Dr. Cortney Crespo: Weight Inclusive Care

In this episode, I am joined by Dr. Cortney Crespo who shares an important message and mindset change around the topic of weight, specifically weight inclusive care, a term new to me. Dr. Crespo is a family medicine physician in Massachusetts, MA completing her Integrative Medicine Educator Fellowship at Tufts University Family Medicine Residency, a novel fellowship designed to foster leadership, teaching, and research in Integrative Medicine. Her goal is to provide and teach comprehensive, holistic care with an equity lens. As we talk, she explains how the power differential between doctor and patient can cause the patient to feel unable to express their desire to not make weight the focus of the appointment. Dr. Crespo shares that clinicians focused on whole person care are also caring for their patients using weight inclusive care. With her patients she follows the acronym VEORS (validate, explore, offer, reinforce, shared decision making) when discussing weight. Clinicians are charged with validating that the patient has control over their body, exploring what the patient is seeking from weight loss, offering medical knowledge pertaining to health, reinforcing what health means, and sharing the decision making. This conversation made me stop and reflect on my practice. I hope the same for you. Enjoy!

Below are resources to learn more about weight inclusive care:

Organizations 

Association for Size Diversity and Health (ASDAH) https://asdah.org/

National Association to Advance Fat Acceptance (NAAFA) https://naafa.org/

Blogs

Weight and Healthcare by Ragen Chastain https://weightandhealthcare.substack.com/

Marquisele Mercedes https://www.marquiselemercedes.com/ 

Books

Revenge Body by Caleb Luna

Fat Talk: Parenting in the Age of Diet Culture by Virginia Sole-Smith

Check out the book: "Healing and Cancer: A Guide to Whole Person Care"
Visit https://www.healingandcancerbook.com/ for more information.

Connect:
Twitter: @DrWayneJonas
Facebook: Dr. Wayne Jonas
Instagram: @drwaynejonas
LinkedIn: Dr. Wayne Jonas
LinkedIn: Alyssa McManamon

Visit Healing Works Foundation www.healingworksfoundation.org for more information.

Dr. Wayne Jonas is a board-certified physician and Dr. Alyssa McManamon is a triple-board certified hematologist/oncologist. The opinions expressed on this show are those of the hosts and guests and do not necessarily represent the views and opinions of their places of employment, the Department of Veterans Affairs, or the United States government. The opinions expressed on this podcast are meant for entertainment and education and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Wayne Jonas and Dr. Alyssa McManamon have no relevant financial disclosures.

Transcript

Please note that this transcript is produced electronically and may not be an accurate representation of what was said. It may not be reproduced, edited, altered or modified in any way without prior written permission. Any use of quotes or excerpts from this interview requires explicit permission from Healing Works Foundation. Please contact us at healing@healingworksfoundation.org if you would like to use any part of this transcript for quotes or other purposes.

“How Healing Works with Dr. Wayne Jonas”

Interview with Dr. Cortney Crespo - Weight Inclusive Care

Dr. Wayne Jonas | 00:07

It's my great pleasure to introduce my guest today, Dr. Courtney Crespo to the program. Dr. Crespo is a family physician like myself and is completing her integrative medicine educator fellowship at Tufts University Family Medicine residency. The focus of her work, in addition to integrative medicine, is the whole issue of weight inclusive care, a topic that is new to me that I was never really trained in, and we're going to explore what that means and how a whole person approach can improve that care for your patients. I'm glad that she's here to shine a light on this topic. She has talked about this around the country, including presenting at the Society of Teachers of Family Medicine and the Integrative Medicine for the Underserved Conference, and she continues to teach residents about this topic. Dr. Crespo, thank you for joining us and spending some time in this area.

Dr. Cortney Crespo | 01:13

Yeah, thank you so much for having me.

Dr. Wayne Jonas | 01:15

The first thing I usually like to have my listeners is to get a feel of how did you get where you are. I mean, we've mentioned the whole issue. You're a physician, obviously, but then you've gone into sort of additional training on integrative healthcare and then weight inclusivity. A lot of people, lot of physicians talk about weight, a lot of patients talk about weight, but weight inclusivity is a topic that I think may be new to many folks. But what's your path there? How did you get into those various ways to get into this particular niche and passion?

Dr. Cortney Crespo | 01:54

Yeah. I would say I probably started with my path to family medicine, thinking about how I always really loved the continuity and relationships that people had with their doctor, the trust that they had with their physician. And during medical school, I was actually lucky enough to meet an integrative med physician and I was just so incredibly inspired by her and how she worked with her patients to really dive deep into what's really going on with them and not just focus surface level on the symptoms. And that takes a lot of time and is very meticulous, and I really loved that approach. I loved that she was talking about lifestyle and behaviors and things that people really could have more control over.

 02:39
That kind of approach just really resonated with me. And then when I sought out residency training, I knew that that was something I would be interested in, and somewhere where I knew that there was integrative medicine faculty and that I could get some additional training in that. And then from there went into this fellowship where I was combining my love for integrative medicine with my love for teaching and academics. And I would say where weight inclusive care came from for me, I am lucky to be in a smaller body and I haven't had to face the discrimination that a lot of people have had to face based on their body size.

 03:17
During residency, I led a patient centered group for wellness. We would meet every week and we would discuss ways to be well, and people just had so much to discuss about how much harm was caused to them based on discrimination that they had faced based on their weight, and not just out in the world, but in the doctor's office as well, coming in for an issue and your issue being dismissed and being told to lose weight rather than being given any really tools that you can use to move forward and to feel healthier. Just based on hearing all of those experiences and the harm that people were going through, myself and a few of my colleagues got really interested in really diving into this work and transforming our residency curriculum on weight.

Dr. Wayne Jonas | 04:05

Yeah, that's fantastic. The idea behind Integrative Health's interest was really to expand to a more whole person care paradigm. I thought that's what family physicians did anyway, but I guess we need to do more of that.

Dr. Cortney Crespo | 04:19

Definitely.

Dr. Wayne Jonas | 04:20

And integrative medicine, that sounds like helps you to be more whole person and comprehensive in primary care. It's a different kind of primary care, I think, and one that National Academy of Medicine and others have said should be the best type, what's called high quality primary care, so that's great. The whole issue of weight is just so ingrained in our culture, back from the Barbie days and the model days, which still persist today, to enter the healthcare profession now saying that "Gee, weight has something to do with your health." In my family, I have a couple people who are overweight, some even would be classified as obese, and yet when they go into their doctor and they get measured in terms of other parameters that increase risk factors, they all seem to be normal. Yet, they focus a lot in the discussion about losing weight and they've all tried multiple things as many people have. And I'm just wondering, would you talk a little bit about the importance of weight and weight management for health and the risks of focusing on weight and weight management for health in those areas?

Dr. Cortney Crespo | 05:44

Definitely. I think as years go on, we have more and more evidence that BMI does not equal your health. Like you said, people in your family, by BMI standards, they might be considered to be a higher BMI, but actually all of their health metrics look great. They're healthy people. How do we cope with that as physicians knowing that we've been taught this way for a very long time to look at the way someone looks and assume whether they're healthier or not? And that feels bad. We don't want to do harm to people where we want to be able to treat people and do the right thing. But as time goes on, we know that BMI isn't an accurate indicator of health. And thinking about your family members who have tried all these diets and like you said, eventually gain weight back, we have good evidence that dieting doesn't really result in long-term weight loss.

 06:39
And I think anybody who's ever been on a diet can tell you that that's true. And really, in a lot of these studies where we're looking at weight loss and we're saying, "Oh, the weight loss caused them to be healthier," that might be actually due to lifestyle changes that are going on during those studies as well, due to socioeconomic factors and not necessarily the weight loss itself. I think that we operate under this assumption that weight loss is what's making people healthy, when actually it might be all of those behaviors. And weight loss is a secondary thing that might occur, but just because you stop losing weight doesn't mean that exercising or having nutritious foods doesn't matter anymore. And then the last thing is thinking about that dieting cycle. That dieting, losing weight, regaining weight, losing weight is something that's actually called weight cycling.

 07:30
And this is a relatively new area of research, thinking about weight cycling and how weight cycling itself might actually be dangerous and might actually cause health risks. Maybe some of the things that we're saying, "Oh, being overweight can cause increased risk of this," might actually be because of all of the dieting attempts and all of the cycling that people have had throughout the years. So, it flips everything a little bit on its head, and it can be hard to hear at first because we don't want to feel like we've been doing the wrong thing. But yeah, we have some pretty good evidence at this point that maybe weight just isn't it.

Dr. Wayne Jonas | 08:11

Yeah. Can you talk a little bit about that evidence? Because I think most people are not really aware of that. And we can also put it in some of the links for this so people can go to the references. I mean, before you do that, though, is this sort of what we did with pain? Pain became the fifth vital sign, it became you got to measure it on everybody, you got to get it down. And so, suddenly everybody's trying to drop your pain. And of course, the easiest thing to do is to go on a drug, and then we started putting people on opioids and we're told initially that was safe, and then found out that it was really creating a lot of harm, getting people addicted and other things. I mean, are we doing something similar with weight by using it as a single index about your health?

Dr. Cortney Crespo | 09:00

Yeah, I think that that is a really interesting parallel because how we made pain the fifth vital sign and we're treating someone based on pain and not necessarily based on other things that are going on. And then it really took a lot of transformational learning for people to be able to get out of that mindset of, "Oh, so I don't need to just treat pain?" And I think that weight is similar in that it does take that kind of transformational mindset to say, "Oh wait, do I not need to look at the BMI? Can I look at other health factors? Can I consider other behaviors that this person is doing?" Yeah, I think there is a parallel there of how it really does take that reflection and coping with what we've originally done and then trying to move forward to not consider BMI or pain as that independent, end all be all risk factor.

Dr. Wayne Jonas | 09:52

Yeah. Well, certainly I used meds and medications including opioids for acute pain, something that comes up and is intense and sudden. But for chronic pain, usually there's many, many other factors like social factors, sleep factors, activity factors, et cetera. And in weight, if you were to look at weight as simply a sign of needing to focus more on healthy living, it's a lot more than food, isn't it? I mean, it's activity, it's sleep. There's a lot of relationship between the amount and the quality of sleep, social networks in those areas and influence on that. Tell us a little bit about how you approach somebody that's overweight who says, "Gee, I'd like to get this down for my health reasons," and how do you have that conversation?

Dr. Cortney Crespo | 10:49

Yeah. And I think that it's important, really, to address with the patient that you're talking to. What is it really that they're looking for? And actually, a framework that we had taught to the residents, myself and my colleagues who are named Dr. Tucker and Dr. Rao, we created this framework. What do you do when someone is coming into the office, you have all this information of BMI doesn't really help, weight stigma causes problems? What do we do?

 11:17
And we have all this information and someone's still coming to you and saying, "Well, I want to lose weight." We made this acronym, which is not a very good acronym. It's V-E-O-R-S. We couldn't think of any fancy word for it. But the V is for validating. Validating this person, they have control over their body if ultimately they want to lose weight, they are in control of their body, and really acknowledging the social stigma that has brought them here to discuss weight, because the wellness industry has told us that we need to lose weight for many, many years, and people's friends and family are telling them that, they're getting faced with that in doctor's office. Really validating, "I understand why you're asking me this."

 12:00
And the next is the E of our V-E-O-R-S is exploring what are you seeking from weight loss? And for some people that can be, "I just want to change my body," and that's okay. And for other people it can be, "Well, I want to be healthy." And that opens the opportunity, which is like... O is offer, our medical knowledge on. "So if you want to be healthy, here are all of these things that we can focus on. Is weight actually what you want to focus on here, or is it these other things?" And really reinforcing, which is the R, our definition of health. What does it mean to be healthy? And for every patient that can feel different.

 12:42
And the last is shared decision making is our S. Figuring out what the next steps are with the patient. After they have that information, you've done your whole spiel on, "BMI actually isn't equal to health." And then really figuring out what the patient's desired R, is how do they want to move forward with their body? And that's okay if they're not on the same page as you and saying like, "Oh, well I don't need to lose weight." I know I can be healthy otherwise, because you're probably the first person in their whole life to tell a patient this. And some people are really grateful to hear a doctor call them that they're healthy. But if they're not there yet, that's fine and you can work with your patient and thinking about whole person care is, it's really important what the patient wants. It's not just what you want. So, really making decisions based on that.

Dr. Wayne Jonas | 13:32

No, I think that's key. I mean, the validate is really trying to put the patient in the driver's seat. I mean, it's the same thing we do in the techniques that we've developed here. And the VA uses asking the patient what matters. What matters to them in their life, what is it that they live for and therefore what do they want to have health for, and how can you support and facilitate that? And we do that through something called the HOPE note and the personal health inventory, and those tools that we can put on that are on our website here, and we can put a stream on. You've used some of those tools, haven't you?

Dr. Cortney Crespo | 14:13

I have.

Dr. Wayne Jonas | 14:13

[inaudible 00:14:14] in those areas. And I understand that they're at Tufts, they've developed a new CME program specifically on how to do Whole Person care and how to embed it in your practice. Would you recommend that your average primary care doc take a look at that and their team, and begin to implement those types of things into the practice?

Dr. Cortney Crespo | 14:37

Yeah, absolutely. And the great part about the HOPE note and the patient health inventory is that those are weight neutral approaches. Nowhere on there does it say, "What is your weight and how much weight do you need to lose?" It's all of these other factors about someone's life. Like you said, the social, the environmental, and what they want to work on to be healthy. Maybe, Dr. Jonas, you're doing weight inclusive care and you didn't even know it.

Dr. Wayne Jonas | 15:04

Yeah, yeah. That's great. How do you handle all these new interventions, pills and procedures that are coming out? I mean, supplements have been used for a long time and there've been some appetite suppressant drugs, but there's a bunch of new ones coming out and are being pushed. STLT inhibitors and surgery. Also new fads like fasting and intermittent eating. How do you deal with all that kind of a thing? I mean, patients are looking for a fix, especially if they're told they need to have one. How is that brought into the weight inclusivity discussion?

Dr. Cortney Crespo | 15:45

And I think it can be really hard for patients, and I think it's hard for us too, even as physicians, to parse out what the right thing to do is. And I think that one thing that I've been working on in my fellowship and in my dissertation is this critical theory approach of really asking the questions of when a new piece of evidence about bariatric surgery comes out, or a new study on weight loss medicine is really diving into the, "Why and who is this for?" Of those articles. Thinking about what assumptions are being made even by those articles being shared and existing.

 16:22
Assumption number one is that weight loss is good for you, which is something that we're contesting right now. And all those places, all those papers operate from the premise of that. And we know a lot of them don't include what lifestyle factors in people's lives changed while they were undergoing whatever intervention for weight loss, but also who benefits from it.

 16:48
I think when you brought up the pain stuff before, we certainly know there was a corporate incentive and a lot of pain management advertising and studies. And I think that can be very similar with weight loss studies. The weight loss industry is huge. The weight loss pharmaceutical industry is huge. Thinking about who benefits, who are the financial involvements of the people who are putting this paper out? And then I think ultimately, I think the question we can ask is there another way that we can practice with the same benefits? We know a lot of weight loss medications have side effects. We know bariatric surgery has side effects, so is there a way that we can operate where we don't have to put people at that risk? I think that's the ultimate question that I ask at the end of reading those papers.

Dr. Wayne Jonas | 17:38

Really individualizing the care, the right care for the right patient at the right time is what you're talking about. And these things that are driven by technologies and new drugs and all that kind of thing, they want to sell things as widely as possible, so they actually don't do the kind of individualization, at least not at the beginning. Later on usually we find out, "Oh gee, it wasn't good for that person might who might be bigger than that person." That's usually later after they've made their billions, right?

Dr. Cortney Crespo | 18:07

Yes.

Dr. Wayne Jonas | 18:08

And that type of thing. How do you that with patients in here? Do you do measure BMI when patients come in?

Dr. Cortney Crespo | 18:16

I think unfortunately, the reality in most of our clinics is that patients get measured the second that they walk in. But I think it's up to you. You can make systemic changes at your clinic to not have it that way, not have people be weighed, and patients can certainly choose not to be weighed as well, which I know is difficult because there is a power differential when you walk into the doctor's office. But I think even if BMI is measured, it doesn't mean that you have to use it as the end all, be all. We can use all of these other health measurements, health behaviors to think about somebody's health other than just the number that's flagging on your EMR.

Dr. Wayne Jonas | 18:51

Yeah. No, that's great. Well, in the HOPE note interview, the integrative health visit that we recommend, those are in the PHI screening, and there for discussion. How are your wellness behaviors? That's basically what it's getting at. And that is really mind, body and spirits. Looking at social supports, looking at stress issues, looking at activity, looking at sleep, looking at diet, et cetera. Food, looking at food intake, and what did you have for breakfast, lunch and dinner? And did it meet the things that we already know are basic healthy ways to eat? Mediterranean diet, and that type of thing that has been well researched and documented in those areas.

 19:30
Let me ask, how can patients go into their visit with their physician and their clinical team empowered to have these conversations in those areas? What do they need to ask for and what do they need to look for in those encounters to try to get the focus of the dialogue and the care on their health? Can you talk a little bit about that? Are there some guides on how to do that?

Dr. Cortney Crespo | 20:05

Yeah. And I think that it can be really hard as a patient. Like I said, there is that power differential. Once we are the doctor in a room, we're in the position of power to say, unfortunately, whatever we want to a patient, which is not right. I think first the impetus has to be on us to make these environments more free of discrimination. But there are things, there are tools and guidebooks that people can use from online. Just thinking about a few organizations that has done work for weight liberation, so the association for Size, Diversity and Health, ASTA, and thinking about NAAFA, who it says a National Association to Advance Fat Acceptance. They have a lot of resources on their pages.

 20:52
There's also a lot of activists, fat liberations, who have been doing this work for a very long time, who have blogs, who have social media pages, books, podcasts about how people can really empower themselves in the doctor's office.

 21:12
I think that Hayes Health Sheets is a website that actually has all weight inclusive ways to address problems like fatty liver and other chronic issues without necessarily focusing on weight. Ragan Chastain's Substack on weight and healthcare is really awesome and I recommend it for any doctor who's interested in this. And thinking about other writers and activists like Marcus Sill Mercedes has a Patreon who has content on weight inclusive care. Tigress Osborne is one of the chairs of NAAFA. Caleb Luna wrote a book called Revenge Body.

 21:47
There's so many great resources out there for people to embrace, and I think that they're... Even on one of the websites, there is cards that you can use at your doctor's office. I think on Ragan Chastain's blog that, "Please don't weigh me" cards that you can bring into your doctor's office. But ultimately, I think some questions that people can ask if they feel like they're being discriminated against for their weight is, "Well, if I was a different size, what would you do in this visit right now?" If someone comes in for a cold and the doctor brings up their weight. You can say, "Well, let's say I was in a different size body. How would you address this then? What tests would you order? What would you do? I think that's one question that people can use to empower themselves, but it's really uncomfortable. It's really harmful the way that we treat people.

Dr. Wayne Jonas | 22:43

Yeah. Well, that's a great list of resources.

Dr. Cortney Crespo | 22:46

Yes. Sorry, I just realized

Dr. Wayne Jonas | 22:48

No, no, no, that's great. We'll try to get those from you, bundle them, put a link on our website on how to find them and access them to make them available, because I think a lot of people will be interested in those. We'll stick them on this show and make them available to people. We'll be in touch with you to bundle those, perhaps make them easier for people.

Dr. Cortney Crespo | 23:07

Absolutely. Yeah.

Dr. Wayne Jonas | 23:07

Because that was a lot of good information. There is a lot of information out there, isn't there? It's not like you can't find anything on this or shouldn't be able to.

Dr. Cortney Crespo | 23:16

Absolutely. Yeah. There is a lot of great information and I think that a lot of the best information comes from people who have lived experience, fat activists who have experience in larger bodies and can really share what their experience has been like within healthcare and how we can better ourselves as physicians.

Dr. Wayne Jonas | 23:35

Yeah, that's great. Well, the whole weight thing is not actually a medical issue, is it? It's a cultural issue. It's not even an individual issue. And we have blamed the individual and said, "Well, if you're overweight, it's your fault." But it's really a cultural issue. And there's quite a bit of research showing that we've not made hardly a dent with all the attempts at weight loss through medicine and identifying it as a health issue, because there is a tsunami of cultural messages, information products, et cetera, driving us the other way and driving us the other way in health. And we see that in our culture.

 24:22
Our life expectancy is going down, the health outcome issues by basic WHO and other national indexes is getting worse. COVID didn't help with that. It actually made it worse. And so, a focus on health is really important and there's a particular problem or risk, isn't there, in terms of bringing this into children's healthcare? If it's not done in a way that is focused on health because children are also gaining weight. Some of the long-term health consequences have been documented, at least in observational studies in those areas. How do you work with families that have children that are gaining weight, and how do you get them refocused on health and healthy behavior and lifestyle when they spend most of their time outside of the family, perhaps in school and other places? What are your discussions with families, mothers and fathers in terms of how to bring their children into a healthier lifestyle in those areas?

Dr. Cortney Crespo | 25:32

I think I take a very similar approach that I do with adults in refocusing onto health behaviors. But again, that can be really hard because for so long we have thought about weight as being equivalent to health. And actually, one of the folks that I actually... I don't think I mentioned her name before, but Virginia Sole-Smith just wrote a book called Fat Talk: Parenting in the Age of Diet Culture. And it is an excellent resource for thinking about weight, thinking about children's health, thinking about how do we teach a child that the word fat is not necessarily morally bad, the word fat is just a word and a descriptor for a body. Would certainly encourage referencing to that book. But another thing I'm thinking about, which is certainly a problem in adults but also in children, is weight stigma. And how even when a child walks in and we start talking about their weight and focusing on weight more than behavior, we know that that can result in stigmatization.

 26:39
And unfortunately, we don't want to discriminate against people, but just because of the way that things have been for such a long time, there is evidence that actually, if someone of larger size walks into your office, they would get less respect from their doctors, less time spent with them, less patient-centered care. Different treatment just based on how they walk in and all of those implicit and maybe sometimes explicit biases. And just that alone can really affect adults and children's health. Weight stigma increases stress-related chronic disease risk, increased mortality with weight stigma regardless of BMI. We know that the number on the scale really doesn't matter for that, and increased risk of substance use disorder, mood disorder. I think for us and trying to minimize harm and taking a whole person approach, if we are going to counsel a child about weight loss, we have to know that all of those background factors that could be harmful are also in play at that time.

Dr. Wayne Jonas | 27:45

This is very similar to saying, "Don't just look on the surface," right? I mean, women also have that problem. They get poorer healthcare, people of color get treated differently. The racism that's built in automatically to seeing what's on the surface and you're saying the same thing happens with weight. In those areas, we have to see deeper into what a whole person is and what a person actually is beyond just the physical appearance and the body if you're going to really have whole person care. That's the mental, spiritual, and the social aspects of a person that are not as easily seen until you bring them out and you get to know people and you see them as whole human beings.

Dr. Cortney Crespo | 28:30

Right. Exactly.

Dr. Wayne Jonas | 28:31

Wonderful. Well, any last comments you'd like to make before we wrap up? This has been fantastic, and again, we'll put that information about how to deal with childhood issues. You can deal with children and families in this area. Sounds like a great resource. But any final comments you'd like to make for our listeners?

Dr. Cortney Crespo | 28:48

Yeah. I think if you're listening to this and this is the first time that you've ever heard anything like this and you think that I'm crazy, that's okay. I think that usually the first time that we tell patients about this in our group or in the room, it could be the first time you've ever heard this before and it's going to cause a little cognitive dissonance and that's okay. If you think I'm absolutely nuts, that's fine. But if you take anything away from this, it's that we can operate, we can treat health in a way that doesn't have to involve weight. Whether you believe me or not about all of the other stuff, maybe just taking a few tools of, "Maybe I'll focus a little bit more on health behaviors today and what the patient wants to focus on rather than their BMI." If that's all you take away from this, I will be happy.

Dr. Wayne Jonas | 29:36

Well, one of my takeaways from this is that if the conversation, either I generate it or the patient generates it and says, "Can we talk about weight?" What I want to do is I want to move that conversation to, "Can we talk about health?"

Dr. Cortney Crespo | 29:50

Yeah. Absolutely.

Dr. Wayne Jonas | 29:51

And yes, weight is part of that, but the goal really is about the health per se, not the weight by itself.

Dr. Cortney Crespo | 29:58

Exactly. And why do you want to talk about weight? Just asking that why-

Dr. Wayne Jonas | 30:01

What matters, ultimately. Wonderful. Well, thank you very much. It's been very enlightening for me and I hope for many of our listeners, and I really appreciate the work that you're doing and bringing it out into the open and helping us to reduce the harm that sometimes healthcare does. Because after all, that's the first part of the Hippocratic Oath, isn't it? Do no harm.

Dr. Cortney Crespo | 30:27

Exactly. Yeah. Thank you so much.

Dr. Wayne Jonas | 30:29

Thank you. Take care.

Dr. Cortney Crespo | 30:31

Bye.