What I Learned in the Operating Room

Dr. Raja Flores, Chair of Thoracic Surgery at Mount Sinai, discusses his groundbreaking work treating lung and esophageal cancers. He shares powerful stories of resilience from patients and families, explains the realities of cancer care, and highlights the importance of trust, compassion, and experience in facing some of life’s toughest diagnoses. 

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Transcript

Stephen Calabria: [00:00:00] From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria, Mount Sinai's Director of Podcasting.

On this episode, we welcome Raja Flores, MD. Dr. Flores is the chair for the Mount Sinai Health System's Department of Thoracic Surgery and the Anne Ames Professor in Thoracic Surgery at the Icahn School of Medicine at Mount Sinai.

Dr. Flores is regarded as a pioneer in treating both esophageal cancer and mesothelioma, the cancer developed from exposure to asbestos.

Dr. Flores walks us through what cancer treatment entails, the resilience shown by patients and their families, and how he continually witnesses patients bounce back from the most devastating of diagnoses.

We're honored to have Dr. Raja Flores on the show.

Dr. Raja Flores, welcome to Road to Resilience.

Raja Flores: Thanks for having me.

Stephen Calabria: Could you give us an overview of your background here at Mount Sinai?

Raja Flores: [00:01:00] I've been at Mount Sinai now for 15 years. Before I arrived here. I was at Sloan Kettering for 10 years, specializing in lung cancer, esophageal cancer, and mesothelioma, the cancer you get from asbestos exposure. And I moved here 15 years ago. Time flies. 

Stephen Calabria: So you specialize in thoracic surgery. First of all, what is the thorax and what kinds of surgery does a person's thorax typically undergo?

Raja Flores: So your thorax is basically your chest from the bottom of the ribs to your clavicles and thoracic surgery is a sub category of cardiothoracic surgery.

So when you do your training after medical school, you do five years of general surgery, and then you do two to three years of cardiothoracic surgery, which means the heart and everything else in the chest.

You can either specialize in the heart where you're operating on the arteries and on the valves, or you can specialize on the lungs, chest wall, [00:02:00] everything else, where usually cancers are the pathology that involves those areas.

So, cancers of the chest wall, sarcomas of the lung, cancer of the esophagus, esophageal cancer of the lining of the lung, mesothelioma. So, basically a thoracic surgeon is a cancer surgeon of the chest.

Stephen Calabria: And you're one of the world's leading thoracic surgeons. But before we get into that, what originally drew you to medicine and the operating room in particular?

Raja Flores: It's interesting. My first love was trauma. I wanted to take care of gunshot wounds and stab wounds.

Growing up in New York in the seventies, you were exposed to a lot of that stuff and I was always curious of, how to get in there and fix things up. So I went into medicine because I thought I wanted to take care of gunshots and stab wounds.

I was always curious as to how things work inside the body. And then as I started studying medicine and going in the [00:03:00] field of surgery, I went back and forth with a few different areas, vascular surgery, heart surgery, and then I just landed in thoracic surgery.

It fit me. I liked the patients that I was dealing with. A lot of 'em are blue collar workers, pipe fitters, construction workers who are exposed to stuff. Today we still take care of the patients who are cleaning up the rubble in 9/11.

A lot of my patients also have some addictions, nicotine, et cetera. Not every lung cancer patient smoked, but many did.

You can't just will it away. You need a support system, so not only do I try and fix them and cure them of their cancer, I try and help them lead a healthier lifestyle and get their minds in a place where they can improve their entire life. 

Stephen Calabria: So treating the patient holistically and not just their specific ailment or whatever they've come to you for.

Raja Flores: That is exactly what we should be teaching in med school. You should treat the patient, not just the [00:04:00] disease. 

Stephen Calabria: Now you do treat multiple cancers, including lung cancer and esophageal cancer. Before we get into the particulars of those, from your perspective, what does resilience look like in someone facing a cancer diagnosis? 

Raja Flores: It's interesting. You always hear of the success stories. You hear about, oh, he was strong. She was strong. She fought that cancer, and she beat it, or he beat it. There's not always a happy ending there.

And resilience is how you handle things along the way. Most of the cancer patients die and the resilience depends on the individual, but it also involves the family. Patients suffer. You're in the hospital, you're in pain from an incision, you're sick from chemotherapy, you can't breathe 'cause your lungs are inflamed from the radiation.

You can only fight so hard. The rest has to be done with the family. [00:05:00] The family has to fight. They have to talk to the doctors, make sure that nothing's slipping through the cracks, the resilience from the patient, most patients are gonna do whatever they can to try and get better to try and get their cancer cured, but the resilience is really how they handle the process as it's going along, because if you beat cancer, they say, wow, he was resilient, he beat cancer.

But it's really biology that determines whether or not that happens. Nobody knows how they're gonna handle it when they get sick. When they get that diagnosis of cancer and I think Mike Tyson said it best, you got a plan, till you get punched in the face.

And only when you get punched in the face with that C word do you know how you're gonna actually handle it. And I've seen people handle it in many different ways. The resilience comes from love of others around you.

When you are just by yourself, there's not always a fight to have, but [00:06:00] it's from the love of the family that surrounds that patient that I have seen strength. 

Stephen Calabria: And for those who have had a family member, a parent go through cancer, cancer often doesn't just affect an individual, it affects a family, and it's the family unit that has to exercise resilience and not just the patient themselves. 

Raja Flores: A hundred percent. A hundred percent. And it's interesting 'cause in my job I have a front row seat to the human condition and I see how the wife and the husband interact, and the son and the daughter and the father and the brother.

How families interact. And it makes you appreciate what you have. It makes you appreciate your health. It makes you appreciate if you can stay, sit there like you and I and breathe without help.

If we can put food in our own mouth, if we can go to the bathroom comfortably, we take these little things for granted. When you're sick, it's a [00:07:00] whole different ballgame. 

Stephen Calabria: Now you specialize in esophageal cancer. What is esophageal cancer? What are its causes and how common would you say it is? 

Raja Flores: So esophageal cancer is a very deadly cancer. There's about 20,000 cases a year in the United States. The vast majority are caught when it's too late. About 80% have already spread where you can't do surgery.

So I see the 20% who are surgical candidates who have a shot at being cured with surgery, and the esophagus is the tube that brings food from your mouth to your stomach. And the cancer that forms is usually in the bottom part of the esophagus, and it comes from reflux where you have contents in your stomach that reflux back into the esophagus.

There's a sphincter there that usually keeps those things in the stomach. And many people know that as [00:08:00] heartburn. The medical term is reflux. And when you have that constant irritation of the esophagus, it causes a genetic change and then you develop this cancer.

And so with surgeons, we go in there and we cut that cancer area out. And then the question is how do they eat again? What we do is we make a tube out of the stomach, we bring it up behind the heart, and we hook it up in the upper part of the chest so that they can swallow again.

And that's the surgical part, but the vast majority of patients are caught late, where you can't do surgery. So that, that happens in about 20% where they can do surgery, and like I said, about 20,000 cases a year of esophageal cancer in the United States. 

Stephen Calabria: So when someone is diagnosed with esophageal cancer, the average person's prognosis is often not that great, it sounds like. What do you typically look at to even make that determination?

Raja Flores: So you get a CAT scan and a PET scan. A PET scan looks throughout your whole body to see if [00:09:00] anything has spread. If the cancer is just in the esophagus, it's curable. You can get that out.

If the cancer has spread to other parts of your body, then you usually need chemotherapy or some other drug, sometimes targeted therapy, some kind of drug that goes in the vein to get those. Typically it's not curable.

That being said, I have patients alive five, 10 years later who have had spread. So cancer is never a hundred percent a death sense, and that's a main thing that I think patients should take away.

Whenever we're talking about cancer and you hear it in a bad light or in a curable light, just it varies from patient to patient and it's never a guaranteed death sentence.

Stephen Calabria: Okay. Walk us through what happens in the esophagectomy surgery itself. You remove a person's cancerous esophagus, is that right?

Raja Flores: Correct. And it's interesting, patients are very practical. [00:10:00] They're like why can't you just remove that part? Why do you have to take the whole thing and bring the stomach up there, 'cause you would think you can just remove that bottom part and put it back together again.

But it just doesn't work that way. The body doesn't allow you to do that. So you have to also get margins where you cut. There can't be any residual cancer there. So what we do is we cut the esophagus we start in the stomach and we make a tube bad of, we start in the belly and we make a tube out of the stomach, and then we dissect the esophagus off of the surrounding areas.

So what touches the esophagus? The covering of the heart, the covering of the lung, the pleura. Something called the mediastinum, which is basically just the middle part of the chest, the crura, which is part of the diaphragm.

We cut all those things and leave it on the esophagus so that you have a good margin. And then we cut up here and we cut down here, and then we bring the stomach up and we sew it together to the upper part of the [00:11:00] esophagus, and then God basically seals it in about six or seven days, and then you let the patient eat.

It's a complicated surgery. It's a surgery that throughout the United States has a very high complication rate. Fortunately here at Mount Sinai, we do it very well. Our complication rate, meaning from leak is less than 2%.

It's about 1.6%, our leak rate, and that means that when you hook the esophagus to the stomach, you don't want anything to come through there, meaning you eat, it needs to stay in that, in those two tubes, it can't come out.

When it comes out, it gives you a bad infection, and that leak rate in the United States is as high. Is 25 to 30% and that usually comes with a bad outcome. Death from sepsis, recurrence of cancer.

We have focused our technique in minimizing that leak and our patients do extremely well.

Stephen Calabria: Yeah. Pizza may be good, it's not good when it's sitting in your chest.

Raja Flores: Exactly.

Stephen Calabria: [00:12:00] This sounds like a gargantuan operation, not just for the doctor, but also for the patient. How do you prepare patients mentally for what lies ahead in surgery and recovery? What do you tell them about what it takes to go through it and to heal?

Raja Flores: Yeah. It does sound scary when you talk about it in words. Many of these patients get an epidural catheter in their back, and that helps with pain. And believe it or not, the vast majority of patients can sail through this thing without any complications.

And it's hard to transmit that, when you see a patient, you always have to talk to them about the risks of surgery, death, infection, bleeding, blood clot, stroke, but the vast majority of these patients will sail through and do very well.

So it's important not to lose that window of opportunity because many, even physicians as well try to avoid that surgery when they [00:13:00] should have recommended the patient to have it done because they were curable.

And as long as you put that patient in the right hands, they should do very well.

Stephen Calabria: What does the recovery process typically look like for someone who's undergone an esophagectomy? Is it typically more difficult to recover from an esophagectomy than it is the treatment for other cancers?

Raja Flores: It's probably considered one of the biggest surgeries you can do out there. By the numbers probably more deadly.

But I don't like to put it in those terms, because if done right, they can do very well. So the typical patient have the esophagectomy, two and a half, three hours. Next day, they're up walking around.

They have some tubes in their chest but they're up walking around. By day six, the tubes come outta the chest. They get a swallow study. The swallow study shows there's no leak. Then they eat on day seven and home by day eight.

The reason we keep 'em in the hospital for a week is because we wanna [00:14:00] be sure that the two tubes seal and that there is no leak. Other than that, they could probably go home sooner.

That's the danger period is, if it doesn't heal, and like you said, if they eat pizza and it ends up in their chest we don't want that. 

Stephen Calabria: What are some of the most powerful examples of resilience you've seen in your patients both during or after surgery?

Raja Flores: I gotta tell you, most patients are resilient. Most human beings are resilient. I haven't seen a patient that just gives up. Now, is it because I'm a surgeon and I'm seeing patients who are healthy enough to undergo surgery?

It could be it because I know when patients have cancer all over the place, they could be resilient and strong as hell, but they get to a point where they just, they can't get their head up outta bed. So I don't wanna confuse resilience with physical [00:15:00] debilitation from disease.

The strength of the human heart, I have to say that I have seen in my entire career, inspires me. I gain strength from my patients when I'm dealing with difficulties in my own life with my own family.

And I see the way patients when they're struck with this diagnosis and they are trying to figure out what to do, the clarity of mind that they have, where they're. I need to do this, I need to do that. I need to worry about my family here.

I gotta get my treatment for this here. I'm gonna get another opinion here. People seem to get their ducks in a row when they're faced with these diagnoses. And I do think human beings are more similar than we are different, even though we can differ greatly by color, race, wherever country your family's from, et cetera, this love that we have for our family [00:16:00] members and friends who step up when you're sick is, I think it goes together with this resilience.

Have I taken care of patients who are completely alone? Yes. And nobody to talk to. So I just finished the surgery, I go downstairs. There's no one to talk to. It's just this patient. What I found in those cases is I develop a bond with them, like a family thing.

And once I realized this patient has nobody, I step into that role. And it's rewarding. When you see how they then will rely on you for many things. They'll basically say if they're, they have some issue with something non-medical, they'll ask you and they'll say, Hey Doc, what do you think of this?

I'm like you know what? I think you should do this, or this and they listen. Now fortunately, that's not the majority of people. Most people have somebody. And no man is an [00:17:00] island. Human beings. We need the pack, as much as they can annoy the hell out of us. 

Stephen Calabria: Amen to that. Now looking to the present and future, you've pioneered minimally invasive surgical techniques and been at the forefront of cancer research. Could you tell us about them and how these advances help reduce the trauma of cancer, both physically and emotionally for patients? 

Raja Flores: So, minimally invasive surgery for lung cancer. Back in 2000, I went out to California. I learned how to do this technique using three small holes to take out lung cancers.

At that time, I was working at Sloan Kettering. I came back to Sloan Kettering, taught all the attendings how to do it, and we started doing it. We started doing it with the robot. We started doing it minimally invasively using a scope and some instruments, called VATS.

And it took off and it did very well, and it is something that is a method to get out cancer, but [00:18:00] many people will misrepresented it into making it seem like it is the be all and end all. You gotta realize these patients have cancer.

The most important thing is for them to be here 10 years from now. And as someone that's been doing this for 30 years, there's certain times when I look at a patient, I'm like, you should not be getting this out using this minimally invasive technique.

They come because they want that. They know that's my specialty. And yes, I can whip out things with a couple of small holes, no problem. But that's not everything.

Stephen Calabria: So the minimally invasive to a patient, it, and I'm just speculating here, but a patient might think minimally invasive equals less trauma on my body and more efficiency on the part of the practitioner, whereas what you're saying, it sounds like minimally invasive doesn't necessarily mean better care. Is that right? 

Raja Flores: Sometimes it may mean a suboptimal cancer operation, [00:19:00] first of all, the definition of minimally invasive varies widely. You can have something that's labeled as a minimally invasive surgery.

So let's say for esophageal cancer. There's this hand port where you actually stick your whole hand in the belly. The incision's about this big, yet it's being billed as minimally invasive. There have been, as mainly invasive surgery evolved where.

They're making bigger incisions to take the lobe out. So when we do a minimally invasive lobectomy, you have a lobe that's this big. You do have to make an incision about this big to get it out.

And important not just to get wooed by the fact that it's minimally invasive, that it's robotic. What you want, is you wanna find a doctor that you trust, a doctor that's gonna say, this is the right thing for this particular patient.

You should come here because we're gonna know who should not have that minimally invasive surgery and when it's between getting your cancer out or, we're balancing, oh, they want [00:20:00] minimally invasive surgery.

We're gonna do what's gonna keep you here 10 years from now. And sometimes that may not be doing the minimally invasive thing. You see something in the middle of surgery and you're like, you know what? This is risking it.

You may not know it right then and there, but you can feel it years down the line when that cancer comes back. Minimally invasive to me is not as simple as get this out, we have a better way of doing it, and you suffer less, et cetera.

No. When you look, there's this database called mod manufacturer or something where it has these complications that you never read about in the in the literature. Nobody writes about it.

When you have a patient that died from bleeding to death because of an instrument or a robot that you use, they're not gonna advertise that. That gets hidden. But you can see it in this database and it's frequently by people who are inexperienced.

So if you're looking for a minimally invasive surgeon, I understand that. But what you really should [00:21:00] be looking for is an experienced cancer surgeon who does minimally invasive as well, but will know when minimally invasive is the right way to go and when actually it's the wrong way to go. 

Stephen Calabria: I imagine for patients it's unlikely they will be wooed by someone who advertises maximally invasive surgery. And that sort of leads to the next question is how do you foresee the role of ai? It's taking place in your surgeries in particular. 

Raja Flores: AI is interesting. 25 years ago when I started using the robot, everyone was like, oh, that's it. Robots are gonna take over. And it didn't, humans still do surgeries better than than robots.

Even if we're using the robot, the robot's not gonna do it independent of a human. We recently published a paper where there was a group in China I'm a co-author on this paper where they did robotic surgery in an area like 4,000 [00:22:00] miles away. And there's a delay.

When you're using the robot, there's a delay. And so there's a lot of things you gotta think about. But when you intersect technology and medicine, you've gotta be careful that unexpected things are not gonna hurt patients.

In other words, you gotta pre be prepared for the unexpected. So AI, how could that help surgically? I'm not so sure if AI's ready for prime time in the operating room, but areas like radiology, pathology where you have pictures and they are being identified as a cancer or as a certain finding on the x-ray, I think that's where AI's gonna be better than human beings.

I do think when you have, thousands, millions of experts all put into one, they're gonna be better at it. But in the end, just like anyone that's used Chat GPT, sometimes it can throw BS in there and you can be like, wait a minute.

And if you do that with the patient, they're [00:23:00] gonna get hurt. So even if, after you turn it out through AI, you gotta have a human being who is experienced, who can look at it and say, this is accurate, or this makes sense or it doesn't.

So I'd be careful about just adopting it willy-nilly, you gotta really vet it. And I do think in the future it will provide better care. Will it provide better surgery? I don't know if that's gonna happen in my lifetime.

I'd love to see it and I'd love to, to work on it and try and figure out how to make it better. I'm just not so sure if we're there yet, technologically. 

Stephen Calabria: You've also done a lot of work around asbestos exposure and occupational cancers. What led you to bring that kind of public health advocacy into your practice? 

Raja Flores: So when I was doing my residency, my fellowship in Boston, the guy that I was doing my fellowship under was an expert in [00:24:00] mesothelioma.

Which is the cancer you get from asbestos exposure. And, growing up, I worked all kinds of jobs. I worked for UPS and I interacted a lot with construction people and stuff like that.

And so I understand that type of a person who's working and taking care of their family. And the next thing you know, because of their job, they got exposed to this asbestos when they were changing pipes their whole life.

These are typically strong men who are self-reliant. Pretty resilient if you ask me. And now they get this diagnosis. So it's not only I found the anatomy of the chest interesting. That's the type of patient I relate to.

And so it combines both my love of medicine and surgery and of the anatomy of the human body with my understanding of the character of the human beings that are reflective to this disease. 

Stephen Calabria: It seems like the kind of thing we're [00:25:00] only fully grappling with now and could take years to rectify. What occupations and environments are generally most at risk when it comes to asbestos? 

Raja Flores: Construction workers, pipe fitters, the people who were down at nine at the World Trade Center, nine 11. And the biggest thing is that asbestos is still not banned in the United States, there's a confusion with that.

People think, oh yeah, asbestos is banned because you see the big signs that say asbestos warning, danger. But that's not the case. Big Asbestos had managed in the 1990s to reverse legislation that was gonna ban it.

And that still exists today. You had the Grace Commission appointed by I think it was Ronald Reagan, but the Grace Commission was in charge of making sure that people were protected.

And it was WR Grace who headed the company that made the asbestos. So it's like putting the fox in charge of the henhouse. Then you [00:26:00] wonder today, 35 years later, asbestos is not banned in the United States.

Stephen Calabria: Which only leads to you having to see that many more people for asbestos exposure. 

Raja Flores: Exactly. Imagine if you would've stopped it long time ago. I'd have half the number of patients getting this disease.

Stephen Calabria: What does the word survivor mean to you? Not just as a doctor, but as someone who's witnessed thousands of people confront cancer. 

Raja Flores: It's somebody who at one point in their life was shocked by a diagnosis of cancer, where their whole world turned upside down, where they had to grapple with their mortality, and then they had to pick themselves up, usually with the help of their family and step into an area that they had no control over, where they had to trust some other human to take care of them, and it's an extremely vulnerable position to be [00:27:00] in.

I'm a horrible patient. I've been on the other side. I do not like being a patient, and I can't imagine, I do imagine, I see it every day where patients have to basically say, Hey, doc, all right, when you're in there, do whatever you gotta do.

And, as a surgeon, I'm used to being in control as far as I'm doing this, I'm doing that. And it is a very vulnerable position for them to be in. So when I hear survivor, I think of not just resilience, but humility, 'cause you really have to trust a human being that you don't know.

I meet people for two minutes in my office and next thing you know, they're letting me operate on them. That's pretty wild, if you think about it.

Stephen Calabria: If you could give one message to cancer survivors listening to this episode, what would it be?

Raja Flores: There's no guarantee with anything. Having a cancer is not a death sentence, [00:28:00] and you learn to live with uncertainty because once you get that diagnosis of cancer, you think, oh my God. I see the end. I see where I'm gonna die.

And we don't know when we're gonna die. You, I've got people who've had cancer, they got hit by a car on the way to the hospital. You just don't know. And some people who think they're cured, next thing you know, this thing came outta nowhere and it's back.

Life is filled with uncertainty. Cancer is not certain, meaning the outcome from cancer is not certain, good or bad. And so we just have to learn to live our lives with uncertainty. But the take home message- cancer is never a guaranteed death sentence. 

Stephen Calabria: What gives you hope about the future of cancer care and survivorship?

Raja Flores: When I see the young medical students who are bright-eyed and bushy-tailed, who are really in it for the right reasons, where they really wanna help [00:29:00] people and they're really in it, just, to help mankind, that gives me hope.

I got students running around all the time, observing and stuff, and, I don't just have 'em around 'cause I'm a good guy and I wanna help them become doctors. They inspire me, they make me not forget why I am doing this.

And when I see in their young eyes the awe of what's going on in the human body and how they're trying to figure it out to make it better, these guys are they're just, they, that's where I get my hope from.

The advancements in esophageal cancer, from my viewpoint as a surgeon, has been that we have developed this procedure where the complication rate is so low our leak rate, from esophageal cancer is as low as 1.6%.

And this was recognized by the Society of Thoracic Surgeons, where we received the three star rating for esophageal cancer.

Which is the highest rating that you can get. Only a small percentage [00:30:00] of programs in the country get it, but that's because we focus so hard on making sure our outcomes are as, as good as can be.

Now everybody tries to make their outcomes great, but we also have the experience in doing it. We have got decades of experience in doing this operation, so we may just change a little move from one spot to another or preserve a certain blood supply to something, and that makes the difference between you sailing and going home quickly or staying in the hospital for weeks on end with a complication.

We also did the same for lung cancer. So the Society of Thoracic Surgeons recognized us as well as a three star program for lung cancer surgery. Now, of course, we toot our horn in that we can do these operations with three little small holes and do lobectomies and all kinds of other complicated operations like that.

But the thing that I'm most proud of is we are able to operate on people who [00:31:00] in other places are deemed unresectable. We've got patients where we've done these big mammoth operations, extra pleural pneumonectomy and stuff and they're doing fine 10 years later.

And it's not so much just doing the operation a certain way, it's deciding who should have that operation. It's the patient selection. So many times I'll have a patient saying, I saw this patient on the internet, you operated on them 10 years ago, can I have the same operation?

Then I'll review their records and realize, you know what, you're not the best candidate to have this.

So when you combine our ability with minimally invasive techniques, our experience with minimizing complications and our long experience in evaluating different patients and you put that all together with our 10 thoracic surgery attendings, I do believe, of course, I'm biased that this is the best thoracic surgery program in the entire [00:32:00] country.

Stephen Calabria: Finally, what was the most difficult situation you've ever found yourself in as a cancer surgeon and how did you confront it? 

Raja Flores: Every day you're faced with things and as the head of the department, there are many many situations that other surgeons get into, and as the head of the department, you need to go down there and land the plane.

And I think that's the thing that we do best at Mount Sinai. We have multiple surgeons who are excellent surgeons. Every once in a while there's a little difficulty landing the plane and we call upon each other to help land that plane in the operating room.

And, two heads are better than one. And when you have two people figuring out what to do, who have a combined experience of a hundred years or even three people that helps you do what's in the best interest of that patient in front of you. 

Stephen Calabria: [00:33:00] Dr. Raja Flores, thank you so much for being on Road to Resilience.

Raja Flores: Thank you for having me.

Stephen Calabria: Thanks again to Dr. Raja Flores for his time and expertise. That's all for this episode of Road to Resilience. If you enjoyed it, please rate review and subscribe to our podcast on your favorite podcast platform.

Wanna get in touch with the show or suggest an idea for a future episode? Email us at podcast@mountsinai.org.

Road to Resilience is a production of the Mount Sinai Health System. It's produced by me, Steven Calabria, and our executive producer Lucia Lee. From all of us here at Mount Sinai, thanks for listening and we'll catch you next time.