Daniel Skinner et al., "The City and the Hospital: The Paradox of Medically Overserved Communities" (U Chicago Press, 2023)

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We've done this many times with many academic podcasts and we would like to help you. If you would be interested in talking to us about how we can help you with your podcast, please contact us. Just go to the front page of the new book's network and you will see a link to NBN Productions. Click that to love the forum and we can talk. Welcome to the new book's network. This is Laura Stark at Vanderbilt University. The new book The City and the Hospital is a remarkable collaborative project. I had the great pleasure of talking to John Winn, Professor Jonathan Winn, who is one of the three co-authors on this project. At the core, the book is looking at this paradox, which is that the people, the residents who live closest to hospitals, actually tend to have poor health outcomes, despite the fact that they're living near these anchor institutions in communities, these places of healing and allegedly well-being. I hope you enjoy this conversation. It is a good one for theory nerds and policy wonks and everyone in between. I had the great pleasure of having this conversation along with students in the course American, Medicine and the World. You'll hear their voices as well in this conversation and we hope you enjoy. We're delighted to be talking today to Professor Jonathan Winn, John Winn, who is at University of Massachusetts and one of the co-authors of a fantastic new book The City and the Hospital, the paradox of medically over-served communities. This was co-authored with two other scholars and it's specifically looking at the issue of why it is that hospitals, which are thought to be considered to be the sites of wellness and healing, are tend to be located in places where the communities near them actually are quite unhealthy by all conventional metrics. This is the puzzle that you were set out to figure out and you look at three case studies in particular, three hospitals, Hartford, Connecticut, Cleveland, Ohio and then Aurora, Colorado and the book has more than 200 interviews that you were based on with those three sites. Before we get too far along though, I wanted to give you a chance to introduce your colleagues by telling us a little bit about them and how those relationships came about. To actually lead us in this direction, I wonder, Maddie, whether you could jump in with your group's question? Absolutely. Throughout your writing process, how did your collaboration with authors of different disciplines shape your perspective? Well, thank you for the question, Maddie and thank you all for having me and my colleagues would love to have been here so they send their regards as well. So thank you very much to them. So it actually started with Daniel Skinner and I being friends from graduate school. We both were in the same cafes sitting there talking and hanging out and actually played music together in Brooklyn and we know each other from these kinds of worlds and we kept in touch after graduate school and we were sitting together and well after graduate school, after my first book, my second book, which also are about culture and place and communities. And we started to think, what would a project look like for the both of us to work together with my expertise and his expertise? Me coming from a place and qualitative background and Daniel coming from a theory and a medical policy background. And we very quickly started thinking about hospitals. What is the story about hospitals? How can we think about that? So it wasn't a puzzle searching for a certain and bringing these people together. It actually came about by people coming together and searching for a puzzle, which I think is sometimes the case. Sometimes we have a puzzle, we see a social problem when we attack that problem and find people to kind of join us on that quest in co-authorship and complement each other's work. But really was the complement of each other's work that then was in the search of a puzzle. And so part of the way through Daniel had a colleague join him at Ohio University, Berkeley Franz, and she was started to join the project as a part of it too to help support us as we are going through. And so it kind of progressed. I don't think I don't know Professor Stark if it was conventional or not. But it does. Maybe it was a slightly unconventional kind of initial plan. No, it actually sounds unconventional at least in its admission. So the fact that people say actually it wasn't something that was all that necessarily empirically driven from the outside, from the outset. But it also sounds like the kind of collaboration that makes the most productive work because you know that you operate together and you think in ways that really chime nicely. And so your work today has been about all kinds of things. I'm not certainly in the medical so sh area. And we were talking, talking previously about your side hustle as a bass player as well. And you've done a lot of work around music and music festivals in particular. So actually, wonder whether you can actually make a case for listeners kind of at the top of the interview for actually the relevance of a space based approach to studying hospitals and health in particular. And you make this case a little bit early on in the book. When you talk about the notion that things are becoming increasingly place lists and especially if we think about telehealth and the idea of a lot of help access happening in the cloud or in a virtual realm. What's the case that you would make for a place and space based study? Well, you stole my answer a little bit, but yeah, I, uh, in the prayer lit, that's great. When I was in, when I was writing my dissertation, I was interested in place and culture and cities I moved to New York City and I was fascinated with New York. I'd always wanted to live there and the chance to study New York was great. And I struggled for about a year afterwards thinking about what I was going to, what I was going to study. And I thought about different, different ways of approaching place. And, um, after the September 11th attacks, I started getting really interested in tourism about how people were using public spaces to kind of take histories, make meanings of them for themselves and for, you know, others to tell stories. And so I was really interested in walking tours, not tours on a bus that just kind of circle through and they've got the same script, but somebody who studies a neighborhood and studies that culture and studies that place and those buildings. And if that group that's with them is interested in, you know, um, radical left politics that they would turn in this way and Google, oh, that makes me think of going two blocks down. Um, and so I got really interested in the idea of the way that culture works in place, that cities and in, in, in general, cities produce a lot of excess stuff and they produce different stories, food, culture, all these sorts of things, music. And, um, there's this kind of collective, what socials would call collective effervescence of living in cities and groups of people kind of rubbing up against each other and producing new things. And so I think throughout all of my projects, there's always this relationship between stories, history, culture and the neighborhoods that they're in. And so while it does seem strange for me to be interested in, in something like hospitals after if you look at all these different works, uh, and, and being, you know, somebody who plays music and, you know, likes tourism, but I am, um, I am a complete sucker for, uh, how communities are different. Uh, I'm, I, when I go to a neighborhood, I want to, or a new city, I want to know what the thing is. I, I will eat the thing. I will eat anything that any place has. I want to know what the, what the thing is in these different places and, um, and talking with people. So I'm, I'm, uh, there was, there's this old professor, how a pecker and he would, he was sitting in a bar and he was talking to somebody, you know, one of his students and he looked around the window and he, he saw the bar and he, he was, um, I'm looking at a picture of how he right now that I keep ahead in front of me. Um, and he, he says, I'll be right back and he runs across the street and runs into the alley to talk to somebody because he saw two people go down that alley. I am interested in plates. I am interested in people. I want to run down that alley and, and talk to, talk to somebody. And so when, um, when we're starting to think about hospitals, I obviously was interested in, in the particularities of those communities and their particular relationships to those hospitals and those institutions, which, for the most part, may be exactly the same on the inside of the walls, but how they relate to the communities outside of the walls may differ and what those histories of those communities, those hospitals and, or institutions are, um, shapes those relationships that they have with their particular communities. And so, um, I think that there is a really clear line between my, my thread through all of my work, and I was really grateful, um, that I could have health policy people who, who could really talk about that, um, you know, from, from an ad, um, the complete richness that would, that allows this book to be helpful to, to class like yours. And, and some listeners like, like you, because I, I will say that it was a new, it was a new adventure for me to be looking at health policy and I'm sure that most of you know, you know, a lot more than I do about, about some, some public health and, and policy stuff. So, um, yeah. Yeah. Um, and for the, the theory nerds who might be listening, it was also really great, um, to have your reflection on W.E. Du Bois as well in the Philadelphia Negro and the, that sort of, um, the urban, urban studies kind of direction from, from a theoretical angle as well. One of the, um, pieces that we spent a lot of time with in this class was actually failing in link and the, the idea of fundamental cause theory, which, um, for, for sociology of medicine, it's kind of like, you know, it's an oldie book goodie in that it is talking about how the things that actually cause immediate poor health are, um, actually quite, um, disparate from that in terms of this, the social networks, the relationships to power and especially socio economic, um, disparities and disadvantage. And your book, like, what we take to be the punchline of the book is that one of the things that, that cities create, at least cities with hospitals, um, sort of to use your really great phrasing, what, there's something extra that cities create is actually they create, um, poor health are at least underserved communities in the areas of hospitals. And, um, but, but unlike, um, sort of failing in link in one direction of fundamental cause type, type thinking and distal, the idea of distal causes is that, um, that literature I take to really dwell on class a lot and class disparities and the advantage that comes from, from, um, higher socio economic status and you're adding into that serious, strong consideration and attention to race, which is, of course, pattern, patterned with class. Um, but you especially share that in the division between the folks that you are interviewing who are hospital professionals who tend to be white and members of the communities, which tend to be communities of color, and that this really shaped the formation stories as you, as you write about in chapter two, um, that affected then the possibilities for what the hospital could do to engage, engage communities and vice versa. So, um, on this note, I want to actually ask Paulina to jump into the conversation. Yeah, so on the topic of those formation stories, which ones were very memorable from Redlands that didn't make it into the chapter, chapter two, but shifted how you understood trust belonging and access to these communities. Um, can you say it again? So, so, uh, those, those stories, those familiar and stories, how did they shape the, you know, kind of flagging trust and access? What, what is the direct cause of like, like, which ones, which ones didn't make it into the book? Well, which ones didn't make it? Oh, that's okay. Like, sit out to you and how these community members, like, didn't have trust or access in the community. Uh, Paulina, I, you know, any book, um, I, I quote Martin Scorsese in my first book, which is that there's no finished movie, only abandoned ones. And, uh, you know, there's only, there's no finished book, only, there's no finished study, only abandoned ones. And, and you're right. Like, there's just so many stories, uh, in, in this that are, um, just on the outskirts or referenced, uh, that couldn't possibly make the, the, the book itself. And, and really, um, you know, increasingly, and you all should know, like, we, we wanted to do a book in, because the book length manuscript allows us to tell more stories than in a way that, uh, that, uh, that an article format couldn't, right? At the same time that politics, the economics of book production are such that, that books have to be shorter and shorter. And so, um, there's a, that's, uh, I think that there's only so much that we could really put into the book itself. Now that said, I, um, I honestly think we nailed it. It comes to, it's like, we brought in, like, some really good stories. And there were some, and there were, we, we, we brought up the stories that we really, we heard over and over and over again, right? And so, it was not the case that we picked one that just was the most resonant. We picked the stories that actually, you know, came up in our, in our neighborhoods and our communities, uh, repeatedly. And so, I think, um, when thinking about, you know, we're talking about race, and I think I think Professor Stark is exactly right, but one of the things that I really wanted to reinforce was culture and history. And so, they might, they culture and history just as informed, informative as race, they, they're, um, racialized, I think culture in, in history are, are kind of racialized institutions in some way. They get, they, they, they are local, they are, um, uh, they, they come up and often in opposition to the organizations, uh, the, the anchor institutions that are around them. And so, I think they're always keyed in, to use Goffman's term of keying, which, which I think does have a musical, you know, kind of metaphor to it. Uh, and, and, and I think for all those reasons, I think the ones that we, that, that came out, um, were ones that we heard over and over again, and it was pretty, pretty traumatic. So what was left on the, uh, outside of the four corners of the project, um, there are a few, but I actually thought that we did a pretty good job. It's a little bit of a cheat of an answer, uh, but it's, you know, I think it's also true. Yeah, and you brought, you brought Goffman into the conversation. So that's always good who, who doesn't love that, uh, so, uh, I, I do want to ask Vic to kind of, to follow up on this because we were, we were chatting a lot about how one actually goes about synthesizing a community perspective without homogenizing the community, which is exactly what you want to be kind of breaking down in, in the book as well, um, sort of showing pattern differences without homogenizing or stereotyping. So, um, basically making a case for collective memory and that actually really factors in the possibilities that are available, um, to institutions. So Vic, I'm going to let you take it away. How did you decide whose stories will represent an entire community's perspective? I mean, how you didn't hear I was, I paused my mic, but I let out a deep sigh. I mean, that's a great question, right? And so especially as, as, you know, kind of racialized white, you know, researchers entering into these communities, that's, that's, I think, was really, uh, at the forefront of, of nearly every conversation that we had. And so, um, I think one thing that we, we were really careful about, and I think it actually goes back to the initial description of the book. We were interested in the puzzle. We weren't interested in the story that we preconceived. We wanted to know how to best tell this story without, um, having our own prejudices against us, you know, kind of where we, this was not a pro hospital book. This was not an entirely anti hospital book, um, in, in some ways, we really tried to, to set our own biases aside and really allow ourselves to, to be open to what the communities were saying and talking to us about. And so it, it was the, the selection of cases and stories. We, that allowed us to not have confirmation bias, which I think often happens with a lot of research in, in sociology. They, they, they know that there's a problem, and then they figure out what there was, and I have graduate student after graduate student coming into my office, complaining that people are just not saying the things that they want them, want to say. And I said, well, I think one of the problems is that you, you have an idea of what you, you want people to say and, and people are, are tricky like that because they, um, they have minds and, uh, they have experiences. And so, um, you know, I, I, I think that that approach of being very, very open, and what that did was, is allow us to, to, to hear the same stories over and over again and really get saturated in all of the stories. And there were certainly some that we, that we weren't able to tell, um, you know, like business owners maybe or something like that. And I think in some way, it was like, small business owners could have been one, one chunk of the story around the, the community, how the small business owners, there's, there's a little references to them, but, um, especially the stories of like the restaurant being invited into the food court and Denver, that was, that was a, that was one of those stories. But, um, we really wanted to kind of, we did try really hard to do that. And I think that one of the things that, that also to cycle back earlier is about the embrace of the WB Dubois approach to research where, where you really do kind of have a strong connection to history and the history of, of the particular communities that are there when we're doing, um, qualitative data work as well. And so that kind of theory, history, research and, um, and qualitative research cycle of having more of an iterative process allowed us to really, um, hone in on, on some of that. And also to check our own, our own biases. I'll say, I mean, just to, just to say quickly, like, um, we probably should have, we, probably would have had a more successful book if we came out pro-hospital or anti-hospital. But, um, but it, uh, a lot, it's universally disliked, I think, because people, it's some people, you know, some hospital folks, the American Hospital Association didn't like it, you know. Um, but we thought we were being, you know, kind of, um, you know, impartial. And, uh, we thought that actually we, it was a missed opportunity for book sales. And, uh, you know, but that's, that's, you know, that's, that's, that is one of this. Yeah. No, it's, it's really interesting to think about, um, the process of research as a process of learning itself, so the idea that actually if you, if you find that your, um, your interviewees aren't telling you what you, what you want to be hearing, but, um, it's actually forgetting that learning, um, element of the research process itself. Um, so although you didn't have a take pro hospital or, or, or anti-hospital with the book going into it, um, I actually, I wonder whether you had a take on the concept of community benefit, uh, that as a legal term, um, and particularly how it was framed out in the Affordable Care Act, um, as well as in earlier, uh, laws as well, which you write about like the, um, emergency, um, emergency care and labor act, what that requires that hospitals, um, provide some sort of treatment if they, um, to communities or for people who come into the ER, um, if they are hospitals that accept Medicaid and then also even earlier the Civil Rights Act. So thinking about this official legal designation of having to have a community benefit, um, I wonder if you had a take on that going in, if you had like a suspicion or maybe if you do now, I mean, sure, probably my colleagues had more suspicion, um, and, and more of a critical eye to how, how hospitals are able to claim community benefit without, uh, with doing minimal amounts of work. There's certainly plenty of horror stories in, in the public health world of, of hospitals claiming all sorts of things because there's a lot of looseness when it comes to what you can claim as being community benefit, including, you know, a hospital saying that it's entire med school because it occasionally will take care of, uh, some, some people in the community that that entire enterprise is a part of their, the count is community health. And so one of the policy, you know, recommendations that we have at the end is this to tighten up the language when it comes to what exactly is community health. And, um, I think that that was, that was, I, my, my colleagues were the ones who were really, really, uh, um, interested in that. And so when, when they raised that, I think that that's, that's actually, that was an excellent point. Um, the, the, the one group that was really interested was with the loan, you know, kind of index to the loan communities, really, where the people who were saying that there's, uh, we should be really interrogating their, they're very much on, um, this idea of what is community benefit and, and coming up with their alternative rankings of, of hospitals based on, um, racial equity is, you know, kind of something that I think is, is incredibly important. We really try and, and elevate that, that, um, you know, that narrative in this book. And that, that was one of the, you know, so while hospitals and communities might be, we're, we're disappointed a little bit in that the loan institute actually was really embrace this project, which I, we were really grateful for. We want to, we want to give enough of that information and their analysis and ranking of these specific hospitals, but also talk about it in general. And so we did have to reach out to them and, and get their blessing because we were almost at the point where we're like sharing too much of their information, and we want to make sure that we were, um, you know, kind of doing the right thing by them as well. And so, so they actually did, um, you know, kind of, um, broadcast this work a little bit in which, for which we're grateful. So, so if anyone's interested in that, the community benefit and, and that, I mean, the loan institute is really where it's at. Yeah, that's, that's great. And I really appreciate you raising up that case as well. In alternative rankings, they're so subversive. I really love them. And thinking, you know, just giving a shout out to sociologists as well. I'm thinking of, um, Wendy Espeland and colleagues work on, um, university and law school in particular, ranking systems and how if you just tweak the rankings and the reactions that institutions have to ranking structures, it really changes how the world works. It's remarkable. Yeah. And I think, you know, this is a pair, this is a mirror image, I think, of, of university. So, I mean, I think we could also be looking at universities as urban institutions that have, um, because of their tax-free status, have, are, should be compelled to do more and beyond just, um, pilot programs, payments and lieu of taxes, um, instead of just paying in occasionally when they want to, uh, because a place like, again, like Hartford, there's, there's a, there's a data point that just kind of blows my mind that over half of the property doesn't have tax, isn't taxable property because it's either a state government institution and educational facility or, or a health facility. And what that means is that the city is actually pretty poor and it's always verging on the, on, on, on teetering on bankruptcy. And, um, and so while, while the hospitals, we're, we're thinking about the community benefit when it comes to health. I don't know if there is, I can be wrong, but the same kind of alternative ranking when it comes to universities, what is the expectation of these universities to do good by their communities, we could very easily do the same project and thinking about the same thing from public safety to outreach and wall, the physicality of the walls and the capturing of property, right? And so I think it is about hospitals mostly, but it is also about just anchor institutions and what we should be expecting from cities, the anchor institutions that we have left in our cities. - Yeah, that's so great. And Larry wanted to follow up on this point about the ways in which community is defined both in residents own terms and also in policy terms as well. Larry, I'll let you hop in. - The book mentions medical administrators using research and education as sufficient community contributions, what creates disconnect between institutional self-perception and lived community realities? - These are such great questions. That's the kind of question I want to ask a hospital administrator, what's your definition of a community, how do you figure it out, right? - For them, they were very strategic about how they defined community and the example in Cleveland is just amazing to me, the focus on Fairfax County in a particular population that they saw as being one that they could actually help and move the needle on, while literally turning their back on the Huff and the more African-American community that we focused on on interviewing folks, right? And so their definitions of community were highly strategic, my definitions of community were, I very early on was interested in this kind of Chicago school ecological model where you have a, but essentially concentric circles around it boy, that's really bad. So what I did was I plotted the hospital on a map and then I looked at the census tracts that were directly around them. And so what I was trying to do was not to try and bias our estimations of health, of the, you know, health poor community by the hospital zone metrics, but just by geography, like you, whether it's, whether it's one mile east or one mile west, you're still one mile away from a hospital, right? What I was trying to do was really, you know, kind of force the, force the conversation and really allow us to have a bigger conversation about what they meant, what, what, and not take what they say is their community, which is like maybe, for example, in Cleveland, heart Fairfax over Huff, but instead looking at the more geographic thing, there's, there's maybe some, some faults in that and maybe it's overcorrecting in some way, but I think I think it was a, that was my argument in, it was my argument. Yeah, it's great and actually since we're, we are talking from Nashville so much of this resonates with the experience in our city as well, because of the very strong and enduring history of segregation. Vanderbilt Medical is just one of the university-based medical schools in the area, but we also have a maherry medical school as well, which is a really esteemed historically black medical school as well. There's a lot of the arguments around the neighborhood and how it plays out with these different institutions with a different set of priorities really, really resonates with the situation that we're, that we see in Nashville. Thinking about these moments and places in which hospital administrators and the, and health professionals actually engage with people who are residents of the area, so folks who actually have, I mean, the statistics you, you give on the health outcomes of people who live really nearby hospitals is truly stunning, like how, how much disparity there is. So you develop this notion of contact zone from Mary Louise Pratt in particular, and so I wonder, I'm actually going to hand this this over to Isabella on behalf of her group to ask a little bit more about contact zones and the ways in which communities, communities and professionals come into contact. So contact zones highlight major economic and demographic gaps between hospitals and the communities around them. How does this tension complicate the claim that hospitals function as true anchor institutions? I mean, hopefully successfully, you know, you know, that was my point, you know, I think I think forcing a conversation with this conversation with, with contact zones was to try and, you know, kind of force the hand when it comes to having more engagement that the contact zone tends to be the ED. And not, you know, kind of, and any kind of other contact zone, we're, we're these satellite, you know, kind of facilities that we, that we kind of flagged a few in a few different ways. Instead of bringing people in and we know, you know, kind of with full awareness that you can't just have, you know, kind of random community members just walking through, you know, kind of ORs and, you know, but at the same time, how is it that we can expect to have hospitals do more? And really, I think one of the things that we wanted to engage with was, I think there's a thread about how hospitals, you know, even unintentionally are undermining the contact zones of communities by, and we have this example in, in Hartford of, of a, a funeral home that was a, you know, kind of a central, you know, kind of community place for, for folks and Latino community. And how when they bought that little property, which was to kind of grab particular, you know, kind of kind of property, they're actually like a racing community zones as well, or contact zones as well. And so I think I, I probably could have underscored that actually a bit more. In the, in the book, I say, I, because actually, like, I'm thrilled you guys are bringing up the things that I, that I was really hot on. So I really appreciate that those are, those are, I say, I, but, you know, there was we in this too. Yeah, I mean, I, one of the things that we especially appreciated about the book was the way in which you're able to write about the formal, quote, unquote, community benefit. And initiatives of the hospital. So things like the, the, the by local, higher local, the farmers market on a medical campus, these kinds of things, and showing that the implication is that this would be a good thing to actually have contact between communities and hospitals. And at the same time, there's things like actual physical barriers that are erected. And also there's pretty strong policing and security around hospital areas. So the way and the, the trickle down effects of the ways in which gentrification, which you write about really nicely in the book happens as well and, and displacement, which is definitely something that's happened with the Vanderbilt Vanderbilt Medical School as well, to kind of capitalizing and colonize on local land. So kind of bending, bending you out to maybe think through or ventriloquize your colleagues as co-authors of the book, the folks who are doing a lot of the policy thinking professionally around this. And we actually wanted to ask you about this the last chapter of the book. So chapter six in which you make a few policy recommendations and a lot of them have to do with community investment by hospitals being really focused on things that we could would consider distal causes or neighborhood effect kind of things, not necessarily like opening your doors more easily in the ER, like things that aren't necessarily obviously directly health related to for acute events. So I wanted to ask Alexis to take this up. How can hospitals shift implicit development strategies to make care more equitable for uninsured or underinsured patients. This is also well scripted. You guys are great. So yeah, I think, I think. I'll say, I'll say once since you mentioned is the public safety, you know, peace as far as that's a, you know, kind of one of the contact points. I'll say towards the end of the book is we're doing all the interviews, we kind of thought that we've finished up. We took a look back. We stepped back and we said, what is the story. What are the stories that are missing? What is a piece that we're really going to be scared of if we, if we don't include it and regretful. And I really started focusing on public safety and how public safety serves as a, as a branch of the like the most kind of out the most, the most obvious public facing part of it. If not, if you don't include advertising that where there's a in between spaces of the streets and how much the public safety works in tandem with urban policing, which we know, you know, kind of I don't think it's the surprise to anyone here is, is a racialized institution as well. That I think is one of the hardest pieces of community engagement that we didn't, we really were, we're going to be regretful if we didn't include it. And so we did start and we did a bunch of and we stopped the writing of the book to then re engage in doing some data collection because we thought that that was really one of the biggest pieces of the of how hospitals really do community engagement and community development in, you know, in a, as a less obvious, less at least arm of community engagement development. Yeah, yeah, it actually reminds me that one of the issue that you're raising around advertisement as well and how, how hospitals are able to appropriate a lot of the sort of the language and the notion, the concept of community in their own sort of symbolic gesturing and really getting a lot of prestige about this. And it reminds me that one of the most striking advertisements I've ever seen for any product actually was for a hospital and it was in the look, it was in the airport. So it kind of speaks to speaks to the audience that's being the clients that are trying to. Yeah, medical tourism, right? I mean, that's, it's not, you know, it's people coming in people, you know, and so, you know, the Cleveland airport as, as just as many languages as they possibly can fit. And it's not because Cleveland is an international community. It is because people are flying into the clinic. And so that is, yeah, absolutely part of a part of the story. That's great that you picked up on them. Yeah, no, and I feel like this idea of medical tourism that you write about in the book also speaks to exactly the point that it's the folks who live around the hospitals who are actually being treated least by it. It's people who are coming in through medical tourism and through other other methods that are actually the people who are the clients, the patients in the hospitals. I will flag. I feel like you're underselling yourself a little bit in this last chapter. Is that you also per the, per the audience of listeners here? You write, I think really important things about medical education and the ways in which community health should be integrated into medical education as well. So I have to give you a virtual pat on the back for that one as well. Almost no, like we should be going in and talking to, you know, people, I don't, I don't get it. Like I think they don't want us. I don't know why med schools are not interviewing us and bringing us in. So I mean, I'm confused. I think that this is this, this should be mandatory reading, I think. At least that's what we sold to the University of Chicago back in the day. We said, like, look, the med schools should be, we should be assigning this book. I still feel that way. Yeah, for sure. No, I'm definitely, I've told, I've told my, my medical school friend friends about it. And actually I consider that in academic worlds really like hot off the press because it was just published like like a year and a half ago. So it's, it's pretty new. I think, I think that you're, you're picking up steam. But thinking of your, your medical health and wellbeing, I will say given that you had started the interview by saying that your, you take your task to be when you go to a new city to find out what's, what's new, what's the thing? Like what's really special about this place and knowing that you spent quality time on your previous book project in Nashville. We're really glad that you survived hot chicken and eating the thing that is the Nashville thing, which is hot chicken, which I've never done. And I hope never to because I know I wouldn't even freeze. That's the thing. I've eaten three so many threes. I have so many choices for those threes. That's the thing. That's that, that for me is the thing. Yeah, that's a meat hot chicken is the easy part. The temperature is that it's, it's not the, it's not the heat. It's the quantity. That's the hard thing. Yeah, point well taken. Yeah, I, you can sign me up for macaroni and cheese with a meat and three any day. So, Professor Wynn, thank you so much for your time. We really, really appreciate it. I hope our paths cross again soon. Thank you so much for having me.