How to Become a Functional Medicine Doctor [transcript]

Written by Christopher Kelly

June 13, 2018

[0:00:00]

Tommy:    Hello and welcome to the Nourish Balance Thrive Podcast. My name is Tommy Wood and today I'm joined by Dr. Rob Abbott. Hi, Rob.

Rob:    Hey, Tommy. It's good to be here.

Tommy:    Thanks for joining me. We just recently got to know each other, actually, although we have a number of mutual friends in the health sphere that we occupy. I think people who don't know you would probably love to hear a little bit about your background before we delve down into some of the ways that you've been building your own approach to medicine and the future of medicine as you see it as an early medical resident. Why don't you give us a bit of your background and then we can really get stuck in?

Rob:    Yeah. Well, thank you, Tommy. I first have to say it's quite an honor to even be on your podcast. I can remember as a medical student listening to Nourish Balance Thrive and just seeing the evolution of Chris and who he was getting to speak with and hearing him on other shows, Robb Wolf, and then just seeing you guys continue to grow. I actually love seeing that journey and seeing where my [0:01:01] [Indiscernible] interweave. Thank you. It's an honor to be talking.

    Like you said, my name is Rob Abbott. I'm currently, depending on when this goes out, about to finish my first year of residency as a family medicine resident in a community program in Virginia. And perhaps we'll get into maybe some of the differences between your training and our training but it can be a little confusing what stage are doctors at. I thought there's just a doctor.

    But essentially I'm still a doctor in training. I completed medical school and getting my specific training to be a general practitioner, a family medicine physician. And it's a three-year long program. I'm on a third of the way through. Beyond that, that was my title and stage of life. I've really grown to see this ancestral way of living and functional medicine and integrative medicine being the true future of how we care for patients.

    It's something that bit me because of my personal health issues as a first year medical student and just really it's unbelievable to see how it changed my life and it's motivated me to help others. I met so many people in this space like yourself just like weekend with the Paleo f(x) and surrounded by all of this passion and joy and people trying to better themselves and better others.

    And so really when it comes down to it I'm really invested in growing this community and this movement so that medicine as a whole can truly change. It may sound utopic but I do honestly feel like we can start a movement as really it already has to help heal so many people.

Tommy:    Absolutely. I know you and I are very much aligned in that manner. I'm very much interested in hearing your path because most traditionally trained doctors, as you are, come around to this kind of thinking after spending years in the trenches with patients who aren't getting any better and just realizing that the tools that they have at their disposal and the system they're stuck in just really isn't working to help their patients. But you obviously got through it much, much sooner, you mentioned, just as you were a medical student. Maybe you could talk a bit about your path and how you came to realize the flaws of maybe a traditional medical model so early on.

Rob:    Yeah. It's funny you mentioned that. I joke to people very frequently at some of these conferences and gathering because they look at me and say, "You look awfully young, and certainly not even old enough to be a doctor. So, how did you already start this?" Because, as you just said, most people go through 15, 20, 25 years of clinical practice in those trenches seeing people not getting better.

    I've heard the analogy of just rearranging the chairs on the Titanic but having this period of dissolution. And I tell them I didn't need to have that period, that clinical period of dissolution. I have my own experience, my own health, but I don't need that period to wait to then say how this is the way I should approach medicine.

    It really sort of came -- I was one of those super just excited science-y nerdy kids in high school. I did everything, super high achiever, played sports, went to a very small private school which allowed me to do that because I really wasn't that good of an athlete but really was driven by my competitiveness and internal motivation to just always be learning.

    So I entered college thinking, yeah, kind of interested in science, so went down the chemistry route. Biochemistry was a passion of mine. But it wasn't really until my second year of college where I had an experience with my grandmother. She was going through and starting hospice for metastatic cancer and actually what kind of awoken a voice inside of me was her deep spirituality and the time that she spent with her pastor and the growth that she had independent of anyone in the medical system.

    I remember even saying something like, "I'm going to go into medicine now and fight cancer." She was like, "Don't fight anything. That's the silliest thing in the world." And just the calm and peace with which she went through that transition. I mean, one of the things she said was, "If I die, I get to go be with Him. If I still live then I get more time with my family in this life." She was completely content either way. She didn't speak enough to negate that thought of, "Yeah, I want to go and save all these people and cure cancer." But that's a thought that always stuck with me and I was a very practical person.

[0:05:02]

    So I said I'd get into medicine and I'm very lucky to be accepted into a scribe program in an emergency room which is kind of a -- It's a new position. It's kind of emerged in the past 15-20 years but they help physicians with some of the electronic medical record. So I would walk around with the physician in the emergency room. This was a small community ER so there wasn't residents and medical students. It was just myself and a physician and walking into rooms with patients coming into the emergency room.

    Some of them, yes, they probably needed to be there. A lot of them, however, it was not a die or emergency. Oftentimes they were seeking primary care that they didn't actually have. And I very quickly realize I wanted to be in that space with people. I know the ER was not the right location. There was this deep need to sit and just to be with people's stories.

    That kind of motivated me to say, "Hey, you know what, I think I want to pursue medicine." So I finished my undergraduate training, that chemistry major, and went to medical school, kind of still has that perfectionist overachieving science-y nerdy kid, not really knowing what I wanted to do and got into school. When it was about six months into school when I just--

    I started to break down physically. I was achieving at such a high level. Realistically my grades were fantastic but mentally I was just starting to break down. Physically I was losing weight. One of things that used to release stress was going on longer bike rides. With the stress of school and with a bunch of other inputs I won't get into, it makes sense now from a functional perspective these triggering events, that just led to this ultimate day when I woke up and I was like I can't do school anymore. I need a break.

    I went to my dean and I asked her, "Can I take a year off? I don't know what this looks like. Can you keep my spot?" And sure enough, they were like, "Yeah, just take a year to get yourself healthy and we will save your spot. We're invested in you." That was probably the single most appreciative and moment of gratitude that I've ever felt was knowing I had this place to come back to.

    I actually went and, to be honest, I went and sought some psychiatric care. I was actually in the combined hospital and residential program for about six to eight weeks. I think it was my second week there, I was able to get -- You could hardly have any personal objects in the program and I was able to get an iPod Nano, this little tiny device. Up to that point I think I maybe had an MP3 player. I'm not exactly sure. I had this little Nano and started listening to podcasts. Up to then I don't know what a podcast was.

    I can't tell you the exact details of how I ended up there but I started listening to Chris Kresser. I think it was his Healthy Skeptic Podcast actually originally. I listened to one of his podcasts either with Emily Deans or Chris Masterjohn, Stephan Guyenet, one of those, and it just smacked me in the face. This is, one, what I need to do to get better and, two, this was what I was supposed to do for a living.

    I'm actually just supposed to come back to medicine and pursue this path. I suddenly, like really smacked me in the face, "This is a calling and you need to pursue this." Of course, it leads you down all these crazy rabbit holes because you hear this one person on the podcast, you go find another one and listeners comment they like this one. And that next year I just went down every single rabbit hole.

    I was listening to podcasts and reading just voraciously. I was a sponge soaking up all of this knowledge and was just driven to learn and to question. I wasn't in school but I had my own medical school. I had notebooks where I would keep notes from podcasts and highlight. I found them actually this past year when I moved to, for my residency, and I was found this stack of ten, 12 notebooks that I kept for -- That was my school for a year, all in the sort of integrative ancestral functional space.

    So when I came back to school I came back with a completely different mindset. One, I had just spent so much time sort of pursuing a practice of yoga and meditation and just embracing mindfulness and of self care and just rooting myself in that deep practice and self-awareness. Who was I? Knowing that when I reentered school I was going to be bombarded by other people's thoughts, other people's opinions, new knowledge, but I was going to have the compass, the sort of internal value system to be able to evaluate what was being put towards me and stay resilient within it.

    And sort of keep my lens, in general, this ancestral lens with whatever knowledge came my way. I could always come up with something to think about it or to question. I didn't accept anything as fact. It wasn't about being cynical. It was simply about being curious. And I realized too that in trying to pursue integrative and the functional medicine it felt like family medicine is a profession was the closest thing where I could be involved with people from when they're born to when they transition to the next life.

    It became very clear right then I'm going to pursue family medicine, I'm going to do an integrative functional medicine practice and the details of which I had no idea but that was what I was going to do and sort of leads me to where I'm at today.

Tommy:    So what does that look like now, finishing the first year of your residency? I imagine you spend a lot of time seeing people who you wish you could help more extensively but time or other aspects of the system might prevent you from doing that being somewhere with people and their stories.

[0:10:09]

    It's very rare that within the traditional medical system you can actually do that. Is that the case? Or are you even now able to carve out some time to do some of these other things that you know will be important?

Rob:    Yeah. That's a very, very good question. I think there's a lot of probably misconceptions and just misunderstandings about what residency training looks like. The reality is it's certainly not like Grey's Anatomy. It's certainly not like, maybe a little bit closer to Scrubs. You get that question all the time. It is very, quite intense. I mean, you're working very long weeks but I'm honestly quite blessed to be at a community program and I chose to go to a community program for a very specific reason.

    I mean, I came from a big academic center with medical students, residents and just everything you could imagine and now I'm working one on one with hospitalists when I'm in the hospital or one on one with the preceptor in the clinic and getting a much more intimate experience in medicine. Realistically the first year of residency as a family medicine resident I joke of all the residencies, the specialties, internal medicine or obstetrics and gynecology, we do very little "family medicine."

    It is very hospital-centric so a lot of your first rotations are time that you spent caring for hospitalized patients whether that's pediatric patients, adult patients. We spend time just working at night and taking admissions both kids and adults. I spent time in the obstetric wards with deliveries, spending a little bit of time now in sort of the surgery area.

    We get right now half a day a week, half a day of outpatient clinic where we're actually doing what you would think of as a family practice doctor. A lot of my experience right now has been in the hospital which you would think is rather restricting. You're like it's a hospital, everyone's sick, we can't really -- the resources you would want aren't really there.

    But the one thing in general that you do have to some degree is you do have time, more time in general than you would actually have in the clinic as it is sort of now with most of clinics where you get a ten or 12-minute appointment with a family doctor. In the hospital, if the practitioner, and in my case as a resident I don't have this incredible workload that the hospitalist do, and still I'm seeing quite a few patients, but I can go back and spend more time with patients because I don't have a clinic schedule. I don't have a time of when I needed to see people.

    If I want to spend more time I will go in earlier to try and spend more time with my patients. I've had some of those conversations, uncovering that story with patients in the hospital. Actually, that moment, for a lot of people, regardless of what that illness is, a lot of times it's an acute exacerbation of some chronic illness, you're able to tap into that person's why and get to start to understand why they might now want to make a change because no one wants to be in the hospital.

    I mean, it's probably the most vulnerable and depressing place when you're giving up all of this and you're sick. Oftentimes people get a new motivation to change. And if get any glimmer and can engage in some motivational interviewing, I'll take that opportunity with people and will use very small steps. Most of them, I'm not going to be seeing once they leave the hospital. A few of them I have actually seen in the hospital, told them about my approach and have come to see me in the family medicine clinic.

    But I can at least try to direct them in certain directions. One area that comes to mind is autoimmune disease. Honestly, it's a bigger problem than heart disease and diabetes. Statistics actually don't lie. And even cancer. If you look at the number of people living with autoimmune disease, it's a bigger problem than cancer and heart disease.

    I see tons of people with autoimmune conditions or complications related to that and so I've been quite blessed to be a part of some trainings and close relationship with Mickey Trescott and Angie Alt with Autoimmune Wellness and they have some incredible resources and handouts that I've been able to utilize and start people on a path to maybe they don't do AIP, the dietary protocol, with every single detail but you just simply saying there is something that you have control over besides these costly and sometimes terrible medicines that we have for you, there's something that you have control over, people's eyes just open up and they say like, "You're the first person who's ever even sat down to talk about food with me and even say that this might be something that could affect my disease state."

    And that type of experience is just, I mean, I have no words for that. I mean, I've seen people moved to tears when they just recognize that there's at least something, whether they do it or not, that they could do to maybe improve their health once they leave the hospital setting.

Tommy:    I think that's incredibly powerful. There are a number of practitioners and people who listen to this who may think that they don't necessarily have the time to do all the stuff that they want to do but maybe just that initial interaction, letting somebody know that they do have the power to control what's happening on some of the disease processes that are going on and have some impact on that because the most common thing you hear is, "Oh, your diet doesn't have any effect on that," regardless of be it heart disease or less usually heart disease but gastrointestinal stuff, autoimmune diseases.

[0:15:11]

    It's very common for people to be told that diet has no impact on that when we know that that's absolutely not the case. So even just giving people that glimmer of hope is something that pretty much anybody can do. It doesn't necessarily take that much time at all. So then with your experiences of the traditional medical system, how do you see your own practice evolving over time? Will you stay within a traditional system or will you move out as many people do into something else that allows you to practice more widely or more differently compared to what you might have to do if you are within the same system that you're training?

Rob:    Yeah. That's also a very good question and also I'll start by saying one of the somewhat frightening things to me as a family medicine resident is that the majority of residents, once they complete their training, they're not going and starting or even necessarily joining outpatient clinics where they're seeing patients in a clinic setting.

    A lot of them are joining and becoming what are called hospitalists which are essentially medical doctors who take care of patients when they're in the hospital. And they establish relationships with local family doctors and sort of say, "Hey, if your patient is really sick, I'll take care of them when they're in the hospital, administer medications, try to get them better and then send them back so they can follow up in your clinic."

    And it's really good relationship and a lot of people like that job because a lot of times you work for a week and then you're off for a week, you work for a week and you're off for a week. The schedule can be somewhat lucrative and the pay is somewhat more lucrative and a lot of times you're not having to worry about business. You just got to show up, you do your work, the hospital is what it is, and when you're home, you're home.

    So a lot of family medicine graduates go on and do hospitalist work. Ss I've just described, which can actually be -- you can do incredible work. I will say the time constraints on most hospitalists are rather restrictive. So what I describe of myself as a resident is not necessarily what's happening with the hospitalists. Make sure that's clear. The other thing that a lot of family medicine residents are doing is going into urgent care or into these clinic settings that are popping up in Walmart or like the CBS clinics, these walk-in clinics.

    Because that's also kind of lucrative thing. Realistically it's an urgent care so you're not actually that much invested in the ongoing maintenance of that individual and you're really kind of just treating things that shouldn't be in the ER and just need some stitches or an x-ray and this and that. And that also has some degree of flexibility. People enjoy that.

    

    To me, that's kind of, for lack of a better term, that's a waste of this training that we do get as family medicine residents. I mean, arguably, the breadth of training that family medicine resident gets is probably the best in most robust any medical profession in terms of your capacity to at least have some idea of what you might be able to do for that individual. But a lot of people aren't going into clinics and the reason is we've gotten so big and insurance is so terrifying and the restrictions and lots of hospitals, they own their own outpatient clinics, so you're still kind of working in a hospital system.

    The idea of a truly kind of independent practice of two or three practitioners is dying away. For me, having seen the restrictions of insurance and billing and a number of people you have to have in an office in order to operate from a traditional model is insane to me. And the amount of overhead that goes to things other than directly caring for the individual, it would drive me crazy.

    Going back to that self-care piece, I knew there's no way I can operate in that structure. And so I've really gravitated to a new model that's emerging called direct primary care. It's something that is being more popularized and there's a really good podcast Robb Wolf and the Paleo Solution had a gentleman, I forget his name, who was doing a quite unique direct primary care practice.

    It's basically a new model that utilizes a membership model and encourages people to either join health shares or get a catastrophic insurance plan should they need to be in a hospital. But structuring a direct primary care practice where you can see far fewer patients, make a living and make yourself available. That's the biggest thing that people want, is your availability, your time as a practitioner.

    And through that model you can make yourself much more available to the people and the family that you care for and increase the network in which you can see them. A lot of people do direct primary care and they don't even have a real office. They'll work in the gym or work as part of a yoga studio and maybe in three different places in any given week. So the flexibility of the types of environments they can see people in is rather unique.

    I recognize the value of that but also recognize we don't get that training from a business perspective pretty much in medical school. I do have luckily in my residency some good practice management and business foundation, at least understanding the traditional model, which has been very helpful. But I've had to go out to seek some of the trainings and understanding of what does it take to start a practice like that or what are some of the things I should be considering? And it actually already started in the past couple of months with two of my really close friends and partners, starting our own functional medicine clinic.

[0:20:05]

    And sort of acting at least initially as a medical director, as I sort of direct my clinical care and my residency training, but basically setting up a clinic and starting to see people to work on lifestyle and nutrition and being able to oversee their work and basically starting that now knowing that in two years time I'll be done with my residency and wanting to start seeing people in that kind of environment.

    Those things don't just, poof, happen overnight. That's one of the reasons why a lot of people join hospitalists because it's a lot easier to just sign a contract or something than spend months and years trying to set up that fairly ideal work environment. But that's what I'm actively doing. The clinic is in Virginia. It's in Charlottesville, Virginia where the University of Virginia is at.

    We realistically don't have a big -- It's not a big functional medicine or integrative medicine presence in the central Virginia area as of yet. It is incredibly growing and I sort of recognize that need. I see myself as much as I'm drawn to some of these places like Boulder and San Francisco and so many more progressive places already, I'm really sort of drawn to go back to that community where I see as my home to help grow this. Because there's so many people there who want it and know this is the way that medicine should be practiced but it's just not quite there in terms of infrastructure yet.

Tommy:    There's many questions that come out of that and I think the first one is: Of the people I know who are doing direct primary care models, they tend to be in small communities or in areas where -- this is just the people that I personally know -- in areas where that kind of functional medicine, if you want to call it that, where that's fairly new and people maybe don't know as much about it.

    So it strikes me that it must be quite challenging to help patients realize that this may be something that's beneficial to them because it's, obviously, a very different way for them to approach both paying for and then interacting with healthcare. Do you end up having to be hard entrepreneur to try and actually get this working? How do you approach a discussion with patients about healthcare models and how things may be different in different kinds of models and why something like direct primary care may be more beneficial to them?

Rob:    You have so many good questions. The easy answer is, yes, I'm having to be an entrepreneur. Actually, James Maskell of the Evolution of Medicine has probably been one of my greatest friends and mentors, like owning that. I don't think enough people in medicine -- I don't like using the term it as a business. I rather like to see myself as an entrepreneur rather than a business owner.

    Because there are a lot of things that I'm doing that I'm not selling a commodity or a good. I want to be part of this person's experience and integrated into their journey for wellness. That being said, I'm definitely an entrepreneur and have that discussion quite often. One of the people that come to mind actually is my -- I'm very active still in my local church and youth ministry and very close friends with my pastor, and tell him all the time of how I envision coming back to Charlottesville with this clinic.

    I would love to be the physician for the members of our congregation, for our church. I'm having an office in the church. I mean, a lot of the space that's there doesn't get utilized during the week. And so talking to him about that kind of model. One of the things that's been relatively new but something that I think is a very positive movement within some of these Christian communities has been the idea of a health share.

    Essentially what that model is, is everyone kind of agrees to assume the total burden of cost by people involved in that community. They also agree to say, "Hey, I'm going to try to take as good a care myself as possible. I'm not going to smoke. I'm going to try to eat healthy nourishing food. I'm not going to directly try to injure myself or abuse medications."

    Part of the contract of joining of these things are making that kind of commitment and that oath. People recognize by doing that, by agreeing to help share the cost between each other, they actually would create an incentive to, in total, utilize less medicine. Through that, if everyone utilizes less, then they would all have to pay less and contribute less.

    When it comes to the insurance model, on the other hand, insurance companies, they're really only worried about the difference between that profit margin. So, if the total cost of a service, a lab, what have you, continues to rise, they will continue to go above that and just keep their little margin with no real concern of what that -- there's no ceiling to them. They'll just keep going into infinity. But with this model people are invested in their health, number one, and two, they're agreeing to help each other out.

    It's a model that lends itself very well to these direct primary care practices and it fits well with the membership structure. Because you can start to do some of the math. A lot of the plans out there now for people contain these very ridiculous premiums or deductibles that are $5,000-$6,000. Basically, you're having to spend, depending on the type of service, but in general spending $5,000 or $6,000 out of your pocket before your health insurance is giving you any kind of coverage.

[0:25:03]

    With some of these health shares, individuals and families, they're contributing $150, $200, $250, $500 a month but getting services. And so sometimes, and I won't go through the math of it, but like the total cost of that that they're getting, they may pay $6,000 in total and that's still be relatively expensive plan, but they're actually getting the services that they want and some of the more maybe complementary or alternative practices.

    And this model is expanding. I mean, it's something that originally with the ACA was only made -- Basically, they were able to kind of get an exemption to the ACA using a religious exemption. That's why some of these, the most prominent ones are founded by Christian communities and have language surrounding that. But there is still a scale. I was looking at them fairly recently, their documents and avocations to become a member.

    There are some out there that are actually fairly open. For example, some things like accepting same sex couples as a family and not having very explicit language about having to believe in Jesus Christ, for example, as your savior. These are just examples. I see that this model, especially now with the Trump administration, I know they're trying to change some things that would actually make it a lot easier for these health shares to not necessarily have to be under a religious exemption. We could expand health shares within local communities as a way t o contain cost and actually give people coverage for things that will help them.

Tommy:    Yeah, I think that's definitely a model that I know a small amount about and I know that Chris, in fact, uses a health share. That's the way he's been doing his own health insurance for his family and other people who work in Nourish Balance Thrive are doing the same. It's definitely something that I know people are starting to take use of and the way you describe it makes perfect sense.

Rob:    I did realize that I didn't totally answer your question about the entrepreneur. I guess, the short version of that is recognizing those health shares, I think communicating with them to see will you cover -- at this stage, yes, the direct primary care practices, even traditional practices, they're covering most of those services. But will you cover these types of services? So then can I market or tell my patients, "Hey, go join this health share because my service and these other services will be covered. Plus, you're probably going to end up saving money."

    And then the next step is going to local businesses, in the corporate level and saying, "Hey, rather than paying for this ridiculous insurance plan, let's engage in some corporate wellness, preventative medicine and do join into these programs because ultimately they'll probably going to save you tons and tons of money." So, the entrepreneur side of things is connecting with these health share companies or going out to these businesses and saying, "Hey, I think this is a good idea because it's only going to improve the viability and value of your services."

Tommy:    Absolutely. And commend you for doing that. I'm thinking of other people who are maybe entering into this space either as current students or wanting to change careers and thinking about the things they might need to do to get some of this stuff going. I'm fairly sure that not everybody is going to be as entrepreneurial and outgoing as you maybe are. Do, do you have any tips on how other people might still be able to set something up for themselves, make sure that they're getting some patients, they can afford to pay the bills, pay the mortgage and look after themselves without having to have such a broad ranging entrepreneurial mindset?

Rob:    Yeah. Sort of listening back to what I just described, probably for most people incredibly intimidating. That's exactly why people join as hospitalist. That's just so intimidating and just like I'm not going to put all that energy and effort. The reality is, what you just said -- you asked a very good question. I've had numerous students reach out to me in the past year and half since I really become a little bit more vocal and involved in this space.

    As I mentioned, James Maskell again has been trying to push me, recognizing, he's like, "Here's this young at that time medical student resident interested I these things. Why aren't there more people at this age interested in these things?" And I've been approached by numerous students both medical students, DO students, PA students, undergraduate students, and the question always comes up of I already know I want to do integrative or functional medicine, is med school the right choice? Who can I connect with to learn more about this? How do you start a clinic? All these questions.

    I've started to come back to people and say a couple of things. The first is, back to what I mentioned earlier, when I came back to school I dedicated so much time to really, and it may sound woo woo and out there but that's self-awareness, identifying those core values. I dedicated yoga practice. I dedicated meditation practice. And really deciding what it was that was right for me.

    Because the hardest thing you're going to find is what do I say yes to? What do I say no to? And whatever train you go through, not just medical school, you're going to be receiving new knowledge. And it's your decision to how do you incorporate that or how do you think about that new information or integrate that into how you approach clinical medicine? And medical training, traditional medical training is extremely rigorous. It's four years of medical school and at the very minimum three years of residency, sometimes four or five, and it's actually years of fellowship.

[0:30:04]

    It's a lot of time to be spending and a lot of money and debts that you will accumulate from that experience. I won't go into the pros and cons of that but you will accumulate a lot of debt. And we are emerging now where these some people will call mid level providers. I don't really like that term because it's a little demeaning. But physician's assistants or PA or nurse practitioners are emerging as a -- it's recognized that we need more clinical minds in this space, not just traditional MD or traditional DO.

    And they have a relatively accelerated program, sometimes two or three years, and the debt load after that is much, much less. You're actually, depending on the situation you want to go into, can have fair degree of freedom in your practice. I've started to direct people who come to me with this interest who may still be undergrad and I tell them to be honest. If you're going to pursue medicine, the traditional medical route, you have to have that foundation, that core, and you have to stick with it each and every day because you're going to be faced with things that you can't even imagine now.

    I mean, I'm not like saying that in just cynical or depressing way but that's the reality of that and you, Tommy, I'm sure know about your training. That's just the reality of what this experience is going to be. I would actually much rather, knowing your interest now, have you go through a program that will be as comprehensive as a nurse practitioner program or PA and let's get you out into the clinical work force faster and, not only that, but see if we can partner you or look for maybe clinics that are established or somebody within your area who you can connect with and get some internship, get some more clinical experience with.

    Don't spend all this extra time joining a hospital system, doing medicine that you don't want to do and just getting cynical and negative about it but let's get you out into the workforce sooner and get some more clinical experience in the areas of medicine that we most and deeply need.

    Actually, a lot of people I talk to about that have received that and said, "Hey, actually, that sounds pretty cool." And my hope is that we do start to see larger clinical teams and clinics start to open up that embrace ancillary providers as a place to have these PAs, nurse practitioners, naturopathic medical doctors, places to have outside of the traditional route and join an integrative practice.

    I'm so interested in that. I do see as I go forward two of the things I'm most passionate about, you could probably tell, education and research. And so I would love to, in the same sense that we have these residencies in traditional medicine, would love to be able to establish as I grow my future clinic a residency program for physician assistants or nurse practitioners or naturopathic medical students who otherwise don't really have that clinical experience and are either going directly into some job setting, which may or may not be ultimately what they want to do, but establish kind of a residency program where they can engage in a community project, engage in some research and get clinical exposure in the context of a team and feel like they're learning something and learning tools to help people.

    Because realistically, right now, it's something we are missing I think in this movement, is that direct mentorship. It is starting but there's so many people who want to shadow and to work with some of these integrative providers and I think a lot of us are feeling it's so new that it's like I started this practice to be on my own, I control my life, this is all I have time for. I'm just learning this myself. How can I be a teacher, a mentor for you?

    And so I will say for anyone listening who might be in that space, I encourage you, push you to see how you can connect with maybe some of these younger students and see you can be that positive mentor to lead them in that direction if they're already interested, help to nurture that and grow that within them.

Tommy:    I think that the discussion is incredibly important and particularly the providers outside of traditionally trained doctors, MDs, and this is something that I've thought about more and more, I guess, recently as we talk about functional medicine. Functional medicine has a terrible branding problem because the word functional in medicine is basically code for the patient is making it up.

Rob:    Yeah.

Tommy:    If you have a functional problem, you're basically saying that that is not a real problem. So then you automatically shot yourself in the foot by calling it functional medicine but that's, I guess that's just a problem we hopefully have to deal with. But the bigger issue is should it be medicine at all? Should particularly preventative approaches or lifestyle approaches to maintaining or achieving health? Should that be in the realm of medicine? Should that be doctors who have control over that?

    I mean, it's never been part of the traditional medical model. In fact, preventative medicine usually just involves screening for stuff so that you can find diseases earlier. It's got nothing to do with actually preventing a disease at all. So, should we be trying to create a system that prevents disease outside of medicine such that medicine itself doesn't even need to worry about it?

Rob:    Man, you really do have some wonderful questions. A couple thoughts on that. Living here in the present, here and now, I was just early this afternoon in our general surgery clinic.

[0:35:00]

    A lot of what the general surgeon does is colonoscopies, screening tests looking for polyps or colon cancer. People are probably pretty familiar with colon cancer screening and colonoscopies. It's the dreaded thing when you turn 50 and all of a sudden your doctor wants you to go get this colonoscopy. Everyone is like, "No, I really don't want to do that. I want to drink all that MiraLAX and Gatorade and poop my brains out then have this doctor put a camera on my butt."

    Everything about it just seems kind of icky so people put it off, put it off, put it off. There's a lot of debate about what's the real utility of this colonoscopy or, as you just mentioned, screening. I think you bring out incredibly good point that we're not really preventing anything. We're still detecting things that are already there. And today talking to a couple individuals who had colonoscopies last week and this is a follow up visit, reviewing we found different types of polyps and what they look like under the microscope and how worried should we be and when should we do the colonoscopy again, this whole preventative mindset.

    It sounds all good, right? We're being proactive. We're going to check you again and we took this out, we're going to check you again in three years. But until then, I think you're going to be good. Nothing grows that quickly. But none of that is preventative. None of that is saying, "Well, what can we change to change your trajectory?" And we have at least some ideas as to how that process began, how those polyps started to form. Like what are you doing with your lifestyle?

    What are you doing with exercise? How are you sleeping? What kind of foods are you putting in your body? What's your social community like? We don't really talk about those things, the things that will actually change whether or not new polyps are cancer growths. But we're still enamored with and so actually fearful of cancer that we're trying to detect its presence or pre-cancer lesions and then remove them and say that we're preventing things.

    Yes, maybe that would have gone on to create cancer but you didn't change anything of that person's trajectory. And it's something that we get tons of training as family medicine providers and all the different screening tests that we should be doing. I have to use an app on my phone to type in the person's age and a number and it comes up about 50 different things that I might, should be looking for in this individual at any given age or time with relative levels of evidence.

    All that sort of brainpower going into this "preventative model" but part of me thinks that we should have a completely different division and education for people that are really wellness providers and doing the things like you just described. Coaching for lifestyle. I loved the conversation -- I think you had with Rangan Chatterjee, Dr. Chatterjee on your podcast and just love, love, love what he was saying.

    Some people might say, "Man, it's just the same story over and over again. We keep talking about lifestyle. We keep focusing on lifestyle." I love it because you know what, we don't exhaust it enough. The easiest thing, the thing that I hear all the time is, "Well, I tried diet and lifestyle and I couldn't lose weight. I tried diet and lifestyle and I couldn't do that." And it's not demeaning anyone's effort or what they put into it but we don't exhaust the capacity for all of those things to improve a person's condition.

    It's not eliminating the use of medicines or targeted supplementation or these other therapeutics that we created with modern medicine but I really want to exhaust our capacity and encouragement to make meaningful change. And the reality is if I'm seeing someone for 15 minutes it's actually pretty easy to exhaust my capacity to help that person because I have no time with him.

    If I'm not aligned with a health coach, if I'm not aligned with somebody who is providing dietary advice, I don't have much to provide them. And so in the current model, the current way of medical care is delivered we can't really do that. So, I think we need a new way to educate certain types of providers or integrate them into teams that are really focused on wellness and create time so that we can truly exhaust our resources into making meaningful lifestyle change.

Tommy:    So, do you have any ideas about how that might happen? Chris Kresser with his unconventional medicine approach, he's big into health coaches, he's training health coaches himself, how do we create a market for those coaches? I think we're getting to a point now where lots of people they have usually success with their own health, certainly happens with other people that we work with, and then they're like, "This is great. I want to help people do this."

    And then they'll do some kind of certification be that the Kresser certification or there are some formally accredited courses that you can do in health coaching now or at primal health coaching, certainly different option exists now. And then you come out the other end and you're like, "Well, where do I get clients from? How do I now be connected with the people who need my help despite the fact that it's the majority of the US population who can benefit from this? How do you connect these people?"

    We have patients who need it and I think we're starting to produce the health coaches that can help them. How do we start to make those connections? Because certainly, like you say within the more traditional model, that's not happening yet. So, do you have any thoughts on that?

Rob:    Goodness. If I had the complete answer to that, or if anyone did, that's few billion dollars right there for you if you can figure that one out.

[0:40:00]

    I mean, I completely agree. I'm very much in alignment with what Chris Kresser is doing. I took his practitioner training year long course and has been really excited about what he's launching with his health coaching program. As you said, there's so many of these programs coming out. I'm a little weary because it certainly is at this point one of those titles that people can theoretically saw around and I think realistically we probably have many more health coaches than we have people who think that they want health coaches or know what a health coach is.

    That is a problem. But I think two things have to happen. Some people might get upset at my first answer but one of the things that came out of being at Paleo f(x) this last week was recognizing how much we need to invest in our own communities. I know they kept using the word change agent and really tapping into our communities.

    I think in our age, we don't oftentimes, oddly as this may seem, turn to our community first. We turn to the internet and social media and online communities which, yes, it's a community but maybe your entire, everyone you're working with is 500 miles away and you haven't tapped into what the people who you're living next to think and really need. That may seem intimidating but I'll give an example.

    Two of my incredibly close friends in the Shenandoah Valley region of Virginia, very rural region, they're both incidental health coaches and they had recognized -- They go to all of these events. They're totally engaged in this ancestral movement. They recognize their passion is the people in their town. That's a few hundred maybe a thousand people. They have one small school system. The types of things that they're wanting to do are to give standing desks in the middle school, to hold an event at the main community center to start to bring awareness about that.

    They've spent so much energy looking for people to come and give talks and bring awareness but do it in their community. And that to me just has been really inspiring and pushing me to push more of my resources to my local community. I mean, it's in the name of our new clinic but we've already started to do, which are arguably the hardest thing to do, but reaching out and connecting with local providers, trying to get into our Farmer's market and get to meet people.

    I do a mailing campaign to local folks and trying to ask what people what they think they need because people don't know what a health coach is. They, obviously, won't know that they probably need one or could benefit from one. But they probably also won't care as much if you're on the west coast and they're on the east coast. I'm making generalizations but if we all started to focus on our individual communities and then we amplify that, so I just worry about my little community, you worry about your community and we all do that, we've suddenly now taken over the whole globe because we're all worried about our own little community.

    So then people may say, "You're so just so narrow-minded. We need to connect." And I do love connecting with people but I think we would be better served to start to really look into connections within our local communities, start to have conversations with people to see what they need. I mean, that's what I'd been doing in the hospital here as part of my training. It's a different population, and getting to understand what people, how they shop, what they need, what's going to be realistic for them.

    The other is starting to really make -- and this is a big thing at Paleo f(x), some of the higher level initiatives like how can we change how our food is produced? How can we change what is available in grocery stores? How can we change -- can we use the term big food and big pharma? And this seem like things that are completely insurmountable but we as a consumer have so much power to choose relatively speaking who we're going to support, what businesses are we going to support.

    Where do I buy my food from? Once again, some people might get upset because we talk about food deserts and the details of this. But start to be as engaged and active consumers and use the money that you have and put it towards people that you support. It's one of the most amazing things for me with fairly limited resources as a medical student and resident.

    I've been so passionate about trying to get as much as I can and support my local farmers at my Farmer's market and I love connecting with them and engaging with local herb shop and trying to support and to get to know them and know where my money is going. I think combining that with some of the initiatives that we're doing on a slightly larger scale for land management, animal management, and what really is available in our food supply, I think we're going to see some major change.

    Because as long as there's still that massive display of cookies in the front of that grocery store that you walk into, that's going to be really tempting to avoid. And people are going to buy what's there. And if we can do a movement can then by what we choose to buy, have grocery stores filled with entirely organic produce and other nutritious foods then that's what really is going to make it easier. As long as these things are still out there, as long as McDonald's and these things, maybe it is inevitable.

[0:45:02]

    Maybe it is utopic. It's going to be very hard for some people to make some meaningful change. That was a bit of a rumble. Maybe it didn't answer your question but maybe it sparked a discussion for some people.

Tommy:    Yeah. I'd like to get back to your first thought. I completely agree that we should be focusing on our local sphere and our local community. There's far too many people who come into this space and decide, "I'm going to be the next big name. I'm going to be the person who fixes healthcare or fixes this or changes this for everybody."

    In reality, literally nobody can do that. It's a fool's errand. No matter how smart you are, no matter how much marketing you do or money you sink into it, you're just not going to be able to do that. Everybody can focus on influencing the sphere of people around them and if everybody does that, the people that you influence in your sphere then influence the people in their sphere then you can have this huge effect.

    That also comes down to people who are trying to perhaps find clients online and do you need to start a blog and get a huge email list and be on social media and Instagram and Facebook? You become this person who's trying to differentiate themselves from all these other people who are trying to do the same thing. Whereas, if you're the only person offering this kind of thing to people in your local community, you go out and meet people where they are and you find out what they need and you're there to offer them help and it's face to face, you don't need to separate yourself out from this huge online milieu because you're right there. You're doing this in person and that stuff doesn't matter anymore.

    I think if people really focus on their communities particularly people who just want to help others be healthier, don't have aspirations to change the world, that's where they're going to really have their impact in their local communities. So, being able to focus on that and go on and speak to your, like you said, speak to the farmers at the Farmer's market and speak to the people around you, speak to the neighbor, that has the potential to have the biggest impact rather than everybody trying to do everything online and have a huge reach because I think you'll almost end up canceling each other out. I think that's a great idea.

Rob:    Yeah.

Tommy:    I have last couple of questions that I want to ask you, sort of pivoting slightly just based on your own individual journey, things that I've seen from you. I'm sure a number of people would be very interested in terms of how you did some of the stuff that you did. So, before we were introduced I heard you on Chris Masterjohn's podcast, I heard you on Michael Ruscio's podcast, you spent some time in his clinic.

    This was as a student. Most people who were students of health in one way or another be they practitioners or wishing to be practitioners would probably bite your arm off to find out how you managed to get such great connections early on in your career. Maybe you can tell us a little bit of how you did that and I apologize to Chris and Michael if they suddenly get an influx of emails. I think it just points to their popularity. But I'd love to hear some of those stories.

Rob:    Oh, man. This is going to be fun. So, really, this boils down to -- and one of my good friends [0:47:56] [Indiscernible] he told an incredible story on my podcast that really I started to see as right now in this moment as that answer to what I really didn't know before. I was always just kind of living and doing. But this really reality of being courageous and not caring what other people thought of you.

    I'll put it in this light. So, he basically tells a story of picture something that you're wanting to do. In this case, maybe it was sending an email to Chris Kresser or to Michael Ruscio and saying, "Hey, I'm passionate about these things. I would love to learn more. What should I do next? And maybe even can I shadow in your clinic?"

    You have that thought. Second thought, it's probably like, "Well, this is completely pointless. This person, they're so busy. They're big names in this space. They wouldn't even bother. They probably don't even check their own email. This is a waste of time." You start hearing that voice. But then my buddy Jamil says, okay, stop for a second. Suppress that voice and start this visualization of so what if you sent that email? It goes into an inbox, maybe it's not them but it goes into an inbox and it arrives on their desk and they read it. And they read through it and as they're reading through it, they're like, wow, this individual, you can feel the authenticity of what he's sharing. Let's send a reply or response.

    And so he responds back and you get that and you're like, "Wow, that was amazing, totally unexpected." And you start a conversation. You send another email, maybe a number and you get a phone call and you start talking and sharing and you have this great moment like we do all day when in social space and you find someone else who really resonates and is talking with you and hearing your story.

    And then a few months go by and then you start collaborating on a project. You get invited to be on a podcast. You're on a podcast and five, ten years later you've started a clinic and you've done research with this individual. And you can just keep going and going. You do this visualization. And the idea is if even the slightest possibility of that happening comes into your mind, why do we even think that's a yes or no answer?

[0:50:00]

    Of course, I'm going to try. If that is a possibility, of course, I want to send those emails. And doing that exercise time and time again of not letting that voice, of that fear of being rejected or not being heard or being a waste time, not listening to that voice and not listening to that fear and just doing it, and then being so wonderfully surprised when you do get a response. That's what kind of what I did for a period of time.

    I was about two years into it. I was a third year medical student and starting to feel more comfortable with some of this material and wanting to take it to the next step and I've been following some of these -- like you guys. Following some of these individuals and just being so passionate about it. And then started sending some emails. I sent a bunch of emails to people and I think one of the first people I actually connected was Stephan Guyenet which happened to be a super funny coincidence.

    His dad actually is a professor in our medical school at the University of Virginia and he's got this amazing French accent. They still live in that community. Stephan was coming home for the holidays one time and we arranged for him to give a talk. That was sort of my first going to Starbucks and having coffee with Stephan Guyenet. Man, how did this happen? And then that led to Dr. Ruscio and connected with him in his clinic where I was doing a tour of residency in Northern California area and got to be in his clinic.

    And so really it was just sending out these emails. These are examples of responses. But there's other, many people I hadn't hear from or responses that weren't that great. I was never discouraged by it. Like I said, I tried to not let that fear stop me, and just being pleasantly surprised I did find those connections. The other piece of it too is, and I heard this idea -- gosh, I forgot the name of the gentleman.

    He has some wonderful content. But this idea of needing to network, this idea that as a young professional I need a network and go find all these people and then that's what's going to make me into something greater. He basically put those points forward and I completely agree. It's like networking actually, even by some of the evidence and data shows that it's not really that helpful. You just need to work on creating something that people can't ignore or focusing so intently of directing your passion and growing your knowledge and creating something that people actually want to engage with and devoting your time and passion into yourself.

    And then people are going to start to pay attention. And then people, you're going to attract the people. You might not have the choice of who you interact with, but don't waste your time just trying to like network with that person just for the sake of saying, "Hey, this is me." Resonate with that. I think that's what I saw myself as. I was in this incubator for a couple of years of just really that sponge, just kind of marinating in all these new ideas and exploring and reading and then I decided, okay, I'm ready. I think I can have something to potentially offer this space and would love to grow and connect with these people.

    Hopefully, that's an inspiration to people to don't let that fear stop you but also like create something for yourself and do something you're so passionate about that you can't be ignored.

Tommy:    Absolutely. I really enjoyed that. Thank you. The question that I have that comes out from that which is part of my own, I guess, personal journey is have you gotten to a point where sometimes there are people who you followed, greatly admired, done fabulous work, and then you actually find yourself starting, just based on your experiences or based on some of the things that you read, that you actually start to disagree with them, that you think, actually , "I don't think that's quite right," or, "I would do things differently there." Is that something you started to experience? And then how would you approach that mentally when you start to -- people who may be you are starting to collaborate with or people who you've admired for long time then produce things which you are less inclined to agree with, how do you think about that?

Rob:    Yes. Another wonderful question. I will say I will not name any. There will be no names in this, anyone who I particularly agree or don't agree with. Yes, that is actually probably the most critical thing that we can be doing in this space. It's something that I've, in connecting with Michael Ruscio, he has been probably the most important mentor to my clinical approach.

    As I've entered the space more fully and recognizing and all we think there is towards new information and questioning dogmas presented and trying to do this as a furthering of the movement. I think you as an incredible scientist recognize science is generating hypothesis, investigating, and trying to further, we come up with something that was wrong. Okay, let's try something new.

    And this sort of adaptive process. And we need to help each other through that. Certainly, as I've gone through this and continue to be critical of what comes out, I had to keep an open lens. I disagree with some of the things that people who I originally followed and everything that came in to my ears from that podcast was gospel, now I'm like, "Well, I don't necessarily know about that." I guess, this won't get anyone in trouble but I think a good example of this -- you guys had Bryan Walsh on pretty recently. He is talking all about detoxification. Well, I think that's a great example of I've always been a little sort of like, I just don't really know what this is all about.

[0:55:05]

    Well, the things that people are doing, it just seems kind of -- is this really helping? And this program we created, was his search deep search into some of the [0:55:14] [Indiscernible]? I don't know if that's really supported. And realistically, maybe we should be doing this instead. It's people like him and when information is presented to me, rather than immediately accept that, especially that's coming from within a space that we align with, I try to use that as a springboard to dive in myself.

    You guys do a great job of having links to studies that are mentioned in certain podcasts. There are lots of evidence in your highlight series. And using that as a springboard to, okay, you're presenting me with this argument. This idea sounds pretty compelling. Let's see what this study says in my opinion or let me start to read a little bit more about this before I just suddenly accept it as gospel.

    I don't want to like demonize anyone there. I'm not saying like if you're not doing that, it's not a bad thing. I myself when I was first in the space I didn't have -- I wasn't at that level to be able to really do that. I had at least enough from a medical training to think critically and read through studies and kind of analyze the quality of data and how it's presented and the conclusions. But it does take a little bit of time to being within that space and giving yourself the time to critically think about what's being presented to you. That is so, so important for us as individuals and as a greater movement.

    Because if we just all live in the echo chamber and we just accept everything that each other says we're never going to be able to get out of that. That's further reason for people who want to for either directly harmful reasons or just because they think we're silly people who eat meat and vegetables and move a weird way, give them more reasons to like to tear us down.

    So, yes, we need to be doing that. I think you guys do a great job or trying to present different sides of the argument and giving people that opportunity and the space in which they can think quickly and not just saying, "This is how it is and this is what we should be doing."

Tommy:    Yeah. I completely agree with you in terms of that approach. You're right, when you start out, you just have to pick some people you trust and go with their recommendation and where they point you and try it on and see how it works. Eventually, like you say, you get to a point where maybe you can start to evaluate the evidence that you have.

    That's certainly something that we try to do but I have people who email me and responds to things I send out and disagree with me and that's the best possible thing. That's absolutely what I want. I will give you the evidence I have and if you have other evidence I absolutely want to hear that. I actually think that's one of the benefits of working in teams.

    You mentioned that you started a clinic with two other people I think. Those who work on their work on their own have the potential to suffer from the issues of not being challenged and not having their ideas challenged. That's where there's a real risk, because if you have convinced yourself that you are right, I can tell you that, but if in my conversations within Nourish Balance Thrive and my conversations at home with my fiancé who is also a scientist, I am told that I'm wrong very frequently.

    And actually, it's one of the best possible things that you could be exposed to despite the fact that the initial response of your amygdala is like, "No, this is awful. I can't." And then the prefrontal cortex kicks in and you realize that maybe this is actually very good for you. But that's sort of being exposed to that, putting your ideas out there and sort of improving them in the process and having people interact in that way I think is incredibly important.

    So, I can continue speaking with you, Rob, for hours and hours but I should probably wrap up because we passed well past the hour mark no. So I really like people to know where they can find you, some of the work that you're doing. I know you're creating some online courses in terms of some training. Maybe you can tell us about that, your podcast as well that you mentioned briefly.

Rob:    Yeah. One thing, thank you, Tommy, for giving me this space. Hopefully, people may get this far and haven't turned away. This has been probably more storytelling than fact and scientific evidence that they're probably used to but thank you for this opportunity. Yes, I am in -- I actually live in Winchester, Virginia which is pretty close to Washington DC, doing my residency training.

    I actually will be moving back in two year's time to Charlottesville, as I mentioned, as part of the Charlottesville Center for Functional Medicine. I started that, as you alluded to early, with two of my close friends and partner, Kerri Cooper and Ryan Hall. Right now we're already starting to see patients and being able to act as that medical director.

    Actually, utilizing a case for reprocess which has been very helpful, as you just mentioned. Ryan and Kerri present the patients that they're seeing, because I'm not actually seeing anyone in Charlottesville. I'm giving some of my opinions. They're asking me certain ideas and I tell them this is what I think. It's a great think tank to realize that maybe that was a dumb thing to try or maybe that was like a better idea. I agree with you 100%.

    So people, if they're interested, locally we're just seeing people in our local community in Charlottesville, Virginia. We want you to please check out our website, Charlottesville Center for Functional Medicine, and you can become a new patient. I have that. I have my own page which I've been working on for about a year and a half at A Medicinal Mind. It's kind of a spinoff of the idea of A Beautiful Mind. A Medicinal Mind.

[1:00:00]

    I have more spiritual content there, if I could call it that. I have a blog and I write regular poetry, integrated a podcast as well where I'm having conversations with people on the medical space, also some that are more spiritually directed. But it's been a blast to do and to share and just learn so much from. That's one of the big things that you'll find there.

    I also created on that page about a year ago, I'm actually updating right now -- When this goes out, it may even have the updated version. But I have an ebook that was designed to be a title of all the best resources for learning about integrative and ancestral and functional health. Of course, it's not exhaustive. It's not an encyclopedia but it was a repository of all the things that I discovered on my journey. I released that last year. You can find that on the page.

    Hopefully, we'll have an updated version with even more content that has come out or has come to my attention for people to help them decide who should I listen to, who should be the podcast that I follow? And then lastly, I guess, I'll put a mention my partner actually who I really had my foundational clinical training with in Charlottesville. She's a functional nurse practitioner Melanie Dorion, just absolutely amazing driven woman. I've been collaborating with her to create some more clinician driven content, really recognizing that there is a gap right now in clinically relevant and practical information that's affordable for new students or clinicians who are interested in learning how to practice integrative medicine.

    I love Chris Kresser's class and his training but it's very expensive and it's only for a small set of people. The Institute for Functional Medicine has some amazing things, A4M has some amazing things. There's lots out there, but they can be quite costly. So we tried to create some very practical evidence-based modules through Pentad Integrative Health. I think as it stands now we have a free diet and lifestyle module, GI imbalances module and then working on a advanced diet module and weight management, which should be out fairly soon.

    But we're talking $200 for modules or videos and some amazing handouts. But trying to find something in the middle ground for people and not delving too much into science and physiology. Because I leave that to Bryan Walsh and by far and away I don't need to be doing that. But if you want some ways to think about clinical medicine and approach a practice then these modules might be right for you.

Tommy:    Fantastic. I absolutely encourage people to go and check this out. I have to thank you, Rob, for joining me. This has been great.

Rob:    Yeah, thank you. It's been a blessing so hopefully -- can't wait to see you in a couple of months at AHS.

Tommy:    Yeah, absolutely. Anybody that's listening to this who wants to come to AHS and meet Rob and I, we would love to see you. Thanks again.

[1:02:45]    End of Audio

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