Episode 138 | Referral Resistance

The scope of veterinary practice is continuously expanding. We are always learning more about animals, their physiology, and their medical conditions. We are regularly developing new treatment modalities and skills. 

The days of a veterinarian being all things to all patients and treating all ailments are long gone. 

Embracing this reality, however, is taking a little longer. 

The ability to refer a case to a fellow veterinary professional, specialist or not, is a great opportunity in our profession.

Intentional referral is not only in the best interest of the patient, it is also in the best interest of our personal wellbeing. 

Don’t underestimate the negative impact hanging onto a case you’d rather refer is having on your net emotional state…

Despite this, many of us resist referring out cases… 

But why?

It comes down to Shame and Fear, which are both tied up in judgement… judgement of self, and judgement of others. 

In this episode

  1. The links between shame, fear, and judgement
  2. The three situations in which referral is a great choice (and no, it’s not limited to the really critical and really sick ones)
  3. What keeps us hanging on to cases that we don’t really want to manage
  4. The opportunity we have collectively to improve our job satisfaction and wellbeing by working in a more synergistic way

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Music Credit: Music by Lesfm from Pixabay


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This transcript is auto-generated and may contain typos. 

Hi there. I'm Dr. Cari Wise veterinarian, certified life coach and certified quantum human design specialist. If you are a veterinary professional looking to uplevel your life and your career or maybe looking to go in an entirely new direction, then what I talk about here on the Joyful DVM podcast is absolutely for you. Let's get started. Hello my friend.

Welcome back to another episode of the Joyful DVM podcast. This week I have seen a variety of really interesting cases in veterinary practice and for those of you who don't know, I've recently begun picking up more shifts in clinical practice because I really want to experience what it's like out there in the real world in veterinary medicine with the way that things have changed and shifted and become a little bit more complex since the pandemic.

And so as I've had the opportunity to be in clinical practice, I've also had the opportunity to see some pretty interesting cases, which has had me thinking this week a lot about the concept of referral and talking to colleagues about referral and their experiences with referral as well. And that really was the heart and the motivation behind this episode of referral resistance referring cases to other veterinarians and other veterinary facilities.

Seems like it should be a pretty simple concept, but in reality there's a lot of emotion around referral for everyone involved. And I want to bring that to light today and talk about it and share about it from a few different perspectives because many of us have a lot of shame and a lot of fear around referring cases that we don't really need to have.

So there's opportunity for us to feel better about those things, but those are also legitimate emotional experiences because of actual lived experiences that many of us have had as well. So let's start out and think about the idea of shame around referral. Why would a veterinary professional feel shame if they are referring a case? Well, that emotion of shame is all based in self-judgment.

So usually underneath there is a belief system that they should have been a vet, ve been a better vet, that they should have been able to handle that case on their own, that they shouldn't have needed help from an outside party. And because there's always this comparison that we do as part of our natural being as humans, as comparison against each other,

as soon as we recognize that we are going to be asking for help, our brain wants to automatically make that mean something bad about us, that we are less than and that the person we are asking for help is more than. And we forget that when we refer cases it's not because another veterinarian or veterinary facility is better, they're just different. And that's where opportunity lies is within remembering they're different,

not better. That shame though is very real. And so every time someone is experiencing shame around referring a case, we just want to remind ourselves that the reason that we feel shame is because we are judging ourselves harshly. And so then we wanna ask ourselves a question, what is it that I'm judging myself against? What is the expectation that I'm holding myself to?

And is it even a realistic expectation? The answer is likely going to be no, it's not. A realistic expectation is an expectation you probably didn't choose for yourself and maybe don't even realize is there until we actually go looking for it. But I promise you that in the practice of veterinary medicine, you are never meant to be all things to all people and all patients as our whole career expands because you know,

medical knowledge just continues to build. And what we know today and what we are able to do today as a collective in veterinary medicine for animals is much greater than what we knew and we were able to do 50 years ago. So of course it is impossible for us to be all things to all people in all cases. And our acceptance of that and embracing of that even will actually help us to not judge ourselves so harshly.

Just because we can doesn't mean we have to. And what I mean by that is just because you can treat all the different animals in all the different ways legally you can, you have that credential. That doesn't mean you have to. And I believe that we serve clients and tr or tr serve, treat patients and help clients the best way. When we really hone in on the area of veterinary medicine that resonates the most for us,

what lights us up? What do we enjoy doing? If we pick an area and we really hone that in, we develop a lot of skills and knowledge and comfort there. And then we can expand that if we want to, to then bring in other areas of interest and other skill sets. But on day one, we were never supposed to be able to do all the things and manage all the cases all the time for all the people.

And referral systems exist because we all need to recognize when it's in the best interest of the patient for a different type of care. So a different type of care. That doesn't mean better care, that doesn't mean what you're providing is worse care, it's just different. Let me give you an example of this. This week I saw a kitty and this kitty when it came in,

it was early in the morning, I think it might even have been Monday morning. And this kitty was just not acting right, didn't feel well. And I looked at this kitty and its mucus membranes were white, like white, not even like slightly pale. We're talking flat out sheet of paper white and obviously not good, not compatible with life, not what we want.

And this kitty was amazingly well compensated. I do have to say that like it was still pretty alert, it was able to stand up, but it was white. And I looked at that kitty and I thought, okay, this kitty's very anemic and I, in my mind, I'm running through all the different things that can be done to determine what's wrong with this kitty.

And I'm talking with the owner about prognosis and kind of how we figure out what's going on and all of that. And ultimately I elected to refer this case. Now, was I capable of working up that case? Sure, absolutely. I had the equipment that I needed to work up that case, at least an initial workup. I had the ability to do an initial hospitalization,

but what I didn't have was an ability to do a blood transfusion, which I knew that this kitty was gonna need more than likely. And so when I looked at what is in the best interest of that pet, I knew what was in the best interest of that pet was to refer that case to a facility that had the ability to provide all of the care that it was gonna need in this immediate situation.

And I was, you know, lucky enough that where I practice in, in the town that I drive to to practice that there are, there are a few options for that. And I had an owner there in front of me who was interested in pursuing that level of care. I mean that's the other piece here. If the owner's not interested in that level of care,

then it's a different conversation. But if the owner's interested in that level of care, when I've explained what I have found on my physical exam, what's in the best interest of that patient for me to, to start all of those diagnostics here and then move it or just to move it and let it have its entire care there. Now there's a lot of reasons why many of us might feel pressured to keep those cases,

even though we know we're not gonna be able to keep them overnight or keep them for the next level of what they're going to need, we might feel a lot of pressure to start all of those diagnostics and keep the finances of that situation in house. I understand that pressure, but whether or not you give into that pressure, that's completely up to you,

you get to decide. And I'm not saying there's a right or a wrong here, I very well could have started that, but I just knew for me and for what we are, we are equipped to do where I work, that this case for this pet was better to be referred. And so I referred it over and it received the care that I needed.

Now I did not feel shame about that at all because I stayed in the focus of what is in the best interest of this pet. And that is our key here with dealing with referral resistance. If we can bring ourselves back to what's in the best interest of the pet and we can get out of our head about what we're making this referral mean about us.

So the self-judgment and we're also getting out of our head about what the referral center might think about us as professionals if we send the case, that's the other big emotion that pops up, which is fear. So referral resistance comes from a combination of shame. I should be better, I should be good enough, I should be able to handle every case that comes in and then fear.

They're gonna judge me. They're gonna think I'm a terrible vet. If I send this, they're gonna think I'm not good enough. They're gonna review my record and decide I'm an idiot that I don't know what I'm talking about. Those two things, shame and fear have us sometimes hanging on to cases that we actually do believe would better served from a patient perspective if they had been referred.

But when we get in our own way through shame and fear, sometimes we hang on to cases longer than we, than we actually even want to because we don't wanna be judged. And yet we are totally judging ourselves. Now I have to take a minute to speak to this whole idea of the fear. Why is it that we're afraid of being judged by our colleagues?

Why are we afraid that they're gonna say nasty things about us when they read our record? Well, we're afraid of this because we've had that experience before. And if we haven't personally had that experience, somebody's probably told us about an experience or we've seen it happen in our own hospitals when we end up seeing a case that used to go to somebody else and we're reading their record and we're judging what they did and what they wrote,

this constant judgment in our profession is one of the greatest dividers and greatest creators of burnout and just poor job satisfaction. When we live in constant fear of each other, it doesn't make anything easier. But judgment is one of those really sneaky things. When we can judge somebody else, it somehow makes us feel a little better. If we can make them right then that makes us wrong.

If they, we can make them wrong on the other hand, then that makes us right. Notice how shame and fear kind of go together. This self-judgment gets ta, this judgment and self-judgment get tangled in this really ugly dance. If we just take the judgment out of it, then what happens? How does the entire experience change if we stop judging ourselves?

We don't feel shame when we decide it's in the best interest of a case to go to a different veterinary facility or veterinarian. If we can stop judging them, them being whoever sends a case our way, the previous veterinarian, if we're referral centers judging our referring vets, if we can stop doing that or then our acceptance of those cases feels a whole lot better.

And on the other end of that, if we can decide if we're the referring veterinarian, we can decide that we are not even going to give a second thought to what they may think of us because it doesn't actually matter. And if you've listened to me long enough, you know what other people believe about you is none of your business 'cause you can't control it anyway.

So why give any focus to trying to control it? If we can just break this cycle of judgment, then our experience of veterinary medicine gets much, much better. So why is it then if we're thinking about referral centers, why is it that sometimes referral veterinarians make snarky comments to clients about us? Why do they do that? Why do they say,

well they should have never done that or they didn't need to send this one to me. They could have handled this one on their own. I've had many clients over the years who have come back to me after being referred and said and shared with me that that was said. So I'm curious, why do referral centers say that? Why does anybody ever do anything,

right? Whatever words they speak are actions, which means it comes from an emotion. And so well they never should have done that or they should have handled that on their own. The they should have never done. That is an ego thing. They're trying to make themselves feel better to justify why those people are here and why they should be the, the people like the veterinarians to handle the situation.

They've gotta make us wrong to feel better about themselves. And for instance, this is not limited to referral veterinarians. I'm not attacking referral veterinarians. Understand this actually happens all the time when we look at each other's records. Even we have been, you know, I'm sure we can all think of a situation where we said something that maybe was unkind about another veterinarian's choice.

I know that I did way back in my early years. Absolutely I did. And so as I get older and I think about what drove that, why did I do that? It wasn't really out of criticism of the other vet, it was out of my own insecurity. And I think that is exactly what continues to happen. Any time we judge each other harshly,

it's from a base of insecurity. So then why would they say, well they could have just handled that there. They didn't need to come here, they should have just handled that here. There. That's not wanting to see the case, right? That's being frustrated that a case is in front of them. And that's probably because they're feeling pressured for time.

Maybe their schedule is crazy. We know what veterinary schedules are like. It doesn't matter where you work, right? Maybe their schedule's crazy, maybe they don't have enough support staff today, whatever the reason is they're feeling pressure for time and they're looking at this case and thinking they don't need to see this one. It's a, it's not important enough to be on their time.

And again, that's not the client's fault, it's not the referring veterinarian's fault. There's a good reason why we were referred that case. Even if the person receiving the case doesn't think the reason is good. And and the thing of it is, my friends, whenever we send a case to somebody else, whether it's a referral center or we just send it to another veterinarian across town,

there is a good reason why we're doing this. And those reasons are not always clear in a medical record. We don't put all of our reasons in a medical record. A medical record is a legal document. We put the medical reasons in there, but there are lots of reasons why we might be referring cases. So if we go back and we think about my example with the kitty that was so anemic,

why did I elect to refer that case immediately rather than even start working it up? Well there were a few reasons. Number one, I knew ultimately that this, that we did not have the capacity or the ability to do a blood transfusion. We did not have blood products in our facility. It's just not the scope of practice that we have. So I knew by looking at this kitty that it was very,

very likely that it was going to need a blood transfusion. And I, in communicating with the owner, I had understood that that was the type of level of care that she would be interested in pursuing. And so that was simply a scope of practice decision. What we did, what we do in that veterinary facility is a blood transfusion and in critical care is beyond the scope of practice.

That doesn't make us bad. That just makes us different, right? It's just a difference in comparison to where I sent this cat. Now I didn't, I could have gotten in judgment and shame of myself over this and oh my gosh, we should have had all these things, we should have been able to do this or not. That's all optional.

That just makes me feel like crap. But it argues with the reality of what is, it's just simply beyond the scope of practice. And what was in the best interest of that pet was to get it to a facility where they offered the full scope of practice that this case and this client needed easy peasy. So what are some other reasons that we refer cases?

Sometimes it comes down to things like time and resources. I saw another kitty this week, it was only a couple of hours before close and this kitty looked terrible. It had a temperature of about 96. It was pretty flat out. And my, I had, it was very dehydrated. I had very high suspicion that it was a D k a d k a kitty,

very high suspicion. And once again, I'm looking at this kitty and there's a lot of things I can do to help this kitty. I'm very comfortable with these types of cases. But the reality is it came a little bit back to scope of practice and also time and resources. We were about two hours before close, this kitty needed a whole lot more help than two hours.

And we don't hospitalize overnight. Does that make us a bad veterinary facility? No. It just makes us a different veterinary facility. And so once again, we're faced with a choice. How much do we start here when we know that this kitty is gonna have to be referred, it's going to have to go to somewhere else. There was zero chance in my medical opinion that this kitty was gonna be stable in two hours.

And so we gave an option to the owner, would you like to just go ahead and go, I can get you in. I can get you into this this center as it's an emergency situation. I can get you in there if you wanna just go there and then they can do the workup and treat your kitty. And she absolutely wanted to go.

So a huge value for that client to know, yeah, this is serious enough that it does need to go somewhere else. And you know, applauding her for bringing the kitty in. 'cause she'd had a hard time finding like somebody who would see her. And so I didn't feel bad about needing to refer that kitty. And I say needing to refer that kitty and I do really feel like need is kind of the right word because what that kitty needed and what I was able to provide just they weren't compatible.

They, it just wasn't the case. And in this case it was a combination of scope of practice. We don't hospitalize overnight. This cat needs critical care and hospitalization over overnight. But then also time and resources. And so this is another reason why we tend to send cases other places. Time and resources. What time of day is it? How,

how long is your facility open? And then what kind of resources do you have? Resources mean physical resources, you know, things like blood products or different types of critical care support, but also staffing. If you do need to keep this animal and you do have the ability to to be open to keep animals overnight, do you even have anybody who can monitor that case if that's what that case needs.

So time and resources and if, if those two things just aren't available at your your hospital, we don't have to feel shame about that. That doesn't make us worse and make them better. It just makes it different. And this is where that partnership is so important. And this is where it's also important I think to check our ego and and say,

you know what? Yeah, there's a lot I could do for this cat in this moment. There's a lot of money I could probably make on that cat in that moment. But what's in the best interest of the cat right now? What's in the best interest of the client? If I have a high suspicion that a lot of what I do right now is gonna get repeated as soon as I refer it,

do I really need to start it right now? Do I wanna start it right now? That's a personal choice. Absolutely personal choice. I'm not judging anybody for their choices. I'm giving you the freedom to make your own choices though and to recognize what feels right for you in the way that you practice medicine. You get to decide your own style. So in this case,

scope of prac, excuse me, scope of practice combined with time and resources was my driving decision to refer this case. And so that is what we did. 15 minute drive, the cat had everything that it needed to have the best chance and the owner got the highest level of service that she was looking for. It was a win-win. Now there's another reason that we refer cases so far.

There's basically three main reasons. I don't know if you've caught them as we've been talking here. But number one, scope of practice. You know, does it, does your patient in front of you just need something beyond what you're able to to give. So like intensive care in a day practice that doesn't hospitalize overnight an animal that needs some very intensive care blood products,

those kinds of things. That's my example. So that would be a, for me, a reason that I would refer time and resources. So a case that I am very comfortable handling or at least getting stabilized. Do I have the time? Meaning are how soon are we closing? Do I have time to actually work this cat up and get it stable and then move it on?

And then other resources. Do I have the staff who's trained well enough to help me for this case in this moment? Sometimes that's the reason too. I may know as a doctor what I need, but I may not have the help that I need to be able to do it. So that would be a very legitimate reason in my opinion to refer.

And then the third reason is just simply experience and interest. When I own my own practice, I was very clear I have no interest in orthopedics and therefore I have no experience in it. So if you come in with a fracture that's gonna need something beyond being splinted, you're going somewhere else. Now I was very honest about that. I don't feel bad about that at all even today.

And I was able to refer a lot of cases over the years because I just don't like orthopedics. It's just not my scope, it's not my interest area. And so I think that's important for us to recognize too, that we do get to decide the types of cases that we will see and we can put parameters on that. So I'm not into complicated fractures and needing platting and pinning and all that.

That's just not my interest. I've never had an interest in it. I know a lot of people love it and I love the balance in veterinary medicine because here's the thing, my friends, the things that you don't wanna do, somebody else loves. This is why this ability to refer to each other, even within general practices, can really help all of us to create a better work-life balance and job satisfaction.

Because if we can do more of what we really enjoy doing and do less of what we don't, that actually all balances out. But to make that work, we have to stop judging each other and judging ourselves. So we have to judge, stop judging each other when cases come our way and we have to judge, stop judging ourselves when we send them shame and fear cannot exist if we are going to create job satisfaction.

We have to learn how to let those go. Shame and fear are our emotions. They're created by what we think, what we believe, our opinions, our conclusions. We can control that emotional experience for ourselves. So when we rely on our veterinary colleagues, three main areas is what the animal need beyond what you have the ability to provide, just simply because it's more advanced than what you do in a general practice.

It would be the same thing if you had a, an animal that had been been getting seen on a very regular basis with a cardiologist for example. And then during one visit the cardiologist found that the dog had a torn cruciate. You know, oh, will you check this out? It's limping, it's got a torn cruciate. Is the cardiologist gonna fix the cruciate?

No, the cardiologist's gonna refer that to somebody else. Right? So this referral, this whole idea of referring, sometimes it's very formal referrals, sometimes it's just simply communicating that they just need to go to a different practice for the whatever the case is. This whole idea of referral's happening all the time. Our resistance to it comes back to shame and fear.

It's appropriate to refer cases whenever you want to refer a case. That's the bottom line here. Whenever you want to, Not because you're not good enough, not because you're scared, That's not why we refer because we want to. And the the reasons that we want to often because what the animal needs is just beyond the level of care we have the ability to provide in our facility what the animal needs is beyond our experience or interest area or what the animal needs is gonna require.

Time and resources, physical resources, human resources that we don't have right now in our facilities. We don't have to feel bad about any of those things. Feeling bad about those things is optional. Judging ourselves for those lack of those things is an individual decision. We don't have to do that, but we have to be aware that we're doing it because if we don't,

if we keep trying to manage these cases that we really want to refer, it puts a lot of pressure on us. It actually amplifies all of that self-doubt and that self-judgment. And those cases are not enjoyable to manage when we have this underlying belief that we're not the right vet or right facility to be managing it. There are many practices out there, and I think I have to take a second to say this.

There are many practices out there that are open 24 hours a day that do op or at least that they hospitalize and they have intensive care 24 hours a day. And I'm talking about general practice, not referral centers. And those are wonderful facilities. I'm thankful that they exist, but that is not what most of us experience. And so are we trying to manage a case at a level that we just don't have the,

the resources to manage it. And if we are, if we're kind of forcing ourselves in that way, why is that? Is it because of pressure we're putting on ourselves to be all things to all people and all patients? Is it pressure that we're accepting from maybe our bosses, from our practice owners to do more, to see more, to make more?

Or could it even be pressure that we're receiving from clients because they don't want to go somewhere else for the thing that you're recommending that they go somewhere else for. You know, we're not gonna make everybody happy a hundred percent of the time. And if I go back to my example about how I just didn't do orthopedics and I still don't do orthopedics, so it would be the same conversation today.

There were probably a handful of people over the years that were frustrated when I said, yeah, this, this animal has a fracture that needs some advanced attention. I'm gonna need to send, send you somewhere else to have that done. And they were frustrated. They liked our practice, they wanted me to do it, they trusted me. I get that you,

you, you spend all this time building up trust with a client and then you say, I want you to go somewhere else for this. They don't wanna go somewhere else sometimes because they're scared because they, they trust you. They don't want somebody else to touch their pet. But the best thing that we can do for those patients when we know that we don't have the interest or experience to be able to help them with the medical situation that the the pet has,

the best thing we can do for them is to encourage them to go somewhere else. You can't force, they can't force you to treat a case that you don't want to treat. And remember, do not let your, that little voice in your head tell you that the only reason you don't wanna treat it's 'cause you're not good at it is because you don't think you're good enough,

because you think somebody is better. That's not true. You're qualified. I'm qualified to treat orthopedics. I have no interest in it. It's not my level of experience. And for me, the litmus test always comes back to what would I do if this was my pet when I know for sure and for certain that if it was my pet, I would take it to a specialist or I would take it to another practice that does this.

I would not do it myself that I feel much more comfortable even communicating that to an owner. Even when the owner is really pushing me to be the one to handle the case. I'll just tell them, if this was my pet, I would take it there. I would not do this myself. This is not my area of interests, it's not my area of experience for my pet to have the best outcome.

I'm gonna take it somewhere different. Sometimes that helps to let them know that. So I know that we've kind of rambled on for a long time here, but I wanted to just really talk through this whole concept of referral resistance because I think a lot of us experience it. And so as you go through your cases over the next few weeks and you can even reflect on some of the ones you've had in the past,

consider what emotion are you carrying around in regard to that referral? Were you able to refer it and just let it go and let it turn out? However it turned out, without judgment, without fear, without shame, without guilt, if so wonderful, you're on your way. But for those of you who are having some linger, lingering shame or guilt or fear around cases you've referred in the past or ones that you might consider referring in the future,

give yourself the opportunity to dig a little deeper, deeper and understand why am I feeling shame? How am I judging myself here? Or how am I taking on pressure from my organization? And what is that emotion being created? Is that shame? Is that obligation? What, what negative emotions being created by that and how can I maybe change my perspective to feel better?

And if it's fear, if it's fear of judgment from other veterinary professionals, I would love to say that the solution for this is for veterinary professionals to stop judging each other because that seems like it would be the the solution, right? If we would stop judging each other, then we wouldn't be afraid. And my friends, that's not how emotion works.

Whether or not they judge us isn't actually what creates the fear. What creates the fear is our worry that they will. So when we're believing we will be judged, that makes us feel afraid. If we just decide to let go of whatever their opinion is of us, we can let go of the fear too. So we can stop being afraid by simply deciding to stop being afraid of judgment because we can't do it right enough to guarantee that somebody's not gonna have a negative opinion of our decisions.

We can't write a medical record perfectly enough to guarantee that they're not going to say something nasty about it or about the way that we handled the case. It's the same concept you've heard me talk about before. You can't write a medical record well enough to to guarantee that you never have a board complaint because nobody's ever gonna look at your medical records unless you have a board complaint in that particular type of situation.

So this is the same situation. You can't do it well enough to keep people from judging you because the people judging you aren't judging you because of you. They're judging you because of them. Judgment is always an outreach of ins, personal insecurity. And so we cannot change any one person's individual journey, but we can change our own. And so we can decide that each moment we do the best we can with the information and resources that we have available to us.

And the best that we can do in that moment may be simply deciding to refer. That does not mean that we fell short. That means that we intentionally decided a path that was in the best interest of the pet. Either because it was outside of our scope of practice, it was outside of our scope of interest or or experience, or we just didn't have the time and resources or we just didn't want to do it.

No matter the reason, when it's in the best interest of the pet, there's no reason for you to then judge yourself for it. And as we are on the receiving end of those cases, we don't know everything that went into the decision for that other veterinary practice or or individual veterinarian to send a case our way. We don't know the reason, but judging them harshly and then communicating that with a client is never in the pet's best interest ever.

We can only help the pets in front of us. We can only look at the information that we have. And from there we'll all make our own decisions. And I think that as a collective, if we would just decide to always have each other's back, even when we don't understand the decisions that we've each other has made, if we've just, if we could just decide to always assume good intent,

to look for positive perspective, to remember intentionally that we are on the same ti side, all we wanna do is help clients and treat patients. If we can just keep that as our focus, as we interact with each other, I think we'll find that a lot of the shame and fear and judgment we'll start to dissipate. And as we become a united front,

the ability to actually serve more patients and clients expands the overall wellbeing of our veterinary profession will improve as well. We must create a united front when it comes to this. And this arguing and judgment and insecurity that we have because of we of the way that we have been taught to interact with each other does not help that cause. So my friends, you decide how you practice veterinary medicine.

Remember, it is the practice of veterinary medicine. You get to decide for you. And as long as you like your reasons for the decisions that you make, it doesn't matter if anybody else agrees. So I'm gonna leave you with that to consider this week. I hope you have a beautiful week and I'll see you next time. Bye for now.