S04E64 COSMETIC SURGERY TOURISM - WHY OR WHY NOT

A number of patients are traveling outside the United States to get their cosmetic plastic surgery procedures done. Patients see fantastic pictures on social media, travel for surgery, and then return home - sometimes with problems that their local surgeons are forced to address. Is traveling for cosmetic surgery safe?

Dr. Sam Rhee @bergencosmetic, Dr. Salvatore Pacella @sandiegoplasticsurgeon and Dr. Sam Jejurikar @samjejurikar discuss international medical tourism, the factors to consider about educating patients, and what instances where traveling to another country for cosmetic surgery would actually be a great idea.

#podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

S04E63 COSMETIC SURGERY TOURISM - WHY OR WHY NOT

[00:00:03] Dr. Salvatore Pacella: Well good morning everybody. We're here for another podcast. Uh, I'm Dr. Sal Pacella. From, from, uh, San Diego, California. Uh, my Instagram handles at San Diego Plastic Surgeon. We have Sam Re, Dr. Sam Re from Bergen, um, New Jersey at Bergen Cosmetic, and of course, Dr. Sam Jejurikar at Sam Jejurikar out of Dallas, Texas.

How are you today? Doing.

[00:00:27] Dr. Sam Jejurikar: Awesome. Excellent. How are

[00:00:28] Dr. Salvatore Pacella: you? Fantastic. So we are going to talk about a very interesting topic today, and it's medical tourism specifically. Um, the process and pitfalls and advantages of going out of country, out of the US for cosmetic surgery. Prior to doing so, let's go through our regular di.

[00:00:50] Dr. Sam Jejurikar: Yeah. And uh, just one thing before the disclaimer, Dr. Ri, I always get it confused. He's from Paramus, New Jersey, Bergen County, right? Bergen.

[00:00:57] Dr. Salvatore Pacella: That's right. Yeah.

[00:00:58] Dr. Sam Jejurikar: My, my mistake. No, I screwed it up on the last show. So I feel like I need to make amend so, um, This show is not a substitute for professional medical advice, diagnosis, or treatment.

This show is for informational purposes only. Treatment results may vary based upon the circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care. Never disregard professional medical advice or delay seeking advice because of something you may have seen on this show.

Back to you, Dr. Pacella.

[00:01:32] Dr. Salvatore Pacella: Alright, Jens. Well, so this is a very interesting topic. I think that has, uh, had some notoriety in the, uh, in the news cycle the last few weeks, um, about going out of country for, uh, plastic surgery care. . Um, and you know, this seems to be, um, uh, quite popular in some of our southern states, obviously in, uh, San Diego.

Um, I have seen, um, a lot of patients go to Tijuana or south of the border for Complica or for, um, Cosmetic surgery procedures and have, of course, many times they come back over the border with complications. Sam, I know in Dallas you probably see a, a bit, um, and Sam, uh, in New Jersey, I'm sure you see probably, uh, people flying back and forth from the Caribbean.

So I'm just curious about your experience with this and what, what you see as, as some potential.

[00:02:26] Dr. Sam Jejurikar: Um, I guess I can start. So, yeah. Um, I, I definitely have seen, um, many patients who I'll kind of break into two types of medical tourism, international and domestic. From an international standpoint, we see lots of patients flying to the Dominican Republic, to Mexico, to Turkey.

Um, that's a very popular destination these days that we're seeing. And obviously we, there's selection bias in terms of the patients that we are seeing. If someone's having a good result or not having any problems, we're probably not hearing anything about it. Um, unfortunately with some frequency, whether it's an ERs, um, in the, you know, in the community around us or calls to our office just seeking post-operative care, um, there's a lot of patients that seem to have these procedures that are being done and then have post-operative complications and know one to actually take care of them and it puts.

Um, but that's all sort of in a difficult situation because our goal is to try to help people. But, but our goal obviously has to be to sort of take care of our own, the patients that we've taken care of first, and sometimes we're stretched a little too thin to give people the care that they need. Sam?

[00:03:31] Dr. Sam Rhee: Uh, absolutely.

I see. A, a, a fair number of patients or no? We are contacted at our office by a fair number of patients. Let me rephrase that. Um, especially from the Dominican Republic. Now, and, and I think the biggest issue as, uh, Sam has mentioned is, is follow up care and complications. Um, I like at least two or three times a week, we'll get a call from someone who says, you know, I had a tummy tuck done, um, out of the country and I, I have a lot of redness now and, uh, I'm, I'm really worried about it.

Or I had a breast augmentation done and one side is really. Getting bigger and bigger. And I called my doctor, um, in the other country and they said, just go see a doctor and they'll drain it for you. You no problem. It'll be totally fine. Like, these are the type of things we get constantly, um, from our office.

It's, it's really a dilemma for patients. I mean, patients never expect to have complications, um, but when they happen, they can be devastating. When you have no support, no help, no one near you to help deal with this.

[00:04:39] Dr. Salvatore Pacella: I agree. It's, um, so, you know, again, as a, you, you make the, you make a great point, uh, Sam, which is, uh, the selection bias, right?

And, and let me also say this. I am, I am a, uh, member of the Aesthetic Society and I'm also a member of the, of IAPs, which is the international, uh, society for Aesthetic Plastic Surgery. And I, I am certainly. Saying that the best plastic surgeons are in the United States, that's clearly not the case. Um, one of the best eyelid surgeons in the world is an Ahman Jordan, uh, Mo Al, who's a good friend of mine.

There's a f We, we just did a couple podcasts on body contouring surgeons, uh, Dr. HOAs in Colombia. . So, but there are bad surgeons in the United States and there are bad surgeons internationally. And, and what's not necessarily, what's important is the complication issue, not necessarily where you're going.

Right. And I would say that at least a couple times a month, uh, my office gets calls about, uh, chronic seroma or an infection. I, I would say that, you know, the, the worst things I see are. Are twofold, um, drained. Uh, so people who come back just a short time after plastic surgery, so weak and have a large pocket of pus or infection, and then they find themselves in the ER one night.

Okay? And, and that causes some issues because many insurance companies don't pay for complications related to cosmetic surgery. And so they may be stuck with a big ER bill or a, or a secondary revision surgery bill. The second thing I've seen, which come sometimes. Comes months after the case is, um, there is, there has been a, a warning from our professional societies about mycoplasm bacteria, um, in the setting of liposuction.

And this is due to really, um, uh, substandard sterilization of the liposuction cannula. So if you think about it, you know, we're taking these big metal cannulas, they're hollowed out and. , you know, passing them back and forth into the, the subcutaneous tissue of the abdomen. And if you have bacteria or some sort of re really resistant bacteria in that cannula, it concede throughout the entire abdomen.

And I, you know, many years ago, about 10, 12 years ago, uh, Horrific story. A young lady, 24 years old came to see me and she had liposuction of her abdomen and she had at least accounted them at least 35 pockets of small areas of pus all the way throughout her abdomen. I literally had to make 35 small cuts to excise each of these, these pus pockets.

It's, um, it's pretty tragic. So,

[00:07:21] Dr. Sam Jejurikar: you know, um, what, what I would say, just kind of to follow up on what you said, yes, there's definitely great plastic surgeons, international. Definitely there's very, very good ones. But the thing is, if you look at the motivation for why people are typically going overseas, the ones that are, that are going for medical tourism are not doing it because they're necessarily seeking out the best plastic surgeons that they can.

Many times they're doing it cuz they're trying to seek out the cheapest plastic surgeons that they can. And they are drawn into the fact that they can get a package price that oftentimes includes their airfare, their accommodations for a week to 10 days, their surgery. Um, and whereas I've had many complications, I imagine you guys have had many complications.

Um, We have the ability to take care of our own complications here, and we're all board certified plastic surgeons. We're members of the Aesthetic Society. We're members of the American Society of Plastic Surgeons. When people are going overseas, they're not oftentimes knowing what the credentials are of the surgeon that's doing their procedures.

There's many stories that in some of these places like the Dominican Republic and Mexico, where people are going, where there's clinics that are doing high volume. There may be some, some well-trained plastic surgeons, but there's many other people working underneath them that may not have the same level of credentialing.

Um, and then we don't know about the credentialing of the facilities. I do all of my procedures, and I know you two guys do as well in fully accredited surgery centers that get inspected on a regular basis by, uh, organizations in the us whether it's, um, you know, hospital accreditation or surgery center accreditation to make sure that they're up to standards for sterilization, you know, for safe practices.

Um, if you travel overseas and your primary motivation is price, There's no way to be sure of these, of these, you know, whether or not the same level of scrutiny has gone into making sure your procedure will be as safe as possible.

[00:09:16] Dr. Salvatore Pacella: That's true quality, you know, quality comes with a premium and that I think patients need to understand that.

[00:09:22] Dr. Sam Rhee: Go ahead, Tim. Sorry. The other thing I have seen is that patients will often not necessarily be the best candidates for procedure or multiple procedures. I've seen patients, um, Were extremely high BMI who wanted multiple procedures. Maybe they wanted a tummy tuck, liposuction, breast augmentation arm lift all at the same time.

And, and, and they had seen either the cost was too prohibitive to do it local or there wasn't anyone who felt like they were good candidates to have this done in the United States. So they ended up traveling somewhere where someone said, I will do all of these procedures. for a very cheap price. And, and it's very tempting for patients because they feel like they don't have the means or, or possibility or to achieve what they really want.

But what happens with a lot of these patients is, is that one, they're, they run into complications because when you do these high risk procedures on patients, even in the safest of settings, you can run into real problems. And second of all, These surgeons will often do really poor jobs doing all of these procedures, and I've seen this time and time again.

Um, there are some places where I've seen, uh, patients say they routinely blood transfuse everyone. And I was like, what? Like for cosmetic surgery? They're like, yes, you have to purchase in advance your blood transfusions in order to make sure that you get. during the procedure because if not, there will be patients that die if you don't buy it in advance.

And so there's this whole subculture of these patients who are so desperate, where they're willing to literally risk their lives. And they know this because they feel like this is the only way that they could achieve their result. And, and. And I don't want to judge patients for, for wanting what they want.

But in this case, it's literally not worth it for you, your family, the people around you to, to try to risk your life for something that, that it, it's not worth it.

[00:11:34] Dr. Salvatore Pacella: So, so let me, let me just get this straight. So you're saying that if you don't purchase your blood transfusion ahead of time, they won't give it to you?

That's

[00:11:41] Dr. Sam Rhee: correct. And, and, and they say for all the other, um, expenses, you might need more bandages, more medications bring cash, because they're not gonna take your credit card down there. So make sure, and at a lot of these places, they're like, if you don't have someone who speaks Spanish well, , you're, they're not gonna treat you well.

So these, there's this whole subculture of patients where they're like giving each other's tips. This, this plastic sur or this cosmetic surgeon, um, and recently had a couple deaths, so avoid that one. Go to this one. Like, it's, it's when you look at the discussion that many of these patients have on Facebook groups or, or, uh, other locations, um, it's truly scary what they're willing to put up with to risk.

In terms of trying to achieve a result and, and honestly having seen this and we seeing it firsthand in terms of these patients, it's not worth it. And so let, yeah,

[00:12:37] Dr. Salvatore Pacella: go ahead. So, so let me, let me ask you a question. Um, and you alluded to this earlier, which was, um, the patients come to your office, or you see 'em in the er.

And they say my, I called my original surgeon and they said, just go to the er. Somebody will take care of it for you. You're gonna be fine. Okay. Le let's reverse the roles here. Let's say somebody came to see you in Jersey, um, or you in Dallas, from outside the country, or let's say from another part of the United States.

How would you broach that subject if you had a complication?

[00:13:13] Dr. Sam Jejurikar: Um, I can go first cuz because I do have this scenario happen a lot in my practice. I mean, I'll treat people from other states every week and um, I think we have to break it into different phases of their care. , I will try to make sure that they stay an acceptable amount of time in Dallas Fort Worth afterwards.

So let's say I'm doing a tummy tuck with liposuction on someone. I'll tell them I want 'em to stay in town for approximately two to three weeks postoperatively. Um, I wanna make sure they get through that initial perioperative phase where there's no substantial issues. I put them on the same visit schedule post-operatively via telemedicine, uh, post-operatively.

So I'm still following up with them in the same intervals I would be if, if they're local. Um, they have a direct line to me. They have my, you know, my, my office number, my cell phone number so they can get ahold of me if they need me with anything. But then I have an extensive network of friends, uh, who are plastic surgeons, board certified plastic surgeons, and pretty much, um, any portion of the country if my patient lived in.

New Jersey, I'd say, Sam, I need your help with something. And I know you would do the same thing to me. They're in San Diego. I would do the same thing with sound. I know you would do the same for me. And, and that's the thing, like we have a network of people in this country who we can guide them to should something happen.

You know, usually I think, I think you guys would agree, most complications of a significant nature are detect. Within the first period, you know, few days to a couple of weeks after surgery so you can get 'em past a certain point. Typically, you don't see a lot of things happening, but you can still care for them, um, very well if they're somewhere else, but you have to keep 'em around for a long enough period of time.

[00:14:52] Dr. Sam Rhee: Absolutely. I think the biggest thing that we all do as plastic surgeons is make sure our aftercare is appropriate regardless of if they're near or far. And, and trust me, it's sometimes it's a struggle for someone. I've had patients all over the northeast, even Long Island, like trying to get across. That Cross Bronx Expressway backed over to see me.

I'm telling these patients, please take that hour drive, you know, hour and a half drive over. And they're like, I'm fine. Just like, let me just talk to you on the phone. Or, or, or, let me just zoom you. And I'm like, okay, fine. But if there's anything you got. You know, I wanna see in person. So we are, I think we're all pretty fanatic about making sure that we, you know, the biggest things that we can do to not, uh, to treat complications is to avoid them.

And a lot of times the, the post-op care that we're providing is literally preventing. Complications, the fact that we are keeping up on things that we're maintaining a communication with our patients. Um, I, I would find it abhorrent if I just sent a patient off after surgery and said, good luck. You know, if they called me for something, say, okay, find someone else.

Like I find that. Just completely antithetical to what we do as plastic surgeons. Like our job is to shepherd them through the whole course, not to just operate and leave them alone.

[00:16:12] Dr. Sam Jejurikar: Well, it's a completely different business model if you think about it, Sam, right? If, if you're doing low cost surgery, You have to do high volume surgery to make that work.

And if you really want to make it work, you need to do really high volume surgery, which means you become, it becomes less about the individual doctor patient relationship, and it's more about. shoveling people through a business. And so, um, you know, a lot of these patients don't even see the doctor until right before surgery and their screening is done by maybe a nurse, maybe not even a nurse, maybe a receptionist.

And so it's, it's a totally different model of doing business and it's not geared with that doctor patient relationship at its very core.

[00:16:54] Dr. Salvatore Pacella: You know, I, I, uh, I find myself in this scenario not infrequently either. I I see a lot of, um, complex revisional eyelid surgery from all over the country, and, you know, un unfortunately, in the eyelid,

Um, although you, you do get complications early on, um, a lot of these things sort of fester for a long period of time, three months, six months, a year. Um, and you know, I un unfortunately, we're not in this scenario where I can just send 'em away after two weeks. So I, I have a specific. Uh, strategy that I tell patients.

I say, you, if you're coming to see me to fix this problem, I want it to be successful for you. But so it's a two way street. Um, I'm certainly willing to send you home at an appropriate time, but you have to be willing to come back to see me at a moment's notice, should there be any problems, because it's critical for me to see.

As soon as possible, if you develop chemosis of the eyelid or lid, now position that because there are, there are strategies that I have to employ very relatively expeditiously in order to stop that problem from getting worse. So it's, it's a big challenge. Big challenge. Um, I think, let me Go ahead. Yeah, go ahead.

Sorry.

[00:18:07] Dr. Sam Rhee: No, go

[00:18:07] Dr. Salvatore Pacella: ahead. Um, so let me, let me, uh, let me ask this question here. Let's shift gears for a second. So, how do you feel. should your domestic health insurance pay for complications when you go out of country for cosmetic surgery? So when you show up in the ER with a rip roaring septic infection, what, what is the, what do you

[00:18:32] Dr. Sam Rhee: think should happen?

I was just about to, I knew you were gonna talk about this, which is why I said go ahead. Um, right now most, most commercial insurances do not cover. Uh, complications from cosmetic procedures and, uh, that is really one of the problems that patients have coming back. And that's also one of the reasons why I am very reluctant to see anyone who's had a complication from outside the country.

It's not that I don't feel for these patients that, you know, I sympathize with them, that I understand that they're going through a really difficult time. It's. They just spent money, even if it was less money than they would've in the United States. They just spent a big chunk of their money traveling, flying, getting care, coming, you know, getting surgery, coming back.

And then they have this complication that they show up into an ER for where, um, you know, where they now have to pay out of pocket for, for additional care and, This was something I talked about with one of the other plastic surgeons, um, uh, who's part of the A S P S, uh, ethics committee. Uh, Dr. Bajaj, I, you know, now you're charging these patients for care when they've already shelled out a ton of money and these patients are already in a financial situation.

Um, as a surgeon, if you end up seeing someone in the er, you are obligated to take care of them in that emergent immediate period. But then your legal obligation to, to take care of them after you've gotten them through that immediate emergent situation is no longer there. But they often have a lot of residual cosmetic issues, scarring, you know, huge, um, ugly, cosmetic, uh, issues that they need or want to get fixed.

And at this. I didn't know who the surgeon is. I don't know exactly what happened to them. You know, this is a tremendous time, uh, and, and money investment both for the patient and for me. That's not something I take lightly. And so honestly, You know, I don't know if insurances will ever pick up the, the bill for these things.

I don't think they ever will. So I, I think it's a moot point. Um, insurances aren't increasing benefits, they're just reducing them. Um, and I don't, and honestly, as a provider, I, although I feel for these patients, I try to stay away from them as far as I can.

[00:20:57] Dr. Sam Jejurikar: Um, yeah, I mean, just to kind of second what, what, uh, Sam is saying.

Um, I mean, they don't cover complications related to elective cosmetic surgery in the us so they're not gonna magically cover it for people that are having surgery internationally. I mean in the US there's supplemental insurance policies that all of my patients are required to buy to cover cosmetic complications that would potentially happen after surgery because we explained to them what your normal health insurance is not gonna cover these complications.

Um, it's only eligible to board the patients of board certified plastic surgeons. Um, and I don't know if you guys use it or not. I think your question though was should they cover it? Right? Not does it cover it? Mm-hmm. , was this more of a, trying to get our, get our feelings should.

Yeah, I think it should. I think it should also cover complications related to, to elective cosmetic surgery, because if I go skiing and I break my arm, that was an elective choice as well, and I broke my arm and I engage in a high risk activity. But the insurance company doesn't give me a hard time about fixing that, so I, so yeah, I believe they should.

I also know that they don't. So I don't know what my opinion, my opinion doesn't count for anything , but that's my personal belief. I mean, it's always choices, any sort of thing that's, that's a traumatic injury. There's usually some sort of choice that was involved that led to that. Yet the insurance companies don't draw the same distinction.

You

[00:22:29] Dr. Salvatore Pacella: know, I think, um, uh, we, we clearly see the whole gamut. I, I've seen patients come in fluidly septic from. Crossing over the border, you know, um, that have to go for emergent surgery, ICU admission, presser support, everything. Um, from minor complications, scarred deformities, et cetera, months later, and, you know, it, it, it, it's a tough pill for me to swallow, to think that, you know, any insurance company wouldn't pay for someone on the verge of death regardless of the choice they make.

You know, I mean, I, I personally feel that if it's a, if it's a life threatening complication or a complication that's related to significant additional morbidity like infection or requiring a urgent surgery within. You know, 90 days of the global period, that's probably something as a, as an insurance in a society, we should be, we should really consider covering, but some of the other complications related to how things look or scarring, et cetera.

I'm a little bit torn about. I mean, you know, patients have made this decision and, and you know, I think they're, they're smart enough to know that there are risks You. .

[00:23:36] Dr. Sam Jejurikar: So it's, uh, I think, I think you can break it down into life threatening complications, medical complications, and then cosmetic complications.

Right. And I would, I would certainly draw a distinction between cosmetic outcomes, cuz there's no medical necessary to get those fixed. Um, you know, I, one of the worst complications I saw was a necrotizing fasciitis after Brazilian butt lift. By the time I got consulted, general surgeons had already removed Sam.

[00:24:02] Dr. Salvatore Pacella: Tell us what necrotizing fasciitis

[00:24:04] Dr. Sam Jejurikar: is. Uh, necrotizing fasciitis is a rapidly ascending, um, infection of particular type of bacteria that, um, rapidly spreads. And if you don't treat it by urgently debriding all of the skin and all of the fascia, which is the layer right on top of the muscle. So flesh.

Right, right. So thank you. Yeah. So if you don't do a rapid surgical debridement, um, patients will die. So by the time I got consulted on this patient, she'd already had the life saving aspect of her procedure done. General surgeons had removed all of her buttocks on both sides, and, um, it skin grafted her as well.

So now she just had a horrific cosmetic problem. So at, at that point then, um, , it is technically cosmetic surgery to, to fix it. And, um, you know, you have to explain to this patient that it's gonna take multiple, multiple, multiple operations to get her to look somewhat passable. It'll never be good, and it's probably all coming out of pocket.

And that's, that's a hard conversation to have with somebody.

[00:25:07] Dr. Sam Rhee: I mean, I realize that we are biased, we are making our money. Doing cosmetic surgery and the people that go out of the country were losing income potentially to other plastic or other cosmetic surgeons in these other countries. And so it's easy for other people to look at us and say, well, of course they're gonna say, don't go overseas.

Don't go to another country. Um, don't go for the cheap option. And you're right. I understand that we may not be coming from a place where PE people would, would find us authentic, but I can only tell you like there's not one of us who would ever send. A mother, a sister, a friend to go overseas no matter what.

And, and that's how I treat my

[00:25:54] Dr. Salvatore Pacella: patients.

[00:25:54] Dr. Sam Jejurikar: I, so I disagree. I actually disagree with that statement. Oh, really? And well, I'll tell you why, because I think we've gotta get back to that first point. That sa, that Sal just said. So. I've talked to my wife about additional body contouring surgery. This is a theoretical conversation that we have.

And I would, she's like, who should I go to? And I said, you need to go to Columbia, to Alfredo Hoyos, Hoyos. And um, he's like, you wanna send me to Columbia? I'm like, one of the best people of, not the best people in the world, okay. To do this procedure. Okay. He is a world class surgeon and then she needs to do exactly.

What Sal me. You deal with any of our patients, then come from somewhere else. You need to stay there an appropriate amount of time. You need to be willing to go back should any complications arise. She's done her research as to who this particular surgeon is. The bottom line is, if you're gonna go overseas, it's gotta be the.

Criteria that we use with our own patients. Do your research. Make sure you're going to a person that is reputable and knows what they're doing. Stay there in appropriate amount of time, go back to them with any complications that happen. And the problem is, is what we're seeing and what we're talking about, isn't that what we're seeing is people that are just going to some sort of factory coming back here and having no follow up of any kind.

I think what

[00:27:15] Dr. Salvatore Pacella: your. Sam, I think your, your question, you know, if I could take the opportunity to rephrase that, would you ever send your family member yourself to go overseas for purely cost? for pure saving money.

[00:27:29] Dr. Sam Rhee: That's correct. Yeah, you're right. And I would never

[00:27:31] Dr. Salvatore Pacella: do, Dr. Dr. HOAs is not gonna be inexpensive.

No, hell no.

[00:27:37] Dr. Sam Rhee: No. If, if anything, it may cost more than all of us, but you're right. I would, you're, you're a thousand percent right. Never. I would never have any of my family members do anything for the cost of it. And Sam is a hundred percent correct. , I would do the research. I would do, I would make sure that I did the due diligence to, to go overseas and, and have the surgery, the right in what I would think would be the right way.

And so both of you guys, um, corrected me and, and I agree a thousand percent with that. I appreciate that. Yep.

[00:28:07] Dr. Salvatore Pacella: You're right. Any, any strategies for dealing with the cartels when you're. Anyway, it's too soon. Sorry.

[00:28:17] Dr. Sam Rhee: I have one of my, one of the guys I, one of the guys I trained with is from, uh, is from Cali, and he's, he's an amazing surgeon.

So I would have to ask him how to, uh, how to deal with it.

[00:28:27] Dr. Salvatore Pacella: I mean, I, not, not to sound lightly, but that, that recent, uh, um, episode was just absolutely tragic. I mean, it's tragic, tragic, you know, it, it sadden. Me dearly. So, um, yeah. Well on that note, Jens, thank you for your input. I really appreciate the, the commentary and, um, I guess that's it.

[00:28:50] Dr. Sam Jejurikar: have a, have a good day, gentlemen. Take care. Thank you so much.