Mental Health and Wellness During a Pandemic

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    Peter Yellowlees, MD is a Professor of Psychiatry, the Chief Wellness Officer at University of California, Davis Health, and an excellent resource for strategies to mitigate anxiety, depression, and social isolation in the midst of a pandemic. 

     

    Dr. Yellowlees and MedCram Co-Founder and Producer, Kyle Allred, spoke in an interview about navigating the COVID-19 pandemic from a mental health and wellness standpoint. Topics in this video range from managing burnout for healthcare professionals, loneliness and isolation, and “physical” versus “social” distancing, to setting personal boundaries and the impact of technology on mental health. 

     

    Watch the full interview here and on MedCram.com, or read through the transcript below.

     

    Learn more about Dr. Yellowlees’ background and research here.

     

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    Interview with Professor Peter Yellowlees, MD

     

    Kyle Allred, Co-Founder & Producer: I’m here with Professor Peter Yellowlees, and he may be the best person to talk with about two very important questions. 

     

    Number one: how do we improve our mental health and wellness during a pandemic?

     

    And number two: how can we use our phones and other digital devices to improve our health and not worsen anxiety? And we’ll talk about many other topics as well. 

     

    Dr. Yellowlees is a professor of psychiatry at UC Davis Health, where he’s also the Chief Wellness Officer. He’s published seven books. What is the landscape now of mental health with relation to this pandemic? This pandemic’s been a central part of our lives for over a year now. Has mental illness rates — have they increased over the past year, and who is most at risk?

     

    Dr. Yellowlees: Sure, well, I mean, I think we’ve talked about this being a mental health pandemic following the COVID-19 pandemic, and I think that’s unfortunately very much the case. There’s no question that mental health illnesses have increased, and there’s also no question that the symptoms that we get on the non-disorder spectrum, the milder symptoms, have also increased.

     

    If you actually look at just the level of anxiety and distress that people have, that is clearly also increasing and particularly among health care professionals. But what is also increased is a term that many people have used and that is “moral injury,” and one of the things that the pandemic has brought about is I think an increased incidence of moral injury, which people often equate with burnout, but I think it’s different.

     

    And so moral injury occurs where we have to as physicians or healthcare workers do something that is not as good as we would like to be doing. We may not have all the PPE we want. We may not be able, for instance, to let people who are dying meet with their relatives, because it’s all going to be done on an iPad. We may not be allowing visitors into places. We may be having to make unusual medical decisions based on resources rather than quality of care. And these moral injuries I think have been dramatically increased during COVID, particularly among the very frontline healthcare workers, such as people in emergency departments and intensive care units. 

     

    Stressors Leading to Anxiety, Depression, and Burnout

     

    Kyle: That’s really interesting, and that’s of course a specific stressor. What other specific stressors have led to increased anxiety or depression or burnout? Are there — income factors, of course, I’m sure are contributing. What other main stressors have been identified?

     

    Dr. Yellowlees: One of the tragedies of this whole pandemic has been the way it has adversely impacted people of color, people from diverse backgrounds and ethnic groups, and people who are poor. And we know, for instance, that people of African-American or Hispanic backgrounds, in particular, have higher rates of COVID and higher rates of death from COVID. And that’s related to many things, but it includes poverty, lack of access to care, lack of trust in health system, and is something that unfortunately the pandemic has really shone a light on. 

     

    The other area that I think the pandemic has shone a light on is loneliness and isolation. We’ve found and we know that in general times, up to about 25 percent of seniors, for instance, 

    actually are lonely and isolated and see very few people. And that about 18 percent of a general population report similar symptoms. Now in COVID, obviously that’s gone up quite dramatically, and we know that loneliness and loneliness and isolation and, whether it’s people living in their homes and being lonely or whether it’s in a nursing home or in a jail or a prison where they can’t have visitors, in any of these situations that people are in, we know that loneliness is essentially quite a significant social determinant of health. 

     

    Loneliness is associated with an early mortality. It’s increased with significant extra both medical and psychiatric morbidity, so that people, you know, tend to tend to eat more, they tend to get aggressive, perhaps, they tend to have more chronic medical problems, maybe, perhaps with less care, and we know that a lot of people have forgotten general medical care during the pandemic, and so that this issue of loneliness and isolation becomes really a major process 

    that we need to think about. And how do we try and confront that and look for solutions? 

     

    Kyle: The word anxiety has been used a lot during this pandemic, and how do you define anxiety? And is it always a bad thing? 

     

    Dr. Yellowlees: Anxiety is a normal defense mechanism that we all have, okay? If you go back to ancient times, and you’re a hunter or gatherer and you’re chasing some food and the lion chases after you, it’s pretty normal to become anxious. That’s a good defense mechanism. So you know we can all get anxious in response to adversity. 

     

    The issue with anxiety nowadays is are we essentially using these fight or flight mechanisms in a way that is inappropriate, and in particular, leading us to avoid doing other things? So what you find with anxiety in COVID, for instance, is that people get literally stuck in their homes, and they become increasingly agoraphobic, they lose their independence, then they then get into a sort of vicious cycle, whereby they see less people, they do less, they perhaps don’t eat so well, they perhaps start drinking too much. They get depressed. They don’t get treatment. They get more depressed, etc.

     

    Obesity, Poverty, and the Pandemic

     

    Kyle: You’ve mentioned one possible result can be people staying in their homes, more afraid to go out. You mentioned stress eating, as well. How strong are the correlations between obesity and inactivity, and depression and anxiety? 

     

    Dr. Yellowlees: So, I think that the really strong link between obesity and the pandemic actually relates to poverty. And if you are poor, particularly if you live in inner cities, particularly if you are from a diverse cultural background, you tend to have to buy your food from the local store, which doesn’t have fresh groceries is more expensive, doesn’t necessarily have the correct nutritional requirements. 

     

    You may well eat far too much fast food now that you can get it delivered so quickly and so easily. And so you’re likely to start putting on weight and, you know, I’ve heard terms such as the “baker’s pandemic,” you know with everybody baking their own bread at home now, and people simply overeating. And so I think people have to be very careful. 

     

    I mean, there are three keys to remaining healthy: the first is to get good sleep and to really focus on your sleep. Make sure you get seven or eight hours sleep and almost use that as a barometer of your wellness. The second is to exercise, and the third issue is good nutrition. On the more negative side, it’s very important to avoid doing certain things, and I mentioned earlier on substance use, and unfortunately, sales of beer have dramatically increased during a pandemic. And quite a number of people are actually probably self-medicating at home — 

    maybe self-medicating their anxiety or depression with too much alcohol.

     

    Kyle: Is there a difference between mental health and wellness?

     

    Dr. Yellowlees: Yes, I think you can look at them very differently. I mean, one of the issues around mental health is that the symptoms of disorders and non-disorders really are a continuum. They’re a spectrum, so you know it’s natural for us to feel anxious or upset when confronted with traumas or difficult situations. 

     

    The next level on almost is, with physicians and and other professionals in particular, is the symptoms of burnout, and again they’re not as yet diagnosed as a psychiatric disorder, although in the ICD-11 that’s going to be the case, and then you finally get to a level again of symptomatology, whereby we actually define an illness, such as post-traumatic stress disorder, anxiety disorders, depression, etc., and so we have to think about mental health as being on a continuum, and most of the symptoms that we relate that we get — and we all get these — are not illnesses and are not disorders. 

     

    So that’s really to a great extent where wellness comes in. What wellness does is — as long as we work at it — is reduce our vulnerability to getting a series of these symptoms that occur on a continuum. And so we can keep ourselves, if we can keep ourselves well, keeping control of ourselves, you know have have a reasonable sort of healthy approach to life, we’re less likely to get any symptoms on that continuum, or if we do get symptoms on that continuum, they’re going to tend to be milder.

     

    Physical Versus Social Distancing

     

    Kyle: I heard you say in a previous interview that the reality of life is that we have a lot of acquaintances and relatively few good friends. How does this relate to the physical distancing that has become such a big part of our lives in this pandemic? 

     

    Dr. Yellowlees: Well, Kyle, I’m glad you used the term “physical distancing,” because I think that’s actually what we have to think about. We need to physically distance, but we need to socially connect, and so the term “social distancing” really isn’t a great term for what we need to do. 

     

    Now, if you look at normal people prior to a pandemic, most people have only between three and five true intimate friends that they can really spill everything out to. They could go and stay with them at, you know, the drop of the hat. These might be friends or they might be family. They might be siblings, parents, children, but most people have fairly small intimate social networks. And I think one of the things that you need to do during the pandemic is really focus on those intimate networks. Focus on those intimate friends — that person that you’ve known for 30 years since college and you’ve always got on really well with.

     

    They might live in another state now, but you know that you trust them completely and they’re someone that you could go to for help. So I think focus on those intimate friends and connect with them more than usual. So you know everybody talks about “Zoom cocktail parties” and equivalent meetings. I certainly do all of these with my family. My family is spread all over the world and we have regular zoom meetups, and actually as a family we’re seeing each other more regularly during the pandemic than we do normally. So really the focus for most people I think should be: think of the people who you really trust and love. And spend more time with them, more energy and effort to connect with them,  and make sure they know how you feel about them. 

     

    Kyle: It seems that, you know, that said, people who are naturally introverted may be a little bit better equipped to deal with some of the lockdown measures in a pandemic. There’s all these personality tools, whether it’s enneagram or Myers-Briggs, or other personality tools. Do you find much utility in people using these to kind of get a better sense of where they fall on a spectrum of personality traits? 

     

    Dr. Yellowlees: You know, I don’t personally use them very much, and I think you’ll find that most people who are reasonably intelligent actually know what their personality style is. They don’t really need to do a questionnaire to sort of demonstrate their major traits. I mean, I was actually seeing a patient just a few days ago who has an obsessive-compulsive disorder and for whom control of everything is wonderful, and she was telling me how actually she had understood that her personality was perfect for the pandemic, because she can control everything inside her house, and she doesn’t feel the need to go out, and she’s actually feeling pretty relaxed about the whole situation. Now obviously at some stage she’s got to go start going out more, and I think she’ll be able to do that in this instance. 

     

    But you’re right; I mean clearly there are some people who just are less social than others or some people who have particular disorders that make it less easy for them to tolerate being alone in a house or in a house just with a family and maybe children. Now I deliberately mentioned children, because children are almost the forgotten losers in the pandemic. I mean, it’s an absolute tragedy that so many children have lost so much school, have lost their social connections, have lost the ability to to graduate, have lost the ceremonies that mark transitions in life and can never get these things back. 

     

    And so there’s a whole lot of people who’ve had major losses, and, you know, and as we all know, parents really don’t necessarily like being locked up with their children 24/7, and that does cause a few problems for people. And so you know that’s one of the major stressors, quite honestly, is how do you keep your children connected with their friends, keep them doing as many age-appropriate uh behaviors  and fun things as possible, whilst at the same time keeping your own sanity?

     

    Setting Boundaries

     

    Kyle: I heard you say in a previous discussion that, as humans, we actually do better if there are boundaries. Can you explain that a little bit more? 

     

    Dr. Yellowlees: Sure, I think there’s two things that are interesting about humans. First of all, we are social animals, so we like to have other people around to talk to. And that’s fun, and that’s why we have parties and all the rest of it. 

     

    Having said that, for children in particular, boundaries are really important. And so one of the things I often say to parents in this situation is remember that your role is to be the parent, not the friend. You’re not the buddy. You’re the person who’s there to ensure that by the age of 18 or 19, you have a fully independent human as a child who you can then in later years become a good friend of and connect with. But bringing out children is not about being their friends, and so you actually need to have pretty clear boundaries. 

     

    There’s no question that this is a good thing to do for the children and for the parents. So regular bedtimes, regular school schedules, regular times for outside activities. Keep a family schedule, so everybody knows what everyone else is doing, and you’ll find, if you can actually get children into a regular schedule, that they are almost always happier and certainly less distressed than if they are constantly having to test boundaries, which is really just a sign that they’re feeling out of control.

     

    Supporting Healthcare Workers’ Mental Health

     

    Kyle: Do you have any thoughts about groups of people that are often assumed to be more resilient, such as military folks or first responders. Are there any specific ideas of how to better support those people, and are the strategies different? 

     

    Dr. Yellowlees: Yes, I think the strategies are different. I mean, look, the best example of a group that is assumed to be resilient are actually physicians. We know that when physicians start medical school that they are more resilient than other graduate students starting PhD programs and yet within 10 years they have twice the level of burnout of those other individuals. 

     

    Now, that shows us two things. It shows us, first of all, that physicians are working under a lot of pressure and in a very difficult system. And we know that about 80 percent of the causes of burnout are organizational. What we do about it is obviously try and improve the organizations, but we also go to physicians and say “okay guys, you people are resilient; you’ve proved it in the past by your capacity to get into medical school and succeed and jump over some very high bars, and let’s just retrain some of the things that you’ve done in the past that used to be helpful that you’ve sort of forgotten about whilst you’ve been working 90 hours a week for the last 10 years.” 

     

    And so we have to remind people to go back to whatever habits they used previously. Now that may be listening to music, it may be getting fitter, maybe doing more social activities, whatever, okay? Whatever worked in the past, and we can get into a situation where because of our work, particularly in overwhelming jobs, we haven’t kept up the behaviors that made us resilient previously. And so, I often will ask people, “just tell me, what did you do that really gave you a buzz when you were sort of in your early twenties? What was enjoyable? What made life worth living?” Okay, and you’ll get all this list of things, and when you say “so how much of those did you do recently?” And they wouldn’t have done anything, so the advice is pretty straightforward. “Okay, try and do what helped you previously.”  

     

    Technology and Mental Health

     

    Kyle: I want to move on to some technology questions. Are these things, cell phones, bad for our health?

     

    Dr. Yellowlees: I think they’re a two-edged sword. If you look at young female college students who are the biggest group of users of phones, I mean, literally some surveys show that they literally spend eight or ten hours per day on their phones. I mean, that is really not a good idea. We have to make sure they don’t stop us  being mindful of the present and of the other world outside of the phone. And so as long as we do that, then I think they’ve got a lot of advantages. I mean, they’re clearly very good for social interactions, again, as long as you can put them down. 

     

    They’re great from an educational point of view. In particular, from a mental health point of view, there are increasing numbers of apps on them, which are essentially like having a therapist in your pocket, and so I regularly use several apps with patients, and particularly those patients who are anxious in their homes during COVID and can have them put their earbuds in and sign onto the app and then go through a series of either meditation or breathing or other sort of relaxation style exercises just as if they had a therapist with them when they get anxious. 

     

    So I think there’s a lot of good things about phones and I strongly encourage people to use them, but it’s like everything: if you use them too much, then —  you know, we used to call that substance abuse or, in this case, a sort of “technology abuse.” What we want is for people to use the technology as well, but not excessively to a stage where they start losing out on the real world relationships.

     

    Kyle: Any specific apps that you recommend? 

     

    Dr. Yellowlees: Sure. I mean, the one that I like best is actually made by the VA. It’s free to everybody. It’s called CBT-i Coach, where the “i” stands for insomnia. The problem with really all of the apps is that they’ve had very little real research performed on them, and so whilst they seem to be nice and to have some good immediate validity, we really don’t know scientifically yet how effective some of them are. 

     

    Kyle: Speaking of phones, we have all this news at our fingertips and one could just follow the news cycle all day if they wanted to. Amidst this pandemic, what do you think is a healthy way to interact with the news? What are some strategies to not get overwhelmed by the news cycle?

     

    Dr. Yellowlees: If you set up some sort of process, whereby you yourself are not going into the apps all the time, the moment you go into the apps, you’re going to get distracted, and you’re going to be looking at something else. I mean, all of the new services we have and many of the apps are deliberately designed to be addictive.

     

    Virtual Doctor Visits

     

    Kyle: Well, you’ve done a lot of research and advocacy for video visits with patients, and I’m curious what your research has shown, what your personal experience has been with it. Do clinicians and patients seem to prefer video to in-person visits?

     

    Dr. Yellowlees: Yeah, I think that’s a really, really important question. It’s been fascinating in COVID to see the changes that have occurred. There’s no doubt that patients like video visits. I mean the satisfaction of patients with video visits has been huge from way back, and it’s so much more convenient, so much easier, saves so much time, and there’s no question about that. 

     

    And in fact, I’ve been seeing patients in what I call a hybrid manner, so they have the choice of seeing me online or in-person for quite a number of years now, and what I find on the whole is that the patients maybe initially come and see me in person and then they revert to video. And once they started seeing me on video, they almost never changed back. So providers are the opposite end of that spectrum. Providers have been much slower to adapt video visits, have had many more concerns, and I think very genuinely held concerns, that video visits were somehow not as good as in-person visits. And that the gold standard always had — if a gold standard is to see somebody in person, then you should always do that. 

     

    Now, the reality is with COVID that a huge number of providers have switched over and we now know that about 20 percent of all consultations in all areas of medicine in total are occurring on video, compared with less than one percent prior to the start of COVID. In my own discipline of psychiatry, something like 85 percent of psychiatrists are now seeing the majority of their patients on video, compared with just two or three percent before COVID, so obviously video suits some disciplines more than others, but I think that the providers have really had a sea change during COVID in many, many disciplines and I know, for instance, at UC-Davis, in our primary care clinics and our specialty clinics, we’re doing about 20 percent of all of our consults by video currently, and our intention is to keep that up long-term, and to continue to offer video visits for patients for situations where it’s appropriate. 

     

    And I think that’s the big change. But that we used to think, or many, many people used to think of video visits as being an all-or-none thing. Do you either see the patient on video, or do you see them in person? Now what people are thinking much more appropriately is when can we see video patients on video where it’s appropriate.

     

    Kyle: Do you have any techniques to gather vital signs or any objective information if you’re mostly seeing someone over video?

     

    Dr. Yellowlees: Sure, I mean I see patients where I’m prescribing stimulants, for instance, for ADHD, and for those patients, we need to know about vital signs, and so I ask the patients to buy the relevant equipment from a local pharmacy or from wherever they want. And so patients take their own blood pressure. They tell me their blood pressure, their pulse. They can take their temperature; they can even buy an oxygen saturation measure if they wish. They’re relatively cheap, so you can actually get patients to buy a lot of very simple things and have them do their own measurements and just report those to you. And that on the whole works absolutely fine. 

     

    I think the other big advantage of the video visits is that you often actually get to know patients better, because you’re seeing them in their homes, although patients frequently see me in the car as well, but you’re generally seeing them in the home. And you can actually learn about people more. I mean, I get patients to show me around the home, to show me what pictures they have on their walls. I can start to learn more about them from their tastes and they can introduce me to their pets, again, an important member of a family I wouldn’t normally meet, and that you can actually meet other members of a family with a patient’s permission, and you can clearly get shown around the garden. You can see the kitchen. You can see how the patient lives on a day-to-day basis, and that essentially gives you, from my perspective, as a psychiatrist really an extension of learning about them as an individual. 

     

    Kyle: So it seems like this may be a silver lining amidst the tragedy and suffering of the pandemic is more video visits or more increased openness to them. Are there any other positive developments or silver linings that you’ve seen amidst this pandemic?

     

    Dr. Yellowlees: Yes, I think you’re absolutely right. I mean, I think the whole use of technology generally has become much more accepted. Another interesting silver lining has been the importance of honesty and messaging in my own health system.I know the leadership has actually been extremely good about regular constant transparent messaging, and we know that people do better if they’re told the truth in an honest way and they respond better and actually feel better if you do that. And so I think that the whole issue of messaging from, particularly, within local health systems has had a light shone on it, and I think will be different in the future. 

     

    What’s a Chief Wellness Officer?

     

    Kyle: Well, you are the Chief Wellness Officer at UC-Davis Health, which is a fantastic title. What does that entail, and should we have a Chief Wellness Officer of the United States? 

     

    Dr. Yellowlees: I think that’s a fabulous question. I think we should certainly have a Chief Wellness Officer for the United States — there’s no question about that — but I think every health system should have a Chief Wellness Officer with appropriate support and also appropriate access to leadership to be involved in decisions and to assist with decisions. And so I think this is clearly the sort of next C-role within healthcare. And I think there’s probably about 30 or 40 people in my position now across the United States, so it’s still a very young area to support the staff and to ensure that the workplace is both safe and a place where everyone can thrive. 

     

    Gratitude and Happiness

     

    Kyle: I’ve heard you discuss how gratitude can lead to happiness. Can you explain this and ways to incorporate gratitude amidst such a difficult pandemic that we’re in.

     

    Dr. Yellowlees: Sure, I think there’s been a lot of research, much was actually done by Dr. Emmons at UC-Davis on gratitude, and what has been discovered is that gratitude undoubtedly improves your sense of well-being and your sense of morale. We know, for instance, that if you are in a system that has a lot of burnout among its staff that one of the indicators of the likelihood of burnout is if mid-level managers actually say thank you to their staff enough and actually acknowledge what their staff are doing, and so if you look at the leadership courses, gratitude has become a major focus of many leadership courses. 

     

    The other area that has really come forward has been the issue of empathy, which is related to gratitude. Obviously, you can’t be really grateful to someone unless you can really understand what they’ve done, and empathy is obviously being able to put yourself in the other person’s shoes and feel how they feel. Now, it’s really important to have empathy and good leaders do have empathy.

     

    But what is even more important, and again what we’ve discovered I think more so in COVID is that if you add action to empathy, you  have a very simple equation, which leads to compassion and so I talk a lot with people about this equation: compassion equals empathy plus action, and having empathy isn’t enough you’ve actually got to have empathy and do something and do something to make some changes or to help people or just to thank people. So I think there’s a lot of interactions between what often people think of very soft terms, but we actually know from hard science and from quite a number of studies now that these issues actually really matter. 

     

    What is Burnout?

     

    Kyle: You’ve mentioned the word burnout a couple times. How do you define burnout?

     

    Dr. Yellowlees: If you think about the symptoms of burnout, really there are three sets of symptoms, and certainly in my view this is not a psychiatric illness. This is really just a set of symptoms that sort of maybe make you vulnerable to developing a psychiatric illness. But they’re very common symptoms, and there are three sets. 

     

    The first is what we call emotional depletion, which is essentially just being exhausted and tired. The second is a feeling of detachment and cynicism. In that setting, you think that you know your patients, no longer have names, you’re not so interested in them, you want to rush through the clinic. Perhaps you think about the fact you’ve got to see 10 more individuals, but you’re not so interested in them as humans. And the third is a sense of low personal achievement. So what is the point? You know, why did I go into healthcare? Why didn’t I just sensibly go to wall street and make a ton of money, or maybe okay I’ve gone into healthcare, but I’ve chosen the wrong health system. I need to go and change, and the grass is greener somewhere else. 

     

    So these three sets of symptoms — emotional depletion, detachment and cynicism, and a sense of low personal achievement — are really what burnout is, and it’s a very common problem, and unfortunately if people don’t recognize it in themselves, it can lead to them making bad decisions. And we know that there are more medical mistakes made by burnt out physicians and nurses, and we know that patients report a lot less satisfaction. And we know that this is very costly to health systems, because of the increased errors and reduced level of work. 

     

    So health system-wide burnout is a significant issues, and I think that’s been one of the drivers behind the development of the sorts of roles that I have as a Chief Wellness Officer, it’s hoping in the long run that we will develop systems that lead to less burnout and lead to more thriving physicians and nurses and consequently better patient care. 

     

    Kyle: We’ve talked a bit about gratitude and, you know, other strategies to maintain perspective during this pandemic. How about hope? I’ve heard you mentioned that in previous interviews as well. 

     

    Seeking Hope in the Pandemic

     

    Dr. Yellowlees: Yeah, I think hope is really crucial. Without hope, it’s very hard to go forward, and we all seek out hope. We all want to have some sort of future and some sort of direction, and people are exhausted with the pandemic at the moment, and they’re particularly exhausted. If you’re a healthcare worker looking at people who don’t wear masks, that makes healthcare workers very angry. And I think, certainly, in the messages that I send out to people. In the health system, in which I work, I focus a lot on hope and a lot on people planning for the future, knowing that it’s still uncertain as to perhaps how much travel they can do, how much other things they can do. But certainly, you know, creating some goals for yourselves, creating some goals for your family, for your children. 

     

    I recently went back and read some of Anne Frank’s book from the Holocaust, and it’s a, you know, an extraordinary diary. For anybody who hasn’t read it, they should read it. And but in it, she remains hopeful through the whole Holocaust, even though she was eventually killed as a teenager at the end. And despite it being a very difficult story, hope shines through, and that’s been a beacon for many people over the years. And I think we will look back on this time of the pandemic in a few years time and think “hey it was bad; we didn’t enjoy it, but we got through it; we life changed a bit; we did things differently, but we’ll still be looking forward,” and I think that’s the most important thing. 

     

    Kyle: Well, professor, thanks so much for  joining us today, really appreciate it, learned a lot, and hope to have you back on in the future. 

     

    Dr. Yellowlees: Thank you very much, Kyle. It’s been a real pleasure.

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