Social media influencers and over-diagnosis

Welcome to the Dental is Anything Podcast, where we dive headfirst into the wonder and mystery of everything and anything dental. I'm your host, Matt Hopcraft. Miss diagnosis and over treatment are significant issues in healthcare. An appropriate diagnosis forms the basis of quality healthcare, but it opens up important questions about what is driving health seeking behaviour and where patients are getting their information and motivations from. Welcome back to Dental is Anything. My next guest is an expert in evidence-based health communication and decision-making with a particular focus on the issue of over diagnosis. She recently led a study reporting on how social media posts have the ability to influence over diagnosis. Dr Brooke Nichol is an NHMRC emerging leader research fellow at the University of Sydney School of Public Health. Brooke, welcome to Dental is Anything. Thanks, Matt. Thanks so much for having me. Look, I'm really excited about this because I came across one of your recent publications and it generated a lot of interest. It was picked up I think in the New York Times and probably in a lot of other media outlets around the world. And it looked at how social media and in particular social media influences a shaping the way that people approach and access healthcare. And through the lens in that research of perhaps a set of controversial medical tests and whether people were being swayed to take up these unnecessary tests that rather than helping them might actually lead to harm. So I'm really interested in this idea of where people get their information from and the importance for us as health practitioners in understanding these issues of the confluence of misinformation and information and social media. But first I want to sort of take a step back and pick your brains a little bit about over diagnosis because that sort of I think underpins a lot of what you're talking about in this research of people having tests maybe that they don't need that lead to an over diagnosis of problems. So what is diagnosis like how would you define over diagnosis? Yeah, so over diagnosis is really the diagnosis of a condition that ends up causing more harm than good to an individual. So it can happen when a healthy person is diagnosed with a very early form of a condition or a disease but that disease or condition would never actually have went on to develop any symptoms or cause any problems in a person's lifetime. And we know that it is a global problem. There's good evidence now from around the globe that this is happening on a lot of fronts. But I guess the clear is the example that we have in the best evidence from the last few decades is in cancer screening. And is there a difference between over diagnosis and misdiagnosis? Yeah, absolutely. So over diagnosis is a correct diagnosis as I mentioned but it's one that would actually not go on to cause any symptoms or problems. So it's a correct diagnosis but it can lead to more harm than good. Whereas misdiagnosis is actually an incorrect diagnosis. So a person's being diagnosed incorrectly. And when you say it's a global problem, I mean, how big of a problem is there a way that we can sort of put a number on it or a dull figure on how much over treatment then is being done? Yeah, I mean, there's various estimates from around the globe and they continue to be. It's really tricky because it is an epidemiological problem. So we know in lots of cases that over diagnosis exists but it's really hard to say at an individual level that a person has been over diagnosed or not. So it makes it this kind of complex and often counterintuitive topic to say that we know this is happening but we can't actually tell you whether it's happening to you or not. So a recent study by colleagues of mine here in Australia looked at cancer screening over the past few decades and they, I guess, the kind of best estimates that they came up with was that, believe it was around 18% of women and around 24% of Australian men have been over diagnosed with cancer. And those were, they looked at a number of different cancers in that but, you know, there's, as I said, estimates do vary but typically for things like breast cancer, thyroid cancer, prostate cancer with an estimate that's been kind of collated. Those are around 20, 25% but the, as I said, they can vary quite widely. That's, I mean, they're really kind of quite staggering numbers and I guess the challenge from a health practitioner point of view and from a patient point of view is that we're talking about, you know, as you say, a correct diagnosis. So the patient has the condition, how do we then know which of these patients are going to go on and that condition becomes worse, that condition causes problems. And in, you know, particularly when you're talking about cancer, then, you know, from a patient perspective, what do we do and is there a sense that, you know, we're better to err on the side of caution and intervene. And so then it leads on to this, I guess, the next part of what you're talking about which is overuse of services or over medicalization of things. I mean, is that sort of partly then where the problem lies? Yeah, so in terms of over medicalization, I guess that's like a related topic to over diagnosis, but it's not exactly the same thing. So over the medicalization can happen when, you know, there's concerns or more frequent diagnoses in terms of widening of disease definitions or changing the label of something so that more people are being diagnosed with that condition or disease. So it's really, you know, creating more disease. And that can then leave to kind of over diagnosis and subsequent over treatment and overuse. And then like you said, there's overuse, which is kind of a byproduct of over diagnosis. So often people who are over diagnosed, I guess the main thing that is of concern is that they will then be over treated. And over treatment can lead to, you know, individual harms in terms of unnecessary side effects from tests and treatments, but they can also, it can also lead to this issue of more wider spread healthcare over use. So getting tests and treatments that cost money to the individual, but also the healthcare system and really taking away resources than from people who actually need it. So treating, testing and treating people who are healthy and may not otherwise need it and taking it away from those people who do need it. And in a healthcare, you know, a system such as Australia, that is really significant where, you know, many people are still in need and there's not always, they don't always have access to the adequate medical care they might need at that time. And I guess we've seen in the recent budget, you know, that there are pressures on a healthcare system and there are funding pressures. And if resources, if funding, if services are being diverted, that don't actually produce an outcome, it does diverted away from, you know, those areas where it is much more needed. But there are sense that, you know, some of this is happening, you know, and I don't know whether the term worried well sort of then fits into this, but you know, people going and getting tests being screened. Do we see that more in some population groups and others and therefore, you know, we, you know, is there an equity issue here about where some of these resources are diverted because people are using the screening in a disproportionate kind of way? Do we not really know that either? Yeah, well, I think we, I think we know that that is happening, but the evidence to lack those statements is still a little bit shaky and maybe not as robust to draw distinct conclusions, especially with things that aren't being recommended at a population level. So for example, we know that there are screening programs, that the Australian government supports and recommends and we know that there is definitely disparities in people who are accessing those. But in terms of kind of tests that we looked at in our study, which I think we'll talk about further, you know, I think anecdotally, we know that because of the costs of many of these tests and the way they are being promoted to people maybe of higher socioeconomic status or have the means to, you know, hear that information or do something about that information that yeah, definitely there definitely would be some kind of problem happening there and really yeah, taking away resources from those who may indeed need it. And a lot of this is around this idea of screening and there's clearly a lot of benefit to screening if we're identifying things early. But there's also risk and harm if we're having these sorts of overdigneauces issues as well. And so as you said, sort of most of it sits in this area of cancer screening. How difficult then does that make it for us to, you know, in a health promotion or health education sense be promoting the value of screening without over promoting the value of screening, you know, where do we draw the line? How do we have that really nuanced conversation? Yeah, it is so tricky, I think, because screening I guess it's really important to note that is for healthy people. It is for people with no obvious signs or symptoms or at a high risk of a condition or a disease. So it's kind of more of a population level approach and we do want to really make sure that there is good high quality evidence to back screening programs when they are implemented or screening tests when they are recommended so that we aren't, you know, weighing the harms from those benefits. It's important to judge the clinical utility of those tests and really whether those benefits do outweigh the harm. So, as you mentioned in screening, benefits can include things like improved cancer specific mortality or reduced advanced age cancers, and harms can include things like false positives, unnecessary biopsies, and the most significant at all is this issue of overdiagnosis that happens. And so, with screening programs such as cancer, the evidence takes decades to collect and ensure that those benefits of the long-term mortality and morbidity benefits outweigh the harm. So, it can take decades and oftentimes things are implemented without that good high-quality evidence and it needs to really be assessed or re-looked at whether or not we need it. And with this kind of advent of direct to consumer testing, we're seeing more and more so-called screening tests kind of popping up without the need for them to be recommended at a population level or by a clinician. So, it's this kind of how would you put it? Well, people taking matters into their own hands really. Yeah, and screening themselves, like you said, in a sense of being the worried well or you know, this guy's early detection and early screening is better when we know lots of cases. It is, but we also know lots of cases, especially when there's no quality evidence that it can actually lead to more harm than good. It's one of the tricky sort of spaces that we have, I think, in dentistry where we recommend regular attendance, a lot of dental disease progresses very silently without patients knowing it's as often not symptomatic until it gets to a very late stage. And so, we recommend radiographs being taken on a frequent basis. But again, does the evidence sort of support the practice that we put in place and the messaging that we're providing to people about how frequently certain things should be happening when perhaps we know that at a population level, the risk profile doesn't match the need to do things. So again, I agree that sort of need to continue to build the evidence to support the practice for the indication for some of these tests that might not seem to us to carry significant levels of harm to people. But there's a cost, there's a financial cost. You know, if we're talking about radiographs, there's a biological cost to doing all those things as well. I want to talk a little bit about, I guess, information, misinformation. Is that sort of feeds into this a little bit as well? And I know that you've done some research in the sort of the health literacy misinformation space because I guess part of this comes back to our patients, our population having a level of health literacy to decide whether to have a test or not or if they're on social media and they're seeing influences talking about some of these things, knowing what is appropriate for them to have or not. I mean, is there a problem with the general level of health literacy that we see across the community? Yeah, I think that a large proportion of the Australian community doesn't have adequate health literacy. And you know, that can vary from actual health literacy of reading pamphlets and brochures, but also to things like e-health literacy and how we navigate information online and search for kind of credible sources and things like that. So there's definitely a major issue there. And I think one thing we did learn from the COVID pandemic was that misinformation is so widespread and that we really do need to build the health literacy of the community to be able to navigate some of that misinformation that's out there as well as have a kind of a top down approach from governments and health systems to be able to provide information at a level that people can understand and also relate to and access. I do really sort of worry about where we sit in this space and are we doing enough to, on the one hand, build health literacy, which is really important around driving prevention and behaviour change, the sort of things that will help people to improve their health, but also to be making some of these decisions, but also where people get their information from and the loss of trust, I think, in health professions sort of broadly. And some of that clearly sort of come out of the pandemic, but I think that it's probably something that's been going on for a long time as well. And then it sort of gets me to thinking about this role of, well, where are people getting their information? It used to be perhaps in media and now sort of moving over to social media. And I play a lot in the media space and TV and radio and print non-line. And I'm really interested in the role of health journalists in shaping opinion and how they can contribute to health literacy or not. And I know that this is something that you've looked at as well. And I was really interested reading about media coverage of Kylie Minogue's breast cancer diagnosis and how that sort of led to a huge increase in all of the media coverage around it in people are uptaking breast cancer screening. So clearly, you know, the media and social media have this role in being able to influence how people think about accessing health care and accessing tests. How important do you think it is for journalists, health journalists to really kind of understand the specifics of some of the stories that they're talking about? Yeah, I mean, I think it is increasingly important as it probably always has been important to some degree. But, you know, we do know, for example, that the media is one of the many drivers of over diagnosis. A big study published in the BMJ probably five or more years ago now, you know, looked at the drivers of over diagnosis. And media was one of them that came up. And we know that it, you know, it continues to increase with this kind of clickbait culture that we live in. And also the rise in expansion of social media and how the media works with social media and kind of the fast-paced journalism that we are seeing. And again, out of the pandemic, I think this became like even more evident that the way people are reporting things and even just kind of the way that we as a community absorb things, you know, possibly only reading the headlines, getting quick grabs. We want things fast. We want things, you know, easy to interpret. We just sometimes take those headline findings. So I think it is really important to have kind of clear messages. And for journalists to have a basic understanding of scientific evidence so that the reporting can be accurate and also balanced. So I mean, I think there's a really clear role there for us in the health space, health professionals, as health researchers around, you know, I guess educating in that journalist space and trying to bring them along. How much do you think that we're all, you know, as researchers, as professional, health professionals or as journalists? Are we driving clickbait culture? Are we responding to it? You know, what's our role within that as well? Yeah, I think it's so tricky, like myself as a, you know, a health researcher. I want to engage with the media and I want to put my messages out there so that they are accessible to the community and that, you know, we can discuss them with the community and provide that important, or what we think is important, health information to them. But you kind of have to play the game that the media is maybe playing and in doing that in a fast pace way or maybe not having all the nuance that you potentially want in those messages. But I think we do really need to stand by the science and we need to be the ones leading from the front, especially researchers, academics and even more so health care professionals. Because I think it's ever more important to have those evidence-based voices in the media and that the information being communicated to the public is really, you know, not backed by vested interests and has this nuance and this balance. So it's kind of tricky because I think we need to be in it, but we also need to be kind of cautious and as balanced as we can be to have those kind of credible sources to look for. And that also goes with journalists to, you know, potentially look for the journalists that are the most credible and the sources that they're producing for our legitimate and we know have had a good history of, you know, providing that kind of scientific rigor or balance in their articles. I find it to be, you know, really quite tricky. You know, as a researcher, you know, you read through your writing your discussion and, you know, it's awful of nuance and caveats about this and that and, you know, it's, we're always sort of, I get trained to be very careful about very definitive statements sometimes about the outcomes of our research. And then at the same time, you know, to get something into the media, to get broader, you know, not recognition, but, you know, broader readership of what you're trying to put out there. I think part for me very much for research is about, you know, how do we shape opinion, how do we change people, how do we change policy, how do we change practice in a clinical setting. You know, it's not about who reads the journal article, it's about who in the broader audience kinds of reading. who reads it. And that sort of, you know, sitting on the fence doesn't, doesn't always work quite so well. You find yourself sometimes, you know, writing in a way that, you know, for the media or talking to media, in a way that's sort of counter-intuitive to the way that you're trained to do as a researcher and find it challenging. Yeah, absolutely. I think it's tricky to kind of let go of the nuance and let go of maybe taking more balanced approach. You kind of get pushed to maybe sensationalize things more than they should be or that you feel comfortable with it and potentially, you know, kind of overstate some of the findings. But I do feel like if you are clear with the message and that even having that more balanced evidence-based message out there is better than not having it at all. So I try to tell myself that, you know, let that go and be okay with where that might land, as long as the message is coming out more or less in the way that I feel it should be and that, you know, it is backed by kind of robust evidence and, you know, it stands for what I truly believe should be the message. Yeah, I really like that. That's a really good approach. So let's then talk about this study that I mentioned at the outset where, you know, you looked at how social media might be shaping people's approaches to testing and therefore then over diagnosis. And you looked at five controversial tests. And so I'm interested to know, you know, why they're controversial tests, what they are. So I guess tell us a little bit about the study and what you found. Sure. So as you probably got the drift of by now, my area of interest isn't over diagnosis. And I've kind of been looking at this for a number of years now and I was at a conference kind of alongside the same time as Kim Kardashian put a post on Instagram that kind of went completely mad and viral promoting the whole body MRI scan. To healthy individuals saying that they were lifesaving and that you know save some of her friends lives and you know all this kind of stuff. And so at the conference they were talking about social media and at the same time I saw this post and I thought, oh my gosh, how dangerous could this be, you know, for the area that I work in and, you know, testing and and treatments and health care generally. You know, I think at that time there was, you know, good evidence of misinformation out there in health care, but that there hadn't been really any evidence showing what was out there for the specific tests or or different interventions that we know have evidence based concerns about over diagnosis. So one of my colleagues, Dr. Ray Moynihan years earlier did a similar study where he looked at media reporting of tests. And so we did a, we took a similar approach to that study and we picked these five, you know, very popular and emerging medical tests, but also controversial in terms of they lack evidence of benefit and can lead to harms including over diagnosis. So we specifically picked five different tests and we looked at how they're being discussed on social media. And the five tests included that full body MRI scan, which as I mentioned was infamously promoted by Kim Kardashian to hundreds of millions of followers. And so that test really claims to test for up to 500 different conditions, yet there's no evidence of benefit for healthy people and real dangers that exists of unnecessary diagnosis and over treatment. We also looked at the multi cancer early detection test, which is not so widespread yet in Australia, but in the US and the UK is being promoted quite heavily. And this is claimed to screen up for 50 different cancers. So it's a liquid biopsy test. And so clinical trials are actually still underway for this. So we actually don't have any good evidence for this test in terms of whether the benefits of screening healthy individuals do outweigh the harms. And then we looked at the anti-malarion hormone test also known as the AMH or egg timer test. And so this test, well, it can be beneficial for certain women. It's being falsely promoted to healthy women as a test of their fertility and fertility potential with concerns that, you know, results can lead to unnecessary and costly fertility treatments, including IVF and elective egg freezing. So we've got microbiome test. And so this is basically a stool sample test that promises, you know, this idea of wellness by early detection of many conditions. So things all the way from like flexual ins to depression and even, you know, risk of cardiovascular disease. And there's no good evidence of benefit and the science is just really early. And it can, there's just really big concerns that that can lead to overuse of health and medical services and also just a waste of costs for the individual. And then the last test we look at looked at was a testosterone test, which has no evidence of benefit for testing healthy men yet there's real dangers of overuse of test, australian therapy treatments. And so long term safety of that in terms of adverse cardiovascular events and early desk death has just not yet been established. So again, we specifically chose those ones because there was this evidence based concerns around over diagnosis. And well, they're all different tests and often promoted to, you know, different people in terms of their age and sociodemographics and gender. They all hold this kind of similarity in terms of their basically just useless at this time for healthy people. And also, I guess, you know, yeah, trying to, trying to promote this idea of, you know, being able to, to, it's not really a longevity thing, but, you know, yeah, promoting this wellness of fitting into this wellness kind of culture, isn't it? Yeah, absolutely. I think kind of the tagline that we looked, we found that came out of most of the promotion around this test was living your best life. And this idea that, you know, early screening and early detection and really being on top of your health and your wellness will lead to, you know, you being happier and healthier. And that's, you know, there's just there's no evidence for any of these to show that. And so what did you, so you, you analyzed a whole lot of social meetings must have been fascinating and, you know, challenging study to do. Just trawling through social media posts. What did, what did you, what did you find on social media? Yeah, so we basically found that I guess the top level finding was that the posts were overwhelmingly misleading. And really what that meant was that the large majority, so 87% of the posts mentioned benefits of these tests, yet only 15% mentioned any potential harms. And 6% specifically mentioned over the harm of overdiegnosis. So they were just really unbalanced in the way they were being discussed and the way they are being promoted. We also found that only 6% of the posts mentioned scientific evidence, well over a third used a personal anecdote to promote the test. And we found that over two thirds of the influencers or account holders who were posting about these tests had a financial interest in the promotion of the test. So they had some sort of partnership or collaboration or sponsorship or they were just selling the tests for direct profit in some way. Would they, would they always disclose those financial links? Yeah, so we actually took a very hard line approach. We toiled with this for a very long time. And we took a very hard line approached looking at the financial interest. And so those were ones that were explicitly disclosed. So we do feel that that is a vast underestimate of the ones that probably did have some sort of vested or financial interest in the test. But it is really kind of the only way that we could accurately say that they did without clicking 100 links through their bio and see where they might kind of lead to. So it's a very, very, very interesting story. But I think that's a really, I mean, it's staggering that, you know, that that broad number of them are doing it for financial gain anyway. But I agree, I suspect that that, you know, there's probably a large number of them that aren't disclosing some sort of financial interest as well. It's direct or indirect financial interest from being able to do this because, you know, yeah, why also they, why also they doing this other than fitting into this broader sort of issue of monetizing what it is that they, what it is that they do. I'm really interested that, that, you know, that sort of, yeah, promoting the benefits obviously. But downplaying the harms and did they not only that only 15% mentioned harms, but did they mention, you know, the more serious harms or did they even just, you know, really downplay what the potential harms might have actually been. Yeah, absolutely. They were downplayed in a lot of the cases. And I think in a lot of the cases where we were able to code harms were from companies where they were trying to abide maybe by marketing regulations and they had to have like one little kind of disclosure at the end that the test might lead to harm. or false positives or something in that guys. So it was either a very brief mention or they were very downplayed so they would quickly mention it but then kind of overemphasize those benefits and really downplay the harms and spin it in a way that was just overly promotional and created this kind of overwhelming need that people should be getting these tests. - And you looked at both health practitioner and social media accounts but then the influencer, the Kim Kardashian's of the world, was there much of a difference between the two groups? Were health practitioners much, much better at disclosing financial interests and much, much better at talking about harms versus benefits? - Yes, so we did do a detail analysis in the end because we were really interested after looking at them. I thought, I don't know if there is a difference. I would because there were some very explicit examples from legitimate medical professionals that just stand out in my mind of being utterly misleading and just actually shocking that what they said could be even happening on social media let alone from a medical professional. But we did, when we did our analysis, we did find that on a whole medical professionals were better in terms of the balance between the benefits and the harms and the discussion around scientific evidence as well. Then for me that flows on from that is the influence that these influencers have. So I'm presuming that the Kim Kardashian's of the world had a much greater number of followers that had much broader reach, that had much greater engagement with their audience and that the medical professionals, whether they were doing things in a more ethical way or whether they were perhaps promoting things, not mentioning harms or over promoting benefits, probably had smaller following, smaller reach, smaller engagement, would that be a fair assessment? - Yeah, anecdotally I would say that was. We didn't look at that specifically because it was really hard to also separate those that were medical professionals that were also influencers. So they were medical professional maybe influencers, but I would say definitely that the more stereotypical influencers had larger followings and definitely a greater reach. And I think we know that from other studies that have been done as well. But I think the thing that we did find that I guess I found really interesting and also important in this space was that some of those medical professionals posts or even posts that were just more balanced from either an influencer or otherwise a news, potentially a news site, they can have, they can still be influential and they can still have wide ranging reach. So I think that yes, there is this kind of tide that we have to push against in terms of the overwhelmingly misleading information and those with vested interests. But I do think that our study did show that good quality, balanced, scientific information on social media can exist and it can also be popular and potentially viral. So I think there is a space for evidence on social media and I think one post that can even reach, you know, a minority of the posts that maybe some of those other posts are reaching is important in this wider context to kind of push against that tide of misinformation. - So is one of the findings then or one of the, I guess the outcomes of this is, you know, how do we, health professionals, health practitioners, health researchers get better in this space? I mean, do we have to fight fire with fire? We can't beat them so we may as well join them and have an army of people out there in social media sort of battling away and building their profiles. - Yeah, I do think that. I think that, I think there is, it's a multi-pronged approach at this and I think that is one of the prongs and an important one because I think from a health literacy perspective, you know, one of the ways that we can kind of get the public to start thinking more critically about information online and some of the tips that have been suggested are to look for more credible sources and legitimate healthcare professionals that are on social media. And so I think the more, that the more kind of evidence-based professionally backed posts that are balanced that are out there, the better. - Do you think there's also a space for regulation? Then, you know, regulation in the social media space in the way that we see it in some senses in the traditional media space around advertising because we're sort of blurring this line between what is traditional advertising and what we used to see, you know, on the gaps between our favorite shows on TV or between our favorite songs on the radio is now being taken over by the doom scrolling that we do on social media. That's, you know, more or less completely unregulated. Do we need to be much, much harder in that line? And then how hard is that to do in a global kind of space that social media operates in? - Yeah, so I think, I think as I mentioned, health literacy and all those kind of tactics and tricks and including kind of pre-bunking or pre-emptively, you know, educating the public about these, the misinformation that might be out there or common misinformation kind of techniques that are being used. I think those are all really important. I really feel that it is hard to place the responsibility on the individual to navigate all this misleading information that exists on social media because it is so pervasive. It's always there in our fingertips. And so even for those that have adequate health literacy, this can often be difficult. So as I said before, I think a multi-pronged approach is needed and I think the most important prolongs involved is stronger regulation. I do feel that we can't place that responsibility on that individual solely to navigate this and that we really need to put regulations in place that stops these posts from being created and being shared and going viral kind of in the first place. - Yeah, it's a difficult, they're gonna be a really difficult area to navigate what that regulation would look like and who becomes the arbiter and what is in it. Do we have the evidence to be able to sort of back up and I guess if you think about your study on those five tests, the evidence is probably there around saying yes, this is not ethical in the way that we're talking about some of these things, but then do we have the evidence in some of the other areas that people might talk to and are we just gonna push the problem into different spaces as well. How much do you see this landscape changing over the next sort of two or three or five years? - Yeah, I think it's gonna just continue actually and that's why I do think regulation is really important, but like you said, it's such a gray and difficult area to go into because we want to give people their freedom of speech to be able to say what they want and share their genuine experiences on social media and there are good regulations put here in place, for example, by APRA for medical professionals for what they can and can't say online, but as a consumer sitting here in Australia, I can still hear from medical professionals in the US, and the UK and their regulations are a lot different. And so I still then might go ask my doctor for some of the tests and the treatments that are being discussed. And also the TGA has specific regulations in terms of medical devices and, but if a person is just talking about their personal narrative or story, and which can actually be more powerful than any real advertisements that's out there, then how do we then regulate that? And so it is this kind of gray area and how does it lead to other tests and treatments whether we know there are harms, but there might also be benefits to some, and it's such a gray area, but I think the evidence is growing that we do need to kind of wind back the harms for the ones that we know that are more harmful than good. And where evidence just really doesn't exist and these tests are just completely useless for members of the public and shouldn't be being promoted to them in the first place. Such a rapidly changing landscape, it is going to be really interesting, I mean, looking back over the last five years what's happened, looking forward over the next five years, and it worries me, perhaps where we might be heading, but I think that's why this research continues to be really important because it shines a light on where some of these problems are and how important it is for us across all of the health professions to be looking at this and understanding the problems and figuring out how we can take action. Broke, this has been a really interesting thought-provoking, challenging discussion, and really got me thinking about what we need to be doing in our profession and in the dental profession, but kind of more broadly in health, to combat all of these issues that you've been raising. So thanks so much for joining me. It's been fantastic. No worries, thanks for having me, Matt. That is all we have time for until next time. (upbeat music)