12actually continue to grow that.
25:13But this is,
25:15this is really our research strategy.
25:18Having mentioned gaps,
25:21let me just say that there are some
25:24emerging collaborations bridging to
25:25other departments and I think this
25:27is a really important theme for
25:292023 to 2024. What are themes
25:32that we can bridge with others?
25:35So, for example,
25:36climate change and mental health is
25:38becoming a very important issue,
25:40is very important,
25:41and there are colleagues in the
25:43School of Public Health that are
25:45actually very focused on this,
25:46but they don't have a
25:48specific mental health focus,
25:49they have a climate change health focus.
25:52So emerging collaboration there,
25:55the new Department of Biomedical
25:59Informatics and Data Science
26:01offers us opportunities to
26:03collaborate around mental health
26:06informatics and also around digital
26:08mental health interventions.
26:09Uche's work, for example,
26:11is around digital mental health
26:14interventions and Uche is now jointly
26:16appointed with this new department.
26:18So these are opportunities,
26:20these are gaps and I think that
26:23especially bridging to other
26:24departments is really important
26:26for our research mission.
26:29Turning to the education and
26:33professional development,
26:34these are the areas that in September
26:37we spoke about that we were trying
26:39to move forward just to call
26:41attention to the box at the top.
26:43We've had now a number of folks coming
26:46forward interested in professional
26:48development and so we'll be filling
26:50that position in the next month.
26:53But as you can read,
26:55we've tried to improve the educational
26:56climate for our training programs.
26:58Really important to develop a
27:02professional development program in
27:04child and family behavioral health and
27:07then consistent communication across
27:09to try and develop a department brand.
27:12So let me show you a few things
27:14that have happened.
27:16So Darren again has developed a
27:18a phase one about learning the
27:21insurance and outs of peer coaching
27:23for our trainees and our fellows,
27:26piloting it with child psychiatry fellows.
27:29And then phase two will be offering
27:32individual coaching sessions to the fellows.
27:34Again the idea of trying to help
27:37on emerging professional identity
27:38and trying to help in the culture
27:41climate of our training programs.
27:45We are now becoming a training
27:48institute or trainers for paediatricians
27:50in the reach training program.
27:53We are, we will be a training site.
27:55We're just finishing our train,
27:56the training and we have ongoing
27:59now in 2024 we'll be offering
28:02training to pediatricians.
28:03Idea of that is to increase the
28:06capacity of pediatricians and child
28:09behavioral health so that we can actually
28:12address that that continuum of care.
28:15And there was a really exciting conference
28:17here in this room on December 2023
28:21that Carter helped organize on the
28:24literate brain with our former Haskins
28:27now Child Study Center colleagues,
28:29Not former in any way,
28:30but present in the global literacy hub
28:33talking about how do we translate the
28:36science of reading into actual interventions.
28:39And they will be continuing that
28:42work and then very excited.
28:45Many of you know that in fact
28:48you sometimes grown.
28:49When I mentioned framing that we're actually,
28:53we're going to become a framing hub
28:56with our colleagues and frameworks
28:58because we're very focused on how we
29:01communicate about children's mental
29:02health and we want to become a framing
29:05hub to train other people in that.
29:07These are just some of the examples
29:10of frameworks work and framing
29:12child mental health.
29:14How do we talk about child mental
29:16health in a way that we engage people
29:19that we get them actually to think
29:21broadly about the questions rather
29:23than to say what do you do about that.
29:26I mean that really is a formal
29:29communication technique.
29:35There's two ways to think
29:37about professional development,
29:38and I want to just present that point here.
29:43Some of the things I've
29:44mentioned are external.
29:45Our REACH training is external.
29:48The webinar on the reading
29:50science of reading literacy,
29:52those are externally facing.
29:54Kasha offers each year a really rich
29:57conference on the state-of-the-art
29:59and infant toddler neurodevelopment.
30:02Wendy and Ellie offer about anxiety.
30:05Our YCEI colleagues offer a lot of
30:09professional development externally facing.
30:11We also have extra internally facing
30:15professional development as we think
30:17about mentoring for our faculty,
30:19the FDAC process.
30:22These these acronyms crop
30:24up leadership workshops,
30:26the workshops on managing research groups.
30:29What I would like to say that for
30:3120 the rest of this academic year
30:34is that we think about a unified
30:37training brand that is centered
30:39around how discovery inspires
30:41care that is our training brand.
30:43But we think about how do we present
30:45that whether it's external or
30:47internal and we have a consistency
30:49across all of our training.
30:53Let me just briefly talk about
30:55operations and communication
30:56and then we'll go to clinical
31:02In in September, we listed a number
31:05of goals and actually these are all
31:08in progress and in particular the one
31:13on clarifying job responsibilities
31:14so that we can actually incorporate
31:16that into the F TAC process.
31:19We can make much clearer about lines
31:22of accountability, all of those
31:24things that is now actively in place.
31:26There's actually a workshop right
31:28after this grand rounds.
31:30The other piece that's very much in
31:34play is again what I've mentioned,
31:36the series of leadership talks
31:38that Darren has put together,
31:40trying to bring this idea of
31:43service leadership very much
31:45into our culture and climate.
31:48But if you want to get tired,
31:51these are all the activities that
31:53have happened in the communications
31:55portfolio since September.
31:57It's pretty amazing.
31:58Thank you, Krista.
32:02We have regularly
32:06regularly updated the comms
32:07related guidance on the Internet.
32:09Hope you find it also made the Internet
32:11how to get to the Internet really clear.
32:14There's a button, push it.
32:18Krista has open office hours,
32:20there's ongoing news stories, the IBO,
32:22the integrated business office,
32:24regular updates so you know where to go to,
32:27who to talk to.
32:29Comprehensive list of committees,
32:32you can see the insider community
32:34surveys and then the upcoming second
32:37annual year in review replacing.
32:39For those of you who have
32:40been around for a while,
32:41you remember every year we did
32:43an annual report and there were
32:45it was printed and all that.
32:47This replaces that and it's much
32:49more vivid and much more available.
32:51So there's been a lot of progress
32:55in communication.
32:56But importantly,
32:57if you have other suggestions,
32:59Krista is very open to those.
33:01Communication to 566 people is
33:06an ongoing dynamic challenge.
33:09So how do we do it better?
33:11How do we make sure that everyone
33:13feels like you know what's going on?
33:16That is what we need to keep working on.
33:18And thank you again, Kristen.
33:21So to our clinical services,
33:25First off,
33:26what's the state of our clinical services?
33:30Well, you can see some updates here.
33:32And this is over the calendar
33:34year of January to December,
33:37we have a 7% increase in referrals,
33:4158,000 plus scheduled appointments
33:43over this year.
33:44All those 58 thousand 16,500
33:48were via virtual.
33:49So you can calculate roughly roughly
33:53a third greater than 3000 unique
33:56youth and families were served.
33:59The average age is about
34:0411.752% of the clients identify as female,
34:07so half And then the racial breakdown is
34:11as you see with 46% having a historic
34:15identity that has been historically
34:18marginalized that those numbers do
34:23not give justice to the tremendous
34:26amount of work that's happening.
34:30Just to drill down a little bit
34:32into that 7% increase in referrals,
34:34the peak that you see January 2021
34:38to December 2021, that was a very,
34:42very high point.
34:43But we have still we are still much
34:46higher than we were before that time
34:49as you see and that one of the reasons
34:52why referrals are up there continues
34:55to be tremendous need out there.
34:57We wonder if one of their leveling reasons,
35:01no way to test this is that the word
35:03is out about wait list and things like
35:06that which we don't know that fact,
35:08but we're still going up in terms
35:11of referrals.
35:12Just want to give you a sense about
35:15our hospital based services across
35:17fiscal year 19 through fiscal year 23.
35:21You can excuse me,
35:23you can see that the behavioral
35:24health Ed numbers children coming
35:26to the behavioral health Ed,
35:28they stayed relatively constant.
35:30But what has dramatically
35:33dramatically changed,
35:34it's the number of hours that children
35:37sit in the Ed waiting for some kind
35:40of disposition whether to get to our
35:43inpatient unit or to services elsewhere.
35:45Dramatic change in that and we're
35:47still waiting on the fiscal year
35:5023 data to be finally summarized.
35:52But I can assure you it's going to be
35:54roughly in the range of fiscal year 22.
35:58You can see the child, the inpatient service.
36:00And again,
36:02while the volume may be relatively constant,
36:05what is changed is the length of stay.
36:10Children are sicker,
36:11children are staying longer.
36:13There's also fewer services out
36:15there to get them to the breakdown
36:17in the continuum of care.
36:19And then the CL service not only
36:22again numbers relatively constant,
36:24but severity,
36:25severity and illness and children
36:28staying in the hospital longer and
36:30needing more is what has gone up.
36:36Just to go back to our outpatient services,
36:39to give you a little bit of
36:40a sense of the distribution,
36:42you can see that about 47% are
36:45on Youth Services assessments.
36:48Assessments are listed at 3.1.
36:50We hope to grow that and you
36:52can see the distribution across
36:54our others of our services.
36:56Our family based recovery
36:58interventions for children with
37:00AIDS intensive ICAP services is
37:03about 1/4 of our outpatient work.
37:12And then to look at our wait list
37:15and we define now our wait list.
37:18As the hospital defines a wait list,
37:21it is even if children have an appointment,
37:23if it's several months out,
37:25we consider them on the wait list or
37:27that they're waiting for an appointment.
37:29So right now for assessment that is our we
37:33have about 398 children on the wait list.
37:37You can see that it varies actually
37:39across the different kinds of services.
37:41Our assessment services have about 200
37:43waiting to be in some way across evaluated
37:48about 106 waiting for therapy and then
37:53their distribution across the rest.
37:55And you can see also the importance of
37:58breaking this down is that shows you that
38:00not the wait time is variable depending
38:04on the different kind of service.
38:07We are not unique.
38:08I just want to stress that while this
38:10is very important data for us to track,
38:13we're not unique.
38:14There are wait times and wait lists
38:16across not only the state of Connecticut,
38:19across the country reflecting shortages
38:22of providers and also reflecting increased
38:26severity of illness so that children
38:28are not moving through services as well.
38:34There's been a lot of progress in other
38:37things since 2020, September 2023.
38:39Very grateful to Cecilia for continuing
38:42to move the racially informed
38:45clinical formulation work forward.
38:47We had a consultation to our outpatient
38:50services in early 2023 from Doctor Kraft.
38:53We're making changes in workflow
38:55and workforce development building
38:56from some of the other efforts I
38:59mentioned this culture of respect.
39:01We're so excited to actually have
39:04been welcomed Veronica as our
39:06developmental behavioral pediatrician,
39:08the first person to help us
39:09continue to build now that program.
39:12And then there's new funds flow
39:14that I will talk about on how the
39:17funds come from the health system
39:19to support clinical services and
39:21I'll talk about that in a moment.
39:26Just to remind you that these are some of
39:29the clinical goals that we set for 2023-2024.
39:32I already talked about the workplace
39:35climate culture. We need to focus
39:39more on comprehensive assessments.
39:40That's where there's a tremendous amount
39:43of need as you saw from the wait list.
39:45We need to build that out more.
39:48We need to also build out more short term
39:51evidence based treatment so that we can
39:53help move children through the system,
39:55developing a self pay practice.
39:58We're continuing to grow our pediatric
40:01psychology program with Lori and
40:04Maggie and then I want to really
40:06focus on that last point there,
40:07professional development funds as we try to
40:12enhance everyone's opportunities to grow.
40:16That is really important that we
40:18develop a fund that is available to to
40:20actually all of everyone I would hope,
40:23but certainly everyone in practicing
40:25clinically that gives them the
40:27opportunity to learn new skills.
40:30Going back to my fundraising slide,
40:31This is why we fundraise unrestricted funds.
40:35So we're actively trying to fundraise
40:37for professional Development Fund that we
40:39can access and make available to everyone.
40:42It's a very high priority.
40:46These two of embedding developmental
40:48Pediatrics in child study center and
40:50the pediatric psychology reflect
40:52our really deepening collaboration
40:54with the Department of Pediatrics.
40:57Pediatrics is really one of our close,
40:59it is our closest sister department
41:01if you will and that collaboration
41:04is very much deepening.
41:06And I've already talked about
41:09professional development funds.
41:10So I want to take a step back now
41:13and I've been referencing September,
41:16but now I want to take a step back
41:18to a year from now or year past where
41:21I spoke in January,
41:22the same kind of talk in January of 2023.
41:27And remind you about three points
41:29that were salient or I hope we're
41:32salient in that talk at that time.
41:34The first being that we are a part
41:37of a system.
41:39We are a department in a School of Medicine,
41:41a School of Medicine existing
41:44in a university,
41:45but we are also a part of the
41:47Yale New Haven Health System.
41:49And the Yale New Haven Health System is
41:51not just this hospital across the street.
41:54It includes Greenwich,
41:55it includes Lawrence of Memorial,
41:58it includes Milford.
41:59It includes a number of
42:01hospitals across the the,
42:03the southern part of the
42:04state and up the shoreline.
42:06We are a part of that system and there are
42:10a lot of changes happening in that system,
42:12which I will talk about.
42:15The 2nd academic medicine is changing.
42:20The growth in the clinical research
42:23clinical versus the research mission
42:26in Yale Medicine and academic medicine
42:29generally is dramatically changed.
42:31The clinical mission now is by far
42:33the biggest in every academic Medical
42:36Center in the country, not just us.
42:40This particular graph shows you
42:42the change just through fiscal year
42:4422 of Yale medicines fees.
42:47But perhaps even more dramatically,
42:49which I showed you a year ago,
42:51is the actual proportionate change
42:54in the clinical income versus
42:57research over 10 years.
42:59Over 10 years, the clinical income
43:02proportion of the annual budget of the
43:04Yale School of Medicine grew by 1.2,
43:07whereas the research income grew by .3.
43:12Clinical enterprise is actually the
43:15driver now of academic medicine.
43:19That is really important and it's
43:21important because it shows you where
43:24the discussion and the emphasis is,
43:26but it also raises important questions
43:28for how we're a part of that.
43:31And then the Third Point,
43:35they said academic medical centers are no
43:37longer the only providers of expert care.
43:40It's a competitive market.
43:42And I realized that many of us who went
43:45into medicine never thought we would
43:47be using terms like market. We never.
43:49Certainly when we went into research,
43:51we never thought we'd be using terms
43:53like market, but this is a survey
43:58and there's many, many like it.
43:59But in this particular survey,
44:01they ask and patients have become consumers
44:06didn't think that would happen either,
44:08but they asked patients,
44:09would you pay more to receive your specialty
44:12care at an academic Medical Center.
44:15Half said no.
44:18And the data are on this graph as well.
44:20Actually, 58% said no for primary care,
44:25but half said no for subspecialty care.
44:30And then even more striking perhaps,
44:33is this is that 58% of patients I'm
44:37going to keep substituting the term
44:40surveyed said that they would choose a
44:42Community Hospital if it was associated
44:45with an academic Medical Center.
44:47Hence why the partnership with
44:49Yale New Haven is so important.
44:53And that argues for these
44:56kinds of partnerships.
44:57So Yale Medicine and all of us
45:00hearing that there's 33 changes
45:03coming out of those messages,
45:05those messages that we talked
45:07about a year ago.
45:08The 1st is closer alignment with
45:10our health system colleagues.
45:12Remember the last point,
45:14patients will come to an academic
45:16Medical Center if or Community
45:19Hospital if it's aligned.
45:20The 2nd is integrating clinical
45:23networks within and outside to
45:26form actually what are called
45:28clinically integrated networks.
45:29And then the third is a new
45:32approach to funding from a health
45:34system that supports clinical care
45:36delivered by the medical schools.
45:39So I want to go into each of those
45:41for first there is active effort
45:44of alignment between Yale New Haven
45:47Health System and Yale Medical School,
45:50very active and that is expressing itself
45:54in these areas joint strategic planning.
45:57There has never been a joint
46:00strategic plan between the health
46:02system and the medical school.
46:04They have never jointly strategically
46:07planned until this year.
46:10Joint infrastructure having a single IRB,
46:14so that if you're going to do a
46:16study in the hospital and a study
46:17in the medical school,
46:18you don't have to have two IR BS,
46:21one single credentialing process,
46:24joint clinical programming coming to decide,
46:27yes,
46:28we'll do that together and
46:30most importantly funds flow.
46:32But just to give you a hint,
46:34this was in October of 2023,
46:38this was the Children's Hospital preliminary
46:41strategic areas and for the very,
46:44very first time behavioral health was
46:48included and this was jointly created
46:51between the school and the health
46:54system and including us as a part of that.
46:58That's really,
47:00really important.
47:02And some of those things that are
47:03in that are about improvement,
47:04access to behavioral health services,
47:07behavioral health services across
47:08the care continuum,
47:09the kinds of things that we've
47:12been talking about.
47:13The second area that our colleagues
47:17all across the school and the hospital
47:20is this clinically integrated network.
47:23And while this may not sound profound,
47:26it actually is deeply profound
47:29that there is now going there.
47:30As of January,
47:31there is one clinically integrated
47:34set of outpatient services,
47:36Yale Medicine and the Northeast
47:38Medical Group.
47:39The Northeast Medical Group was the
47:42health systems outpatient services,
47:43Yale Medicines was the schools.
47:45These come together now as one entity
47:48including also some aligned community
47:51physicians or community practices.
47:53But that one entity is led by Doctor McGovern
47:57who is Yale Medicine and the hospital.
48:01Why is that important?
48:03You have one voice, 1 voice,
48:05one entity working together,
48:07all these kinds of clinical operational
48:10things that we talk about 1 entity
48:13and while the clinically integrated
48:16network or another acronym,
48:18the SIN is talked about a lot without,
48:22there will be pediatric practices
48:25with embedded child behavioral health
48:27in bed and then finally funds flow.
48:31A number of you in our clinical
48:33practice have heard a lot of our
48:35talking about funds flow and how
48:36funds flow it's going to impact us.
48:38And remember my first snapshot slide
48:40showing you the difference between
48:42what we build and what we collect
48:45and then our that our clinical gap.
48:49So let me just walk everyone through
48:51where we are on funds flow and this
48:54really is how funds come from the
48:57health system to support clinical
48:59care in the school.
49:01So this has happened since July,
49:03but we have much more data than
49:06when I presented in September.
49:08So the traditional past model is
49:11that our space cost we paid for,
49:14we paid an assessment to Yale Medicine,
49:16we paid that,
49:18we paid malpractice and the clinical
49:22income was based on whatever the
49:25insurance carrier would pay us.
49:27Now with the new funds flow model,
49:29all of those first three items go
49:31to paid by the health system and
49:34we're paid based on what's called
49:36an RVUA relative value unit that
49:39is we are paid for what we do and
49:42it is paid by the health system.
49:44It is.
49:45It is payer blind.
49:47You don't have to worry or think about this.
49:50This patient have insurance or not,
49:53are they on Medicaid?
49:54You don't have to think about any of that.
49:56It is pay or blind.
49:58There are some subtleties in this.
50:00I mean,
50:00so for example as the bottom
50:03lines that there's some services
50:05such as medical directors,
50:07our pediatric psychology program that
50:08are not RVU but are on a staffing model,
50:11but that's a subtlety.
50:13We are basically paid for what we
50:16do and the impact of this is this.
50:22Our deficit goes right now and there's a
50:25lot of still things that we have to work on,
50:27but drops from 6.9 to 2.6,
50:31we are generating actually more
50:33clinical income and all of those costs,
50:35those fixed costs that we had
50:37little ways to influence and now
50:39shifted away from our budget.
50:41So it's really important for us.
50:43We are doing really well even though I know,
50:46I know there's still an unpaid
50:48gap that we will work on that.
50:51Importantly,
50:53what does it actually mean for an
50:55individual clinician and this is
50:57what I think is really important
50:59for individual clinicians.
51:00You are seeing patients you're
51:03actually freed up in many ways
51:05not even having to worry about
51:07do they have insurance or not.
51:08You're seeing patients you
51:10are responding to need.
51:12The impact is really on the
51:14department that we have now are paid
51:17for what we do and all of those
51:19costs are covered that we couldn't,
51:21we couldn't address those
51:22fixed cost are covered central.
51:27So I want to talk about levels
51:29of change and I'm glad to take
51:31any questions about funds flow.
51:33We continuing to talk about talk about
51:37enduring mysteries and Stonehenge,
51:39it gets clearer, you know,
51:41month by month and I'm glad to talk about,
51:45but I want to talk about levels of
51:47change because it may not be obvious
51:49that I've actually been talking about
51:52systemic change and local change.
51:54And what are the things that we have
51:56tremendous input over and what are the
51:59things that we have less input over?
52:01So systemically,
52:04we're talking about being a part
52:06of the New Haven Health System.
52:08And I've given you 2 examples,
52:10funds flow and joint strategic planning.
52:13Our examples of strategic systems
52:15change that we are a part of and
52:18we can influence in some ways.
52:20But actually, it's happening and we,
52:23we have, we have the ability to influence,
52:25but we're not driving the change.
52:27We're a part of the change.
52:29And then local change is the ones
52:32that I've been talking about,
52:34such as expanding our assessments
52:36or changing our workflow,
52:38the things that we can actually
52:40do in our practice.
52:41And so it's important to keep those
52:43two levels of change in mind and
52:46we're working at both of those levels.
52:48But really important to distinguish them
52:54in the last few minutes though I want
52:56to now switch to this question and
52:59ask the question of what holds us
53:03together and ask this question because
53:06I'm very aware that in the last,
53:08particularly the last few minutes,
53:11I've been talking about things
53:13like Rvus and all of that.
53:15And I want to ask the question
53:17of did the implicit,
53:18often transactional expectations that are
53:22built into the system that we live in,
53:26the system that we work in.
53:29So they actually sometimes over shadow
53:31what are our common goals and purpose.
53:34And so let me just give you
53:36my thinking on this.
53:37So for example, if you're working clinically,
53:41we try not to.
53:42But I think there's a lot,
53:44a lot people are thinking about,
53:46am I meeting my benchmarks?
53:49If you're running a lab,
53:52I think you're thinking
53:53about grants and funding.
53:55How do I keep my lab going?
53:59If you're in the education
54:00part of our mission,
54:02you're thinking about training expectations,
54:04you're thinking about the burden of workload.
54:07But there is something that unites us that
54:10I think we need to be very cognizant,
54:12ah, across Those are the things
54:14that I think are the implicit kind
54:18of transactional expectations.
54:20But I think we're actually united by these.
54:24We're united by caring for patients,
54:26seeking out new knowledge that will
54:28actually improve our understanding of
54:30disease processes and change how we care.
54:32We're united by training the
54:34best clinicians that we can,
54:36best researchers that we can.
54:39Those are the more explicit things
54:41that bring us together and would
54:43suggest that that is why we say we're
54:46discovery inspires care that what we
54:49are held together is this excellence,
54:52this focus on excellence
54:54state-of-the-art care driven by research,
54:56education or clinical work for families.
55:01And it is extremely important that
55:03even as we are in the midst of these
55:06huge changes in the health system,
55:09local or systemic, that we keep that in mind.
55:13What are we united by?
55:15Even though there are a lot of
55:19implicit transactional expectations.
55:20Which brings me then to the final point.
55:24Why do we stay grounded?
55:26This was our theme for September
55:29and absolutely why staying grounded
55:31in this time of enormous change
55:34is absolutely critical because it
55:36is through staying grounded that
55:39it allows us to focus on that.
55:41Where discovery inspires care To
55:44perhaps stretch a metaphor too far.
55:47Staying grounded keeps us from not
55:49being swallowed up by the darkness.
55:52Helps us to keep a little bit of sense
55:55of where we're going in the midst of
55:58how such tremendous, tremendous change.
56:01So I want to thank you.
56:03I appreciate this opportunity to give
56:06another update for the department.
56:07Thank you for all the work you're doing.
56:09And I hope we have some time
56:11for discussion and questions.
56:13Thank you.
56:19You'll be monitoring on
56:20Zoom if there's questions.
56:22I'll just turn the mics on in the room
56:24for anyone who wants to ask a question.
56:30Thank you. Appreciate it. Any questions,
56:38we probably could summarize the
56:39whole hour by saying we're actually
56:41in good shape there's there's,
56:42there's a lot going on,
56:44but we're in good shape.
56:45That would've been simpler, wouldn't it,
56:51Richard Lynn, Grace. Yes, ****
56:55yes, Linda, thank you very much.
56:57Fantastic presentation and very encouraging,
57:00particularly with regard to the funds model.
57:04I I wonder if you could comment on what
57:09struck me as somewhat surprising with
57:12regard to sources of income and that's
57:15the the absence of clinical trials that
57:19that that that seems like an opportunity.
57:22I wonder if you could comment on that.
57:24I can comment by saying **** I
57:26couldn't agree more that I think
57:28that's a remarkable opportunity for us.
57:30The app that we need to build up our
57:32clinical trials. We really, really do.
57:34We have an opportunity to partner
57:36more actively with pharmaceutical.
57:38Dr. Block does a lot of that work,
57:40but the more actively with pharmaceutical
57:43companies we have, we really have the,
57:45we have the infrastructure,
57:47we have the science,
57:48we really have the it's a it's
57:50a missed opportunity for us.
57:51We need to grow that.
57:53Carla, when you say clinical trials,
57:54do you mean medication trials
57:56specifically not the NIH funded both,
57:59both but the but the small slice
58:02of the income is really from
58:05pharmaceutical sponsored trials.
58:07I'm not saying that should
58:08be our only clinical trial,
58:10but there is off there
58:12are opportunities there.
58:13Thank *** **** for the question.
58:15Other questions,
58:20were there surprises?
58:24Relief. Oh, really? Relief.
58:25We're in good shape. Oh, OK,
58:27good. OK, All right, good.
58:32Any other online questions?
58:35Yeah, actually I have a comment.
58:36Yeah. I don't know if the question is
58:38I was struck by we have
58:41to vote.
58:45I was struck by what you said about
58:47how a clinical revenue is driving
58:49the train now and that research
58:51funds are kind of staying the same.
58:53And I think that's partially because
58:55NIH hasn't raised running levels.
58:58And so it's true. We can't, we can't.
59:00I mean we can write more grants,
59:02but we're not going to get more
59:04money more than likely in that way,
59:05which is actually really problematic
59:07because even talking to program
59:09officers, they know
59:10we can't do the work we want to do with the
59:13RO one funding amount. So I,
59:15I I guess it's just I I wonder
59:18like how the system can, how
59:20the health system or how Yale can
59:22advocate for that. Yeah.
59:24So so Carl, that's a really important point.
59:28So what drives that is not just that we've
59:33done such a good job about educating
59:36everyone and you know cutting edge
59:38care that they can now go other places.
59:41The other thing that drives that is
59:43research has become more expensive.
59:45So it's become more expensive and
59:47and so it's grants just don't cover
59:49it as you're saying.
59:51And so that also drives the
59:53increase in clinical revenue,
59:54so that you can funnel that back into
59:57research the catch 22 for behavioral health.
01:00:01It's because we're not adequately reimbursed.
01:00:03We can't funnel it back into research.
01:00:06So that becomes really a
01:00:09particular dilemma for us.
01:00:11The solutions,
01:00:12So what I didn't talk about because it just
01:00:15would have gotten too far in the weeds,
01:00:16but we can go into the weeds is
01:00:19the funds flow model has another
01:00:22component to it and you can call
01:00:24it a shared risk component.
01:00:26In essence what the hospital or
01:00:29the health system has agreed to
01:00:31is that as clinical revenue is
01:00:34generated across across the practice,
01:00:36not just by individual departments
01:00:39as you get a clinical excess if
01:00:42you will or clinical profit,
01:00:44then that gets funneled back into
01:00:47the academic mission that gets
01:00:49funneled back into research.
01:00:51That's what they have agreed to.
01:00:52That is a part of the and how the the
01:00:54various details of how that works.
01:00:56All that has to be worked out.
01:00:58But it's it's an important agreement
01:01:00that across the practice as a whole
01:01:03not just by department when there
01:01:06is clinical surplus that that will
01:01:10come back to support the academic
01:01:11mission distributed evenly that's
01:01:13that's the detail to be worked out.
01:01:15I mean that's for not young child
01:01:17study you're in a deficit.
01:01:18No, no, no,
01:01:19no I don't I don't think that will
01:01:20happen actually frankly I don't
01:01:22think that will happen because
01:01:23that would not be equitable.
01:01:24And then there is also a real
01:01:27commitment and funds slow to be
01:01:29equitable on to not have these
01:01:31individual deals and all of that.
01:01:33So that's really important but but I
01:01:35think that you're going to see that
01:01:38happening across academic medical
01:01:39centers across the country that
01:01:41there will be a more explicit using
01:01:44of clinical revenue to fund the
01:01:46academic mission has to be otherwise
01:01:49it's not a sustainable model.
01:01:50Does that help?
01:01:52Yes,
01:01:52it does think
01:01:56I still think the government needs
01:01:58to increase. Well, I yeah I would
01:01:59agree with that too but but given
01:02:01our current political climate,
01:02:02I'm not going to have, not immediately
01:02:05that was great and and very transparent
01:02:08in the same way that that the hospitals
01:02:11reached out you know buying up the other
01:02:14hospitals and the other practices to
01:02:16to associate and to increase income.
01:02:19What what about you know us as we
01:02:21have been in the past and still are
01:02:24going more national and international
01:02:26with multi centre grants and efforts.
01:02:29I mean, I know people are doing them,
01:02:31but is there a department, you know,
01:02:33thinking with people together
01:02:34about how how we do that
01:02:36We could, we certainly should
01:02:38do that, think we should expand.
01:02:39Isn't that what we should?
01:02:41Just seems like we're right
01:02:42for some of that stuff.
01:02:43I agree. I agree. Yeah, I agree.
01:02:45Todd would not disagree in any way.
01:02:48Thank you. Sure. Oh, yeah.
01:02:50Oh, no question. No. OK.
01:02:54OK. I think we're just about a time.
01:02:55If there are no further questions,
01:02:57maybe we leave the last comment to George
01:02:59Gannon said perfectly extraordinary
01:03:00presentation of privilege to attend it.
01:03:02So thank you. Appreciate it. Thank you.