Pediatric Thyroid Disorders: Update Course 2016

When I was a resident, I had two attendings who did thyroid operations, and one was super meticulous and everything was tied off by a 50 silk and no drains, took a long time. I thought the operations went pretty well, a few complications. Another one was a little more, uh, uh, was faster, a lot more blood, um, not much tying, and everybody got a drain and everybody did fine as well. And at that point as a resident, I don't know how much. 30,000 ft view on what's important for quality and safety, and I didn't really pay attention to beyond maybe supplementing calcium and the PACU and the next day. And so when we talk about Becoming a thyroid surgeon or taking on thyroid disease, it's really not about the thyroid operation, it's about the whole system. So as we talked in our institution about creating a system to take care of kids with thyroid disorders that got us thinking about this, I was glad to have the request to do this talk because it made us really think about the system. So I'll talk a bit of this talk is sort of an update on thyroid and thyroid uh complications of thyroid surgery, and then I really think the most informative may be about uh, the recent guidelines from American Thyroid Association, which some people may be familiar or maybe not. So thyroid disease comprises a wide spectrum of benign and, and, and malignant disease, and really we focus on. Somewhat on Graves, but mostly on the differentiated thyroid cancers, papillary, follicular, medullary, and poorly differentiated, which are the rarity in In kids. There's definitely an increase in pediatric thyroid disease, which is a SER database two decades reporting, and it's not so much important the actual numbers, but you can see the increase. And this was, this included large thyroid nodules, not just small ones that you might attribute otherwise to better screening. So this is definitely an increase in the incidence of of thyroid nodules. Just this is a US population. The upper bar is males and the lower bar is females. Uh, let me talk about the difference in pediatric particulars. Uh, I think we all recognize that thyroid nodules are more prevalent in adults, but probably also know that thyroid malignancy is, is lower in adults. So the numbers are roughly 4 to 5% of kids have a thyroid nodule. Of those, maybe 30% or so are malignant, whereas in adults it's a bit of an inverse ratio. Thinking about what thyroid nodules represent for both groups, adults and pediatrics, it's mostly uh papillary thyroid cancer, but you can see on the left column that other than pediatric papillary thyroid cancer in the pediatric population, it's really a small percentage of follicular and others, which would be multiple endocrine neoplasia syndromes and and poorly differentiated cancers, which comprises a larger group of the. Adult populations So thinking about what is a nodule that's also different, and I think we recognize as we move from adult training to pediatric training that it's not simply a nodule size or the presence of a nodule that's important. Oh, pardon me, so I meant to also point out that in pediatrics there tends to be more incidence of nodular disease. nodal disease, uh, cancers tend to be more multifocal and more likely to be metastatic, whether that's to lung or bone. Uh, a nodule, I think we, we're used to this idea of a 1 centimeter, 1.5 centimeter nodule being important in adults. In kids, it may not be important simply the size, but more the clinical setting, whether there's associated hyperthyroidism and or the characteristics. So predictors of malignancy, a group reviewed sort of retrospectively all of their Uh thyroid nodules over a long period of time and found these predictors. So the, the patient predictors were male gender, compression symptoms, and palpable lymphadenopathy. Lab wise, the only important predictor was a higher TSH. And then the ultrasound findings were were significant microcalcifications, indistinct margins, hypochoic pattern. And increased nodular vascularization. This guides our ideas about whether a nodule should be investigated or simply followed. And a heart nodule is also a bit of a different beast perhaps in adults than kids. In adults, there is a tendency to control hyperthyroidism, and if that can be controlled, then simply follow these nodules in kids. The incidence of a differentiated thyroid cancer is upwards of 10 times higher than in adults, so the general recommendations are to remove hyperfunctioning nodules. Despite our treatment advances and generally long-term survival from cancer, there's a balance to be had between low cost specific mortality, which is a good thing, and fortunately we are some evolving data on secondary malignancies from cancer treatment. This is predictably and mostly from radiation. So 10 to 40 year follow-ups have shown something like a 98% survival overall from pediatric cancers that are treated, and of those deaths that occur, 2/3 are non-thyroid malignancies, and of those, most kids had received radiation. So there is a movement to balance, just like we have done in all of the cancer trials, to balance. Best treatment, best survival against reducing the secondary effects of treatment. Part of this comes in the risk stratification. I think it's an evolving, uh, theme in uh. In pediatric thyroid disease treatment. I'll come to it at the end of the talk as well, talking about the new guidelines from the American Thyroid Association. But if you can just, if you can stratify by uh by presence of disease confined to the thyroid, and perhaps just microcalcification, sorry, micro metastases to regional lymph nodes versus true uh lymph node disease or, or a distant disease, then low risk. Uh, cancers really ought to be treated with, uh, thyroid removal and, uh, limiting or really avoiding, uh, post-operative radiation therapy, and that's, I think, a, a shift a little bit in mentality. Also, there's a question of what should be done with a 1 centimeter nodule, either bigger or smaller. I think many of us grew up on the idea that papillary thyroid cancer, because of its multicentricity and because of its potential for recurrence, needs to be treated with a total thyroidectomy. This is a group from Washington that looked at. And the National Cancer Database at about 4000 groups, 4000 patients either undergoing partial thyroidectomy, so IPs lateral thyroidectomy and isthm mastectomy for a nodule over 1 centimeter, comparing them to those undergoing total thyroidectomy. And although there were some questions about, about the prevalence of nodal disease in the two groups, they really found no difference in 15 to 20 year follow-up. So they really suggestion that total thyroidectomy for papil may not be the right. Knee jerk, knee jerk response. Let me talk a little bit about uh possible complications and how we look at them. I think many people are aware of volume complications, volume associated complications, and I have some data to share with you on that. Uh, this is a group, uh, uh, a, um, a study from the, uh, nationwide national inpatient sample, about 1200 patients that looked at, uh, general, uh, complications and endocrine specific. They counted that as recurrent laryngeal nerve injury or hypocalcemia. Uh, and these were all inpatient complications. That's obviously a skewed proportion, but you can see that, uh, kids overall, both in the endocrine and the general populations, uh, sorry, types of complications had, uh, higher rates than their adult, uh, comparison cohorts. If you look at volume, this is a hot topic in everything we do and what everything that adults do. This was on the y axis. You can see the additional risk conferred by overall complications comparing this to high volume surgery, which is defined as more than 25 cases per surgeon per year. This is also the NIS, the National inpatient sample, looking at about 16,000 adult patients over 10 years. You can see a pretty striking difference in additional risk of overall complications by volume. That is probably not surprising to us, but what does that mean to us as pediatric surgeons? Uh, this group, uh, also use a smaller sample from the NIS, but you're looking at pediatric specific and found that, uh, there was a volume associated, uh, complication difference almost twofold. Can you go back to that last slide? Mhm. So does that mean that if you do one thyroid a year, you're gonna have almost a 90%. Greater, no, no, sorry, on the y axis additional risks. So a surgeon doing 1/3 a year compared to a surgeon doing 25 a year, is it 90% more likely to have a complication? 90% more likely, right? Is it all complications measured as inpatients? So it's a skewed sample, but yeah, OK. Am I dissuading you or encouraging, yeah, no, I'm, these are adult patients, so the data on pediatrics is more because that's about what I mean pediatric surgeons don't do that. So if you look at all surgeons as one group, the pediatric surgeons are gonna be on the lower volume side. They're gonna have a higher complication rate. So I think that, um, as you. You know, we've all enjoyed doing this operation and I think as time goes on as you invest in this and your both your endocrine and your oncology group recognize that you're that you're gonna go the extra mile to do this, then your practice is gonna change and so um our volumes have about doubled in the last couple of years and so I, I mean I, I was doing 10 a year a couple of years ago and now doubled from where? Well they. I'm surgeons, huh, well, I think, I think our, our plan was, and I, I'm, I'm getting a little ahead of David's talk right here, but the, but when you create, um, A tumor board in a center where everyone's working together on this, then the word gets out and those teenagers that are being done as one-off patients by adult general surgeons are gonna come to your place because you're providing a coherent complete set of care. But do you find that in Atlanta, were you competing against the ENT doctors or adult surgeons? Yes, but the, um, but we've, we also addressed the general surgery ENT thing in a fairly constructive way, I think. So sorry to digress. Can you go back to slides, please? But I'll tell you that slide would tell me that I'm, if it was my kid, I would send him to an adult surgeon. No, no, it would tell you that you'd send him to someone who does 20 or 25. No one. How many do you guys do? So, so Kurt's doing, that's OK, but that's very unusual. But, but, but, but, but, but it's not, it's not that a pediatric surgeon shouldn't be doing it. It's just, this should be somebody who's doing a high volume. But in most cities, I mean, you guys have one of the highest volumes in the country, but I, most, but Todd, I think that this is one of these situations where. We have accepted kind of an ignorance about this for a long time and now that we know it um we've adjusted our practice and our emphasis to draw and and we've we're drawing more patients to us which makes me sleep better at night because I know that if I've done 25 a year that that my team works well and my partners work well and so forth and and. So it's uh we're we're using these and I get to do more lobectomy it all works out. So I think I'll skip ahead to one of the, uh, my important takeaways from learning about this was to steal Doctor Herman's line that every kid should have that operation at our hospital, and we need to bring the, what shouldn't say in the Buffalo area. You know, and we need to bring our duty is to bring the resources to our hospital to provide a safe operation, so we'll get to that, OK, um, so, so here just looking at from the nat national inpatient standple also, and then this is pediatric patients. Uh, comparing high and low volume, now they're defining low volume as 1 to 2 a year, just as Todd implied. There's really, you know, almost a twofold difference of inpatient, uh, overall complications. Interestingly, if you look at pediatric specialties versus others, so this is pediatric versus adult specialists versus ENT specialists, slightly higher, uh, no difference statistically, um, and this, in looking at the volume, so they only had 5% of the pediatric surgeons in that sample had more than were high volume surgeons. So most pediatric surgeons doing thyroid surgery are low volume surgeons. So the, the, the two, OK, I'm, I'm a little slow. So just, well, no, the question is, are pediatric surgeons perhaps better trained or more adept at doing thyroid surgery than because it goes against the date that goes against what you just showed. So because that was all adults skewed, I get it. I understand. So pediatric surgeons have a special so you can spin it any way you like. Let me talk a little bit about, uh, specific sort of what we call endocrine specific complications. So hypoparathyroidism, which I think Kurt has some strong uh uh uh thoughts on that we'll come back to a little bit, uh, which can really can consign a patient to lifelong, uh, pretty burdensome medication supplementation, uh, are there, there's, these are relative risk factors, uh, again, uh, from the national inpatient sample. That shows you that no dissection confers over 2fold higher relative risk of either transient or permanent hypoparathyroidism. Other things like a total thyroidectomy, Graves' disease, operations, and malignancy also confer a higher risk. So these are things that we think about going into an operation. Overall, the best I could find was that there's a 5 to 15% rate of hypoparathyroidism after an operation, after either partial or total thyroidectomy. It's a little bit hard to know. Most of those are transient, but some of those are permanent. Um, that's among low volume centers or low volume surgeons, and it goes down to about 2.5%, so nearly a fivefold higher rate of hypoparathyroidism by low volume surgeons overall. If we look at the relation of hypoparathyroidism or we're currently on laryngeal nerve palsy or injury relation related to a central node dissection, clearly the, the red bars, which are the the patients who underwent total thyroidectomy with a node dissection, have a much higher rate of palsy, transient or permanent hypocalcemia, and the 1st and 3rd columns simply have no palsy in the non-central node dissection groups. So you can stratify patients by what they're going to have. So this naturally leads to the question of what's the role of central node dissection. So let me get to that towards the end of the talk. Looking specifically at recurrent laryngeal nerve injury, these are again relative risk factors for laryngeal nerve injury, uh, large tumor, non-visualized nerve malignancy, nodal dissection, or a redo operation. Nothing surprising, but at least quantified by by by how risky these are. Overall statistics, just to take some numbers away, that there's about a 0.3 to 1% risk of permanent recurrent laryngeal nerve injury. Uh, in pediatric, uh, Uh, thyroidectomy patients, this wasn't stratified by any means by who did it just overall, uh, and a 1 to 6% risk of transient palsy. Some people had even done pre and postoperative nasal fibro endoscopy to quantify that. I don't know if that's an important thing for us to do, but I think that the high volume thyroid surgeons suggest that that a pre-op DL as well as a post-op DL is a useful thing because A modest percentage, like 15% of these kids when they come to the OR and they have cancer, are going to end up with nerve dysfunction at the beginning. It would really make you sleep better at night if you knew you were starting with that rather than it's something that you caused. So since I learned that at a thyroid meeting years ago, we've just done, we just, as we put the. Patient asleep. We look at their cords going in and we look at their cords coming out so that we can say to the parents with some sense of confidence, this is what we expect post-op. I think there is a difference, however, between looking ourselves and then doing the, you know, fancy photo machitoscope, machitoscopes stroboscopic evaluations which may be perhaps reserved for either a study or for complications that you are suspecting. Uh, I think we've all seen this from, uh, HCup or ARC. Uh, what is it that patients are supposed to ask their, uh, surgeon or their doctor actually? So I just pointed out a little bit, a little bit small to read, but how many times have you done this procedure? Are there alternatives? What are the possible complications? And which hospital is the best for my needs? Now there are other questions to ask, but when we're talking about low volume operations, I think we have to ask ourselves on behalf of our patients, what are the answers? How many times have I done this operation? Well, if you can say to a patient, I've done, uh, 20, but I, the last time I did one was 2 years ago and I said thyroid, I think you really gotta ask yourself if you're the right person to be doing the operation. One of the most useful documents that have come out in the last probably 10 or 15 years is uh is this summary by the American uh Thyroid Association on guidelines for pediatric thyroid cancer. There have been multiple iterations of guidelines on thyroid disease in general and some previous allusions to pediatric thyroid cancer specifically, but this was a group of maybe 15. Uh, Endocrinologists and, uh, mostly adult head and neck or endocrine surgeons who went through the iterative process like a Delphi approach, looked at the best evidence and came up with a, a very long document talking about all the details of thyroid possibilities. A patient walks in with this nodule or comes in with nodal disease or uh has a recurrence later and one other thing and rather than go through all of them, I just wanted to bring up a few of the highlights. Uh, nodule significance may not only be based on size. I think I alluded to that. So ultrasound characteristics are important, and they've also made the point that FNA is an appropriate next step but must be done under ultrasound guidance. I think adult surgeons will often or sometimes do this simply on palpation or just in the office, and it really should be done image, an image-based approach. Uh, there is not enough evidence in pediatrics to suggest that the character of specific cancer can predict outcomes or predict which patient, uh, should have a certain, uh, treatment. So I think it's a good, uh, analogy to the National, uh, uh, Wilms Tumor Study Group and the other, uh, cog groups that have really looked over years iterations of. Uh, data to look at what's the best, most complete treatment, and then how do you pull back on therapy to prevent secondary malignancies. So we don't have enough data in the pediatric thyroid disease yet to say a genetic footprint can predict which patients should get treatment or not. Surgical resection for any heart nodule. Again, controlling hyper hyperthyroidism is important for operative safety but doesn't get you away from having to remove that nodule, which means a lobectomy almost always. This is probably a big change for most of us perhaps who weren't paying attention to details since adult training. Is that while radioactive iodine ablation I think is a pretty standard armamentarium in the armamentarium of adult endocrine and adult surgeons, it's not recommended across the board for low risk patients. Remember those are patients who have thyroid disease confined to the thyroid itself or perhaps only incidentally found in a surrounding lymph node as opposed to those who have metastatic disease or multiple bulky nodes with. Disease in those nodes. And I think perhaps the most important point is that children with differentiated thyroid cancer should be taken care of at a, at a center of excellence. Uh What is, so what is, what should pediatric thyroid surgery look like? We talk about value being benefit over cost, and this is not simply a monetary equation. This is a, what's the value added of having a thyroid specialist, an endocrine surgeon specialist, as endocrine surgery center specialist, and also most important is reducing risk, and this includes questions about long-term quality of life, complications, collaboration with adult surgeons, and also transitioning care as patients get out of the teenage years and may need to be followed. Who's going to be following them. Both on the medical and the surgical side. So, uh, what should a pediatric thyroid surgery center look like? These are sort of my thoughts, and I don't think there's anything unique, but just to perhaps make a pitch, multidisciplinary approach is, I think, critical. I think we've all had either experiences personally or had, have had attendings where the surgeon does the operation, sends the kids to endocrine, and those are the two people that, uh, perhaps make every decision. This should include nuclear medicine, oncology, pathology, pathology that's really Uh, talented at thyroid specifically, it's not fair necessarily to ask a general pediatric pathologist to be well versed in FNA examination, cytology, and so on. Interventional radiology in our center, the interventional radiologists do the FNAs. That doesn't have to be, but they certainly are a useful adjunct and obviously the surgeons. A tumor board, I think, to me is critical and one of the evolutions in our center has been finally establishing a monthly tumor board that combines adult and pediatric surgeons, uh, pathology, oncology, uh, endocrine, uh, nuclear medicine, and. I think those are the 6 groups. Uh, it can be hard to do and if, if you're trying to corral in adult surgeons, but we, we, we're doing it by tele, uh, by telemedicine or by camera links. Sometimes people can come over to your institution. That's obviously institution dependent. I'll know your local resources. We've come to understand that there are a lot of, uh, local ENT surgeons who have privileges at our hospital and do what you said, like a one-off operation here and there. It's, it's hard sometimes to. Restrict practice, but maybe to encourage their participation in the tumor board at the very least and understand who's referring to whom. We have family practice doctors who are seeing kids with thyroid disease. We may have one referral pattern. We have our own endocrinologists. We have community endocrinologists. We have had a history of uh surgeons at the local cancer center who took care of all teenagers but since have retired and moved on, and now there's a new pool of patients who are in need of consultation. Volume question. Well, high and low volume in most publications tends to be between 25 and 30 a year. I think that 25 sounds like a great number, but I think that may be open to discussion. And certainly it's a question that your endocrinologist may ask of you. They may have one pathway they trusted kids to be operated on by adult surgeons. Now they're asking a new person in town, well, how many have you done? And the answer needs to be something that you can defend to them that you're going to do, uh, quality surgical care. Standardization of care, I think this is super important, uh, is a trivial example of how do you measure postoperative calcium? How do you prescribe, uh, calcium supplementation and vitamin D afterward? How long do they stay on calcium supplementation before you recheck? There are some operative techniques that ought to be standardized. There's a question about using intraoperative, uh, nerve monitoring. There's an operative a question about, um. reimplantation of parathyroid. So to some degree I think care and surgical care and postoperative care can be standardized. And lastly, just as a personal interest, and I think an important part is the long term follow up, not only just to see if they have recurrent disease, but talk about quality of life, our oncologists feel strongly that kids with differentiated thyroid cancer, even though it's typically treated by surgeons and endocrinologists, they still have a cancer diagnosis and have some of the same long-term survivorship issues that kids with Wilms tumor and. Would you not leave that slide for a second? So, uh, two brief comments about this. Uh, over the course of the summer, um, historically we communicated as a group by email and occasionally met in person, but over the course of the summer we've put together a thyroid tumor board at the, at the encouragement of a number of people in our group, and, and the conversations that occur are dramatically different. Um, the nuclear medicine person, uh, presents a patient that had. Partial node dissection and a thyroidectomy a few years ago and now they have a thyroglobulin level that's climbing and they've had a certain amount of grays in because of the radioactive iodine and so then the issue about having 500 mg of exposure becomes a big deal. And then the question is should this person get ablated again. If they can't find solid disease, or should they be re-explored or should they get a PET to see where the activity is, and the level of conversation for that patient's benefit changes dramatically when there is a thyroid tumor board. The second point I would make is that. Um, we have gotten to the point of double scrubbing. Uh, Dave Wesson presented this nice paper at ABPSA where he had a smaller volume, but he had two attendings double scrubbing, uh, in this that made their complication rate very, very low, and it drew the patients back into the Texas Children's Hospital system from the, the community, and I, and that's certainly one way to address the, do you have enough numbers you guys do, um, well, um. I'm not 25 anymore and I have two partners that are really hoping that I fall over from a VTE sometime in the near future so they can have my and, and so, um, I have uh invited uh both of them intermittently to scrub with me and um. And so that's bringing their numbers up. That's to bring their numbers, but, but, uh, in your mind is a, is a pediatric surgery fellow an equivalent to another attending. Um, some, but, uh, I have, uh, two of my partners who are very, very invested in this, and, and then when you're doing a difficult case, uh, there's no, no substitute for having a second pair of eyes and so forth. But the, the third point I would make is that the same thing, by the way, huh, the third point I would make, which really, um, very few of us are going to have recurrent laryngeal nerve injuries, we're very meticulous and the comments you made about we're special and so forth when we do. You know, genetic thyroidectomies in kids who are less than 5 years of age, we have to be able to be very good at doing this, but so relatively few of us are going to have recurrent laryngeal nerve injuries, I think. What is a really big deal is the hypoparathyroidism, and we take out huge goiters because the endocrinologist has been really cautious about sending them to you or you have a child that didn't have. The value equation is access times quality over cost, and some people don't get access, and they show up really late and have massive glands, and when that happens, your chances of having hypoparathyroidism post-op become quite a bit larger. And so we've been really aggressive about reimplanting our parents, and that has from the transition from Doctor Ricketts to myself as being the. The person who has most of the thyroids, uh, that's dropped my hypoparathyroidism rate dramatically. So to which reimplantation? Um, until I talked to, to Kurt, I was just identify them, leave them alone, but now I think identifying them may actually lead to hurting them. Um, and so your approach has been to look at them, cut them, and, yeah, because when you're in the post-op period, if you, if you, if you check the IPTH afterwards and it's zero or unmeasurable, it's too late to. To do this and so you really want to do your best if we find them and they look dusky, we cut them. If there's red blood, we leave them. If there's not red blood, we take them out and reimplant them and it takes about a month for them to return, um, but they do return and then we measure IPTH in the recovery room and again 6 and 8. Hours afterwards, if the IPTH is less than 10, we start him on vitamin D and calcium. If it's, if it's in the 30s, we tide them over and expect that things are gonna get better. So I'm totally out of it with our, I mean, I, I, I, I'm not with the current stuff. So is this, is this something that's becoming more of a standard thing because I don't remember ever doing that. I, I, I, I wanna compliment, uh, both Jason and David on really good presentations. The, the thing that's so important about what, what David just said is. There's probably not another profession that has changed more in the last 10 years than thyroid surgery, and in 10 years' time, the thyroid guidelines have been rewritten 4 times, and this is a profession that is moving very, very quickly. And so I think the baseline is anyone who's going to do thyroid surgery has to have read that pediatric thyroid surgery guideline list to make sure that. You know they can sleep well at night by knowing that they're complying with those guidelines because these are done by people who who live and breathe this and if we're doing one-off cases once or twice a year we're really not providing. That's not the theme of what pediatric surgery is. We're not providing the good care that we can in other areas, so. Well I think that was, that was a great talk and I think it hit on a lot of points not directly related to how to take out the thyroid but all the other things that go along with it and uh. We just, the, the podcast we just did on thyroid, I, I felt like it was totally different. Uh, a lot of the stuff is so new to me, uh, than what I learned, uh, in, in residency. So thank you for that. That was very good. Any, uh, comments or questions you guys which you do as well? I don't know if there's any other. You don't do any anymore. You do lung resections instead, right? So I think you got the better end of that trip. So do I. So do I, especially, especially when it came to the IBD patients. Like I'm, I. Really do miss doing the colectomies. I don't miss following them post-op. That's all I'm gonna say. And several of my partners thank me for doing the IVD pinch. But, but one of the other pieces though is that we do not ever want to have a single point of failure. And I, I know that a lot of the, and we've really been, I can tell you that our group, we're not all like saying, OK, we all need to go specialize, and this is, this is easy. Because it is hard, um, but there are, you know, somebody else gets a thyroid again, or if I get a Wilms tumor, I'll still take the Wilms tumor out, but I'll go get Megan Durham or, you know, to, to say, hey, is there something I'm missing? Do I need, you know, what's the latest and greatest, uh, and, and, you know, and I'm in a little different position because a lot of times I'm, you know, have to be stuck in meetings the next day, so I do pass stuff off. But, you know, but to Kurt's, uh, well. That's what my partner said, but, but Kurt, uh, you know, Kurt's point about having, you know, somebody to have a point person, you know, thyroid is a great example where over the 10 years this has completely changed, and I, I learned a bunch today. I learned a bunch from Jason, from David. Uh, it's, you know, it's, it's impossible for any one of us to keep up with all of this. So I, I, the one last thing is about the double scrubbing thing. We, we published a paper this year showing how pediatric surgery has completely changed in the last 1520 years that, that we do abscesses and appendectomies. That's, you know, the, the, the, the fine, fine cases of pediatric surgery are, are lessening and so I think we have to start doing that for our numbers to stay adequate. Uh, to be able to do enough of everything, we're gonna see more and more, uh, of a benefit of having two attendings, uh, together so that they keep their numbers up.