Christina Madison, PharmD, FCCP, AAHIVP, sat down with Ryan Haumschild, PharmD, MS, MBA, to discuss current issues in oncology.
Christina M. Madison, PharmD, FCCP, AAHIVP: Hello, everyone, and welcome to another episode of Public Health Matters, part of Pharmacy Times’ Pharmacy Focus podcast series. I am your host, Dr. Christina Madison, also known as the Public Health Pharmacist. I have another incredible guest with me here today, someone who I had the pleasure and joy of meeting in person, which he's actually more fabulous in person. But since I can't bring him physically to you, this is the next best thing. So without further ado, I'm going to go ahead and introduce our guest and have him say a little bit about himself before we dive into some questions. Dr. Ryan Haumschild.
Ryan Haumschild, PharmD, MS, MBA: Hey, thank you so much. I appreciate being on. I’m definitely a fan of Public Health Matters and all the work that's going on within the podcast. For those that don't know me, my name is Ryan Haumschild. I'm Director of Pharmacy here at Emory Healthcare and the Winship Cancer Institute, and really a lot of my practice really involves overseeing infusion oncology medications, inpatient hematology, work with retail specialty pharmacy, and really working on pharmaco-economics and making sure that we're making really good clinical management of patients but doing it in a cost-effective way.
Christina M. Madison, PharmD, FCCP, AAHIVP: Well, thank you for everything that you do for your patients. And on top of all of that—which you are being very modest—and you also are, you know, very much an advocate for vaccines and vaccine safety. And I know that you've done some incredible work with pharmacy times and MJH Life Sciences, which is how we met each other because we were both part of a series looking at some vaccinations and the need for vaccinations in special populations, which is partially why I was thinking, you know, what an amazing opportunity to talk about the intersection of oncology and public health. Because I think so much of what we do within the oncology space is around prevention. Once we are trying to treat this rapidly dividing cell group, wherever that may be in the body, we need to prevent people from illness, because we are compromising their immune system.
So, with that being said, I would love to talk about just a little history of how you got to your role, because obviously, for those of you who are listening, but maybe not watching, because we do have a video version of this as well, Dr. Ryan is quite young. So, to have a leadership position, and I know you've held this position for a while and you've done quite a bit within your pharmacy career, if you could maybe take us through a little bit of the journey and how you kind of found a love for oncology, since I know that this is something that is being heavily recruited for within pharmacy right now.
Ryan Haumschild, PharmD, MS, MBA: Yeah, well, thank you for the background. And, you know, I know so many people have unique ways in terms of, you know, how they get into their roles. I've been really passionate and throughout my years have really good exposure to more of the, you know, high-touch, high-cost disease states, but really oncology separated itself. For those that are unfamiliar with my background, I did start off getting a bachelor’s degree in health services administration. I knew initially getting involved and helping improve the lives of our communities was really important and so I started there, and then from there actually transitioned to getting my MBA before pharmacy school. So, I actually front loaded a lot of the MBA work again, because, you know, I realized health care has a unique need, but it's also a business and you've got to understand the fundamental economics of it. From there, I went on to the University of Florida, got my Doctor of Pharmacy degree, and spent some time as an intern at Johns Hopkins. And I think there is really where I understood the intersection of leadership, but also political management and I spent a lot of time with the inpatient hematology and solid tumor team at Johns Hopkins and saw the unique role they played. Just like you said, Dr. Madison, you know, there's a lot of screening involved in cancer and getting to connect with patients before they're on their journey with cancer or patients living with cancer survivorship. Pharmacy plays a really unique role. And when you think about transplantation and the different vaccinations that are required, or those that may not get an HPV vaccination and end up with head and neck cancer, there's so much prevention that pharmacists can play a role in. And so, from there, I actually matched to your residency program at The Ohio State University Wexner Medical Center; they would be upset if I just said Ohio State. So, it's The Ohio State. I ended up getting a master's degree there in health system leadership. And I think, again, that really propagated my involvement because the James Cancer Center there, one of the largest cancer centers in the country, and I got to be a part of that. And so that is really where my passions come from.
And then I got recruited down to Emory and it's been just an incredible opportunity. Emory is the only NCI-designated Comprehensive Cancer Center in the state of Georgia. And so, we have such a unique role and I take that so seriously. How do we build our team to complement the great physicians and researchers that we have? The great nurses, the great public health leaders, to really make an impact. And so that's what we're doing right now. We're reaching out to patients, we're designing treatment pathways, we're getting pharmacists involved in all these disease specific clinics, and really playing a role not only in treatment recommendations, but just like you mentioned, preventative health care. Have you had your vaccinations? What can we do to be preventative to stop these side effects? How can we engage you in your community to make sure that we're being inclusive of underrepresented or disproportionate share communities to make sure they're having the same and equitable access to cancer care? So that's kind of a little bit of background, let me know if you want me to go any more in depth. But hopefully, that tells a little bit about my journey and why I'm so passionate about it.
Christina M. Madison, PharmD, FCCP, AAHIVP: No, that's great. So, a couple of things, because there's quite a lot there to unpack. So, I love that you, you know, did your bachelor's in health care administration first and then went on to get your MBA, which also, kudos for that, for anybody who's working in that space. Also, if anybody is looking to kind of look in this space and wanting to have some of those leadership skills develop, in addition to an MBA, I would also recommend an MPH, if that's something that your college or university offers, because I know that there are some combined degree programs out there, and then going to get your PharmD. You know, typically, it's the other way around, which I think it's really cool that you did it that way. And you saw such a need that you were like, “No, I don't want to just be the one managing the health care professionals, I want to be the health care professional.” So, I think that's incredible. And then ultimately, the fact that you were at Johns Hopkins, which I think is really cool. You know, they're also known for public health, in addition to some of the other accolades that you stated. And then being at Emory, which is such a beacon of hope and light when it comes to cancer care, and just, you know, being able to treat the whole patient, which I think is really incredible.
And then I also just wanted to echo the sentiment that good health care can also be good business. So, I don't want to, you know, not acknowledge that and skirt over that. Because oftentimes, we don't think about the fact that when we are engaging in preventative care, we are helping to, you know, economically unburden the health care system, because when people are seeking acute care versus just being managed for chronic medical conditions, it causes the ability to not have access to care for everybody in the system, right? Because we're overburdening the system, we're getting to the point where people who need critical need are not able to get critical need because the ERs are being filled up with people who are there for things that don't have to be treated at an ER, or if they are there it was because they couldn’t have gotten preventative care screenings. And unfortunately, you know, it's led them to need additional care. And instead of going to a primary care or maybe not even having a medical home, I think that that's a big deal.
So, one of the things I wanted to talk with you about is sort of the point that you made about high-touch, high-cost, and really kind of wanted to dive into that a little bit. As someone who's worked in the communicable disease space for a long time, I know that oncology kind of intersects sometimes with some of our other, what you consider to be high-touch, high-dollar. And so, I wanted to know if you could maybe explain that in a little bit more detail for people who maybe are not as familiar with that terminology or that concept around specialty pharmacy.
Ryan Haumschild, PharmD, MS, MBA: Yeah, absolutely. I mean, it's a great call out. I think it's something that's developed, really over probably the last 10 years, where we're starting to now see oral medications or self-injectable medications that have unique considerations [and that] are almost the same as an IV product. And so, an example would be an oral oncolytic, or oral chemotherapy. And when you have a medication like that, not only is it important, but there are also labs that you must review, there are toxicities that you have to manage for patients. There's limited distribution, meaning not everyone can purchase the drug, but it's also costly. So, as a pharmacy, you've got to be a good steward of your drug expense, making sure that you're not putting an undue burden on the patient, you're able to purchase the medication and kind of see it through. And we're seeing more and more as we look at the payer side of health care and the provider side that if payers are going to spend a lot of money for an oral oncology medication or specialty medication, they want to make sure that patients are successful in therapy. So, it's our job to make sure that patients are educated around the medication, that they understand how to take it. If there's any supportive care medications, they have those, such as, if you have a rash, making sure there's a cream being dispensed. If there's anything like diarrhea, they’re given an anti-diarrheal, or nausea, vomiting. And then also to make sure that, you know, we're checking in with patients and that we don't have a patient that maybe has weight loss rate-limiting toxicity, like neuropathy in their fingers. And if we don't check for that, or we just keep treating them, it's going to end up in a grade 3, grade 4 toxicity, and they're going to have to suspend therapy. And now the insurer or the health plan has paid all this money, right, to give this patient an optimal outcome, and they don't reach it. And it kind of falls in the pharmacy—how are you managing it? Did you have clinical oversight? And that's really what's allowed us to develop a lot of our clinical services to handle what I call the high touch, right, is that the high oversight and the high cost. And to your point earlier, you said it well, and I've heard others say, you know, even if you're not-for-profit, if there's no margin, there's no mission, you've got to have something that allows it to be a sustainable delivery of care. And I think that's what we're looking for is, you know, good clinical management, but also financial stewardship.
Christina M. Madison, PharmD, FCCP, AAHIVP: Thank you so much for that explanation, I think that really helps, and especially for those of us who work in that kind of specialty pharmacy space. You know, I think about all of the years that I've spent working with those affected and infected with HIV, and how it's changed over time. You know, in oncology spaces, you don't have something like a gap where, like, there's a federal program that's like, “We will pay for your med because we know that, from a public health standpoint, if we don't treat you, it could be, you know, a problem for everyone,” right? So, I feel like that's kind of the difference between public health versus disease state management by individual care. One is, you know, health of the one, versus health of the many. And so, I feel like there is an intersection there, because of the fact that public health is really about the health of the community, and then also population health.
So, I'm not sure that you guys track this necessarily, but one of the big things that's sort of been like the new buzzword within, you know, my space, is the term ‘health equity’ and sort of looking at the thought process that, you know, even if things are all equal, they're not just right. And so, the term ‘health equity’ is meaning that things are not just equal, but they are just, and we are making accommodations for those who need accommodation. And for those who have difficulty accessing the system, we’re providing a safe space and affirming space for them, so that they can get the care that they deserve, because it's a human right. So, I'm not sure if you guys are tracking that mechanism, or if there's an initiative you would like to discuss, but I know that those are also part of metrics, when we look at, you know, how hospitals are judged. It's not just, you know, the 1 individual procedure or treatment course: it's about outcomes now.
Ryan Haumschild, PharmD, MS, MBA: I mean, first off, you did a great job going through the definition. And that's exactly how I see it. And, you know, even though hospitals require so much of my guiding principles, it's the right thing to do for our patients, right? And I feel like when just speaking, you know, here in Georgia, in Atlanta, we have such a great population to take care of. And I feel like we do run into equitable care, and, you know, just and quality don't always come together. And so how do we address it? You know, one of the first things that we're working on is building out social determinants of health—how do we better understand each patient? Just like you mentioned, one person might have a financial toxicity, another might be in a food desert, someone else might have transportation issues, and how are we reviewing those and coming up with kind of an opportunity to interject there and provide support? So that's one thing that we're working on, is when we bring patients in and we look at their social determinants of health, do they have a transportation vulnerability? Because just like you mentioned, it could be someone 6 miles away in an urban environment that has transportation vulnerability, getting onsite to get their treatment, as well. It could be a farmer 300 miles away, and how do we make sure that we're looking at that? And what are the tools that we have available?
You know, it's interesting, ASCO, as well as Vizient, both have databases where you can actually look up a patient's zip code and find out if they might be exposed to transportation vulnerability and be able to have that conversation. Or looking at a patient potentially and asking them about, you know, what type of copay do you expect? And how can we create an open dialogue about sexual orientation, right, even language, and even caregiver support? And how do we engage in those to make sure that we're taking it into consideration. I think we have a long way to go, but I think those are the things that we're focused on. And then just lastly, how do we focus in on patients as a whole? Why are some patients getting CDK 4/6 for HR-positive or triple negative breast cancer having worse outcomes than their counterparts? Why don't we dig into that deeper? And I think that's really, those are passion projects, but also projects that we're working on as an organization to improve our delivery of care.
Christina M. Madison, PharmD, FCCP, AAHIVP: That's incredible that you guys are working on all of those things. And I think it's wonderful to hear, and I'm hopeful that it's not just something that is unique to your institution, but becomes the standard across all hospital systems, as well as all health care, you know, aspects of our system. Because I do feel that, you know, this newfound appreciation, I'll say, for population health and social determinants of health, I think was really propagated by the pandemic. But really, what it's shown us is that the problem was always there, it just became worse when we were dealing with challenges around COVID. Because, you know, it was the great equalizer, it impacted everyone. And so, before these things were happening, it was just disproportionately impacting persons of color, you know, persons who were historically marginalized. And really, the thought process there was, you know, if we don't talk about it, it doesn't exist, but it's definitely there. And I'm glad to see that, you know, that your organization is focusing on it.
One of the things I did want to chat with you a little bit about is this concept around delay in diagnosis. I have a personal friend that was up for her mammogram during the pandemic, and because of that, she delayed her screening, her regular routine screening, and unfortunately was diagnosed with a later stage of breast cancer late last year. Luckily, she was able to get care and had to actually go out of state to get part of her care. But I'm curious if this is just maybe a one-off, or if this is something that we're seeing sort of across the bow for a lot of our solid organ tumors, and, you know, issues around lack of preventative care. And we saw that with Chadwick Boseman, passing away from colorectal cancer. We've seen quite a few high-profile celebrities passing away. And I’m just curious what your thoughts are about that, because I see that as kind of a missed opportunity to really get the word out around preventative health screenings.
Ryan Haumschild, PharmD, MS, MBA: I mean, that is so important, it's a huge part of public health. And actually, to your point, it is a phase of care that we want to engage in our community. And, you know, during the pandemic, I think, based on people trying to probably be protective of themselves, you know, being protective of others, and also just not really being motivated to go into these different facilities when the pandemic was high, which I don't blame them. But unfortunately, it did lead to some delays in diagnosis. I call it more detection than diagnosis, right? Because if you can't detect it, you can’t do that diagnosis with underutilization of services. And I think now we're seeing more of that demand building back up, right? Patients are now coming in, like you said, later lines where they're presenting with more extensive disease. And really, I think it puts it on our clinicians—how are we engaging individuals that should be coming in? And if they're not coming in, how do we create opportunities for them even local in their community. We're making it easier, so they don't have to drive to a main academic center, you know, look for parking for 30 minutes, wait in the clinic for 45, just to get a screening. Are we decreasing those barriers? Are we creating more access to the community? Are we reaching out and engaging the community around key signs and symptoms that would cause them to come in early? And then as we have early detection, are we getting time to treatment reduced, because there's been such a long time before they've been diagnosed.
I think those are public health goals that we have. And honestly, as pharmacists, once we've diagnosed the patient, how can the pharmacist be really engaged in that patient's care, so that clinic can see more patients and you can have better throughput? And to reduce the time to an appointment? And I think one of the main goals that I know I'm really centered around is how do we decrease time from appointment to screening to diagnosis, and that whole kind of line of therapy? Now, you know, we're back to normal per se, but not really. How are we decreasing the lead time that it typically took? And like you said, I've heard people say, you know, never let a good disaster go to waste. Well, COVID was kind of a national, international, you know, not disaster, but, you know, pandemic. And so how do we take lessons learned and utilize them moving forward? And if we can make something more expedited during the pandemic, how do we apply that to cancer screenings? And I think that's what we're in the process of right now.
Christina M. Madison, PharmD, FCCP, AAHIVP: I'm really glad to hear that. And actually, I'm going to push back for a second and say I'm pretty sure it was a disaster for some people. Some of them have had a bit of a silver lining and it could have turned out positive, but there were quite a few of us that I think it was a bit disastrous. I feel like in general, you know, because of a lack of investment in public health and public health infrastructure, we did not start out on good footing. And I would say that the start of the pandemic might have been disastrous, but ultimately, with the good of people like yourself and others, I do feel that the profession of pharmacy really did come to the rescue in a lot of ways, especially because we know that the average American is within 5 miles of a pharmacy. I just heard another statistic that the average adult—obviously, this could be a little bit more, a little bit less—goes to a pharmacy 35 times within a year. Can you imagine how much we could amplify the number of services that we could provide? A pharmacist could actually practice at the top of their licensure. It’s, like, incredible. I just even think about, you know, how infrequent people go to visit their primary care provider, you know, maybe once, like, it was just such an incredible thing to hear.
And then also, you know, being that trusted health care professional; I think a lot of times people go to the pharmacy not just because it's convenient, but because they know that there's someone there that they can easily access and we'll give them the information that they need, right? So, I feel like we need to, as you said, leverage disaster and really try to look at ways that we can provide better care in those 35 visits that people come to a pharmacy within a year.
One more thing I did want to ask you, because this is something that I've been asked about just in the last maybe 3 to 4 months, I think it's gotten a lot more media attention—the issues around drugs shortages. Obviously, we know that this has been something that's been going on for many, many years. And we know that the way that manufacturing for drugs works is that if there's no profit line and things go generic, there's not a lot of an impetus to continue to make that product. However, I do think that, from a legislative standpoint, from a federal standpoint, we probably should think about ways to limit that practice when it comes to life-saving medications like chemotherapy. So, I don't know if you want to comment on that or talk about if that's directly impacting your patients. But I've heard stories of, you know, rationing and limiting and I was asked about it for a media appearance, and, you know, was trying to explain why manufacturers do not want to make a drug if it costs, you know, under $100.
Ryan Haumschild, PharmD, MS, MBA: You know, this has been a huge area I've been engaged in recently, I'm always working on drug shortages. But I would say most recently, it has kind of taken over my schedule and a lot of what I'm working on, you know, I'd say the good news for Emory patients is we've been able to sustain supply. So, I want to lead with that, even though things have gotten pretty stringent and pretty lean in terms of supply chain. But you're right. You know, with a lot of these manufacturers, what we found is there was, you know, a manufacturing facility in India that provided a lot of the resources, and when that got shut down due to quality concerns, not every player either could ramp up supply or was still kind of providing medications at the time. And I think the difficult piece is, you know, not only is the generic manufacturer trying to provide a cost-effective product to them so they can actually drive some value, but then they also have to worry about wholesalers and how much they're going to pay and general-purpose input/outputs. At the end, is it worth their time? And some manufacturers, like you kind of astutely mentioned, may say it's not worth us being a part of it. But the problem is then you have the reliance on the market share that has slim margins. The second they have any deviation in product production, we're also dependant on that and it hurts.
And so, I've been on calls with other NCI Comprehensive Cancer Center directors of pharmacy and some of them have said, you know, the banks got the bailout; what about the drug areas? And I think that's a legislative area that I think will be discussed probably further. But I would say, yes, right now, ASCO, ASH, the leading organizations—so the American Society of Clinical Oncology, and Society of Hematology have come up with recommendations. What do you do if fluid air venous shortages occur? And you have cell therapies and bone marrow transplants as well as you know, ASCO coming up with stewardship for carboplatin and cisplatin, especially when, you know, patients have a chance at curative intent. And so those are things that we've adopted, we've looked at them. And I would encourage anyone going through this to not only partner with your manufacturer, because they do have to have a sustainable way to provide product, but also connect with your ethics department, make sure you're prepared when these conversations occur. How are you going to steward supply both for curative and non-curative intent—adjuvant, new adjuvant, metastatic. And then what are you going to do for patients that are in clinical trials? And make sure that you have an agreement before these things occur, so you're better prepared and more agile.
So, that being said, that's been a lot of work we've done luckily. Some of that work, especially working with the ethics team, is brought forward because we have a great communication pathway here at my organization. Medical leadership works very closely with pharmacy leadership, and we've been able to really stratify and utilize our order sets and pathways. But ultimately, I'm hoping there's light at the end of the tunnel. I think there might be, but the sustainability, to your point, and the way we manage drug production moving forward for life-saving generics really needs to be changed, or really looked at by our governmental leaders. And I think that's really what we're advocating for heavily here.
Christina M. Madison, PharmD, FCCP, AAHIVP: Wow. So that was quite a bit. I wanted to maybe touch on something that I heard you say, because I don't want to miss the importance of it. So, some people may not realize that, you know, there are quite a few cancers that can be cured, or get into remission that, you know, lasts years or decades, right? And so, I do think that that is something to consider. And I love that you brought up your medical ethics department, because that’s also something else that I don't think is maybe thought of as much. But these are very much ethical situations. This is not just something that comes up for an [internal review board], if the person is in a clinical trial, like how do you choose? Right? Like, it's not just survival. But if you know that your protocol has a 95% chance at providing this person with an additional, you know, 10 years of life, how do you determine whether or not it's their age, their sex, their other chronic medical condition? Like, how do you decide that? And so, I really appreciate that you brought that up.
And then also the difference between curative and non-curative, right. So, quality of life versus quantity of life, I think, is also something to consider as well, because we know that there are some individuals who may choose a palliative health care option if the chemotherapy is so toxic that they feel like their quality of life is not sustainable. So, I love that you brought that up. I definitely want to include in the show notes some of the organizations that you mentioned and some links to their websites, so that people can research this more if this is something that is impacting them in their clinical practice, or if it's something that's impacting them personally, because I've had people reach out to me and say, ‘You know, I don't know what to do, like, we can't get access to this medication, our physician is telling us that we're going to have to go on a different medication, but the success rate isn't as high.’ And so, again, these kinds of ethical conversations, I definitely think need to be made.
But ultimately, looking at it from a public health lens, the more we can help with routine recommended screenings, making sure that people have their routine recommended vaccinations, making sure that we're minimizing risk of infection, risk of harm, risk of adverse effects, like you said, grade 3, grade 4 clinically relevant adverse effects. Which also, we'll be happy to put that in the show notes as well to kind of explain like, what the differences are between those clinically relevant drug-drug interactions and adverse effects associated with some of the use of the chemotherapy agents, just for reference for the audience. Because, really, it's a difference between someone maybe having like a tiny rash, and somebody like having, like, a horrible rash all over their body. And it's from multiple consecutive infusions. Not to mention you have things like mucositis, where it's like usually from the top of your throat down to the bottom of your bum. So, you know, little things like that. It's been a little while since I've done oncology, you know, since residency, but I do know that some of those things are not pleasant and a lot of it rests on pharmacists’ shoulders, because it's up to us to explain it not only to the patient, but to the provider. So, I always say, you know, our patients are not numbers. They are people, they are human beings that are deserving of love and care and compassion and having that ability to have that connection with the patient is so important because then it helps them to want to be an active patient and to take, you know, a dynamic role in their health care.
So, I see that we are coming to the end of our time, which is so unfortunate, because I know that you have so many more little tidbits to share with us. And I'm glad that, you know, I wanted to do this. Oncology was kind of a little bit out of my space but, you know, I was thinking there's such a demand right now for pharmacists working in this space, I really wanted to take the time to talk to somebody who I knew was really immersed in all things. And then we also had this lovely aspect where you really are passionate about vaccinations and preventative care, as well. So, I’m definitely so grateful for you taking the time out of your schedule, I know it's late in your day, we're about a 3-hour time difference apart. So, I really do appreciate that.
So, before we leave, something that I typically will ask my guests, just to kind of get some little pearls of wisdom—because again, I am grateful for your knowledge and expertise—if there was 1 thing that you could tell your younger self, what would it be and why?
Ryan Haumschild, PharmD, MS, MBA: Well, that's a great question. By the way, you know, when I think about that, I think one of the things that stands out to me is whenever you get a project or if something comes your way, even if it doesn't seem exciting or it doesn't seem like it interest you, usually if you can learn and make yourself an expert in it, you're going to have something that stands out, and it's going to help you in the rest of your career. And it's going to help you impact lives, because not a lot of people want to get involved with it. And ultimately, you can turn it into an expertise that can really benefit, like you said, the public health of others. And it also can improve yourself. And that journey of learning something that's uncomfortable really goes a long way. And so, I wish I would have told myself that a little bit earlier, [to] not just pursue the passion projects, but pursue the things that no one else wants to do sometimes. But there's a need for it, because it can take you a really long way in your career. But most importantly, it can impact a ton of lives along the way.
Christina M. Madison, PharmD, FCCP, AAHIVP: Well, I wish that your younger self had been told that earlier, because I'm sure that you would have been able to impact so many more lives. But luckily for us, you are in your current role, and you are so passionate about what you do, so I look forward to seeing everything that you're going to be doing in the future. So, thank you so much for what you do for your community, and also what you do for the profession of pharmacy in really highlighting, you know, ways that we can expand our scope of practice, and practice at the top of our license. So, thank you for that.
Ryan Haumschild, PharmD, MS, MBA: Thank you so much for having me on today, I really enjoyed talking about oncology pharmacy, and how it really blends well with public health, and how pharmacists are really leading the way and managing a lot of these patients. So, Dr. Madison, thank you again for having me on.
Christina M. Madison, PharmD, FCCP, AAHIVP: My pleasure. And just as a friendly reminder, we will be including some of those websites and organizations that Dr. Haumschild mentioned during our episode today. And then also, if people want to find you on social media, because I know you have a social media presence, and for those of you who are listening and not watching, you are quite stylish and you have a signature bowtie that you like to wear. So, also as a lover of fashion, that was something that we bonded over when we met in person. So, if people want to find you, how can they find you and find out more about the work that you're doing?
Ryan Haumschild, PharmD, MS, MBA: Yeah, you know, I try to have a presence there with the bowtie on always, but you can really follow me on LinkedIn, I tried to keep that updated pretty frequently. And then also on Twitter @RxHaums. Those are the 2 areas that are most, you know, accessible. And I’m always happy to engage and, you know, engage with your listeners about any other topics. So, thank you for the shout out and thank you for the compliments on the bow tie. Coming from you, that is a huge compliment.
Christina M. Madison, PharmD, FCCP, AAHIVP: Well, thank you so much. And again, this has been another incredible episode of Public Health Matters, which is part of Pharmacy Times’ Pharmacy Focus podcast series. Again, my name is Dr. Christina Madison, also known as the Public Health Pharmacist. I am your host, and I hope you join us again for another episode. Please make sure that you subscribe for more content, not just for myself, but the other offerings that we have in the Pharmacy Times podcast series. Thank you so much and remember: Public Health Matters.