FAACT's Roundtable

Ep. 206: Patients Are Not Commodities

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Dr. Shaker explores patient care from the angles of practice guidelines, cost-effective care, equity, partnerships, and policy. Getting the best care should seem straightforward, but it can get complicated when dealing with insurance/payors.

Note: Dr. Shaker's views shared on this podcast are his own and do not reflect any professional affiliations or organizations.

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Caroline: Welcome to FAACT's Roundtable, a podcast dedicated to navigating life with food allergies across the lifespan. Presented in a welcoming format with interviews and open discussions, each episode will explore a specific topic, leaving you with the facts to know or use. Information presented via this podcast is educational and not intended to provide individual medical advice. Please consult with your personal, board certified allergist or healthcare providers for advice specific to your situation. Hi everyone. I'm Caroline Moassessi, and I am your host for the FAACT Roundtable Podcast. I am a food allergy parent advocate and the founder of the Gratefulfoodie blog, and I am FAACT's Vice President of Community Relations. Before we start, we want to highlight FAACT's National Gold sponsor, the National Peanut Board, and thank them for the years of continued support and partnership. Today we explore patient care from the angle of practice guidelines, cost effective care, equity partnerships, and policy. These issues directly impact how our community receives the care that they need. Getting the best care should seem pretty straightforward, but it can get very complicated. For example, all too often, insurance companies, also known as payers, do not cover guideline recommended therapies. To help us unpack this a bit today we're going to sit down with Doctor Marcus Shaker, professor of pediatrics and medicine, section of allergy and clinical Immunology, Dartmouth Geisel School of Medicine, to learn about physician guidelines, shared decision making, cost effectiveness, and advocating for change. Please note that today's conversation reflects Doctor Shaker's personal thoughts and opinions and do not reflect any official or affiliated professional organizations. Welcome, Doctor Shaker, to FAACTs Roundtable podcast. We're absolutely thrilled and delighted that you are here with us today to really help us unravel an area that's a little bit of a mystery to our listeners.

Dr. Shaker: Thanks so much for having me. I've been looking forward to joining you and getting your perspectives and chatting with you about some very timely challenges that we're all dealing with, both as clinicians and as patients.

Caroline: Well, thank you once again. We know you're so busy, so first we're going to talk about you in your online bio at Dartmouth Health, your philosophy regarding patient care is mentioned. Can you share your background and explain your approach to food allergy management with our listeners before we get started?

Dr. Shaker: Oh, golly, Carolyn. My philosophy is really about meeting patients and families where they are and realizing that there's not a one size fits all solution to most things in life. You have to find out what people need and what matters to them. So it's important to me that clinicians and allergist immunologists are able to treat each patient individually, providing the right care at the right time every time. I think tailored care is key. You know, I'm a big believer in patient partnerships. You know, patient partnerships across the board, top to bottom, soup to nuts, from policy to individual visits. And, you know, this brings into the clinic and the conversation, shared decision making, and shared decision making is really a key aspect of the care we provide. It really engages patients and their families in a conversation to provide really bespoke care, care that's right for them. You know, an important part of my practice philosophy is to keep an open mind, to realize that then much of the time we have evidence based medicine. But the longer I practice, the more I realize that there's probably more we don't realize to the way the systems work than things we've solved. But one thing that I've really enjoyed in my career is working with my colleagues across the country to learn new ways of doing things and to get better at the value we provide. I think that through the decades, you know, medicines evolved. When I was in training, evidence based medicine was huge, and we were really focused on understanding, you know, the best evidence so that every patient could receive evidence based care. But over the past two decades, we've learned that evidence based care is key, but evidence alone is not enough. Evidence has to be contextualized to individual patient circumstances because patients are not clinical trials, and clinical trials may not represent every patient. So I think that, golly, what's my patient philosophy? I think it involves keeping a very open mind, being willing to meet patients where they are, and to work with families to provide the best care in the moment they can.

Caroline: That really comes across when you're talking about shared decision making. Like, as you're speaking, I'm getting such a vibe of how the patient comes in, and now you're a team. You know, I grew up, you know, as a child with healthcare being very different. You go to the doctor, they ask you questions, they tell you what to do, you thank them, and you leave. Where I'm getting a completely different, you know, feeling right now, which is wonderful, right? How you're talking, how medicine is evolving, where the patient's coming in and you're working with them. You're looking at their abilities, their capabilities, their economics, everything, right? And then together, you're coming in with that treatment plan or idea.

Dr. Shaker: I couldn't have said it better, and I haven't quite heard that before, so I like that very much. This idea of team based care, where the team members are clinicians, as well as the patients and their families and their support structures. I think we think about team based care quite a bit, but leveraging this with shared decision making, I think, is a really key aspect. The idea that clinicians can provide the expertise in the evidence base and their experience and really provide the patients and families with the information they need to make the right decisions for them, because, you know, allergists and immunologists are experts in cutting edge science around allergy immunology, and they have decades of experience, but patients and families are experts in their own values and preferences, and so much of allergy immunology really relates to values and preferences. So one of the great opportunities of my career has been to work with the Joint Task Force on Practice Parameters. I serve as the American Academy of Allergy Asthma Immunology chair of the Joint Task Force on Practice Parameters, and I work very closely with my friend and colleague, Doctor Jay Lieberman, who serves as the chair from the American College of Allergy Asthma and Immunology. The JTF was formed in 1989 to provide evidence based and provide guidelines and parameters. And on that group we work with allergists immunologists across the country. We have over 100 different allergist immunologist experts across the country currently working on projects across the range of allergy immunology care. These include food allergy, urticaria, sinusitis, asthma, anaphylaxis, drug allergy, many others. And when working to evaluate the evidence to provide recommendations, the evidence is really very important. But when considering evidence in the context of other features that may apply to individual patients, such as cost effectiveness and equity and feasibility and preferences and resource stewardship, recommendations are usually made either in a strong fashion or in a conditional fashion. For example, if you have a situation where you, you have a severe condition, say I present to the emergency department and I'm having a heart attack, you know, those recommendations that the emergency physicians are going to treat me based on are not conditional. They're not going to ask what my preferences are before they treat me. So those are strong recommendations, but that's often not the case in allergy. Many of the recommendations that are made in allergy are conditional. And so, well, take, for example, Omalizumab, newly approved for food allergy. So maybe a tremendous medication for patients who have significant anxiety about food allergy, who are not able to engage in the important things of life that they want to be doing. And this might make a huge difference for folks, but other individuals may not have a significant impairment from their food allergy. Maybe they have a food allergy that is not particularly severe or doesn't have a risk for a severe reaction, and those patients may not opt for that therapy. You know, there are many therapies in food allergy now, oral food immunotherapy, sublingual immunotherapy. These are conversations I have every day. Similar things like, when should we decide to repeat the skin testing? When should we decide to repeat the blood testing? How often should we do that? When should we decide to move forward to food challenges? These are all conversations where, as an allergist, I can share my experience, and then I can give a family the space to explore what's important to them, what are the risks and the benefits that they're really considering, what are the trade offs? And so that's what shared decision making is, and I think it's so important, and it really ties into some of the conversation we're going to have. Because shared decision making within our guidelines that we produce is really a critical aspect, because, as I said, recommendations are either strong or conditional. And a conditional recommendation is a navigational signal that the standard of care is shared decision making. And shared decision making, as you can gather, requires flexibility. It requires flexibility from the standpoint of allowing a clinician to have a conversation with a family and a patient. And as we bring in issues of third party payers, third party payers need to be able to recognize that conditional recommendations demand flexibility. So rigid criteria to allow healthcare, which is what funding is really doing, it's allowing healthcare to happen, need to have that built in flexibility.

Caroline: That was a great example. Thank you so much for that, because, again, this is such a mysterious area to us, so let's just backtrack for just one hot second here. Back to the joint task force for practice parameters. Again, how do does that directly impact the average patient, and what should they know about it? I mean, actually, you gave us some really good examples, but is there anything else that you would like them to know about it? And then I do know there's something called grade. And then what does that mean and what does that do?

Dr. Shaker: So the joint task force is definitely something that clinicians should know about. It's something patients and families should know about. It's something payers should know about. What it produces are practice guidelines, standards of practice ranges within which practice is appropriate, and it's available to anyone who has an Internet connection. It's at allergyparameters.org, and all of the parameters are freely accessible and downloadable. I referenced it. Just earlier today I was writing a letter of medical necessity for a patient about their urticaria, and I directed the payer to the urticaria practice parameter to help them understand what appropriate care is. So yes, so it's an important organization. The JTF, as we call it the Joint Task Force, produces both traditional expert based parameters as well as grade parameters. So grade stands for grading of recommendations, assessment, development and evaluation. And it has really been a seminal approach to guideline development. It is used across organizations in the United States and internationally. What it does is it allows for a very clear description of evidence certainty, but within grade are contextual features that are critical to recommendations. These include cost effectiveness, feasibility, acceptability, patient preferences, and importantly, the balance between benefits and harms. And so grade has really been a tremendous advance because across medicine we can all speak with a common language. Grade and medical recommendations come down to, very simply, a recommendation for or a recommendation against a course of action. And then those recommendations are caveated as strong are conditional, very simple, very easy to understand, and within that recommendation, for or against is baked evidence, certainty and contextual factors. So not just within allergy immunology, but across medicine. Recommendations can be described not as ABCDe a one a, a one b, what have you. They can simply be described in transparent language, which is strong or conditional for or against. Once again, a conditional recommendation representing a navigational signal for shared decision making. So the JTF develops both traditional practice parameters as well as grade based evidence guidelines, which is really the highest level of guideline based development in 2024. And all the JTF recommendations are framed as recommendations for or against in transparent language. Strong or conditional. A tremendous resource for patients, for clinicians, easily accessible. I actually frequently access it during the day when I'm taking care of patients. What else can I tell you about this? We might get into this a bit more in a bit, but I think the important thing, both from the standpoint of practice philosophy and practical care delivery, is that patients can receive the care they need. I think you probably heard some of my passion about this when you asked me about my practice philosophy. You know, we don't live in a perfect world, but the perfect is not the enemy of the good. And working together, we can try to leverage systems that work for us instead of against us. I mean, golly, as a patient and as a clinician, it feels like most of the time the system is not working for me, it's not working for my patients, and sometimes I'm scratching my head to wondering who it's working for. And then I realize, you know, our healthcare system was not handed down at altitude on stone tablets. It is an accidental system that developed over time because of cooperation and coordination to try to make things better. And so there were third party payers that entered, and those third party payers were negotiating margin. And somewhere along the way, those marginal negotiations did not get translated to the patients anymore. And patients, over time, have found their freedom to choose therapies increasingly, increasingly restricted. I mean, you know, you've probably experienced this. I mean, do you ever scratch your head and say, why did my insurance allow me to have fluticasone this year? But last year it was beclimethasone?

Caroline: Oh, yes, this happens all the time. Both of my kids have food allergies and asthma, and they're in their early twenties right now. So we've been dealing with this for a long time. But absolutely, you go to the pharmacy counter and all of a sudden your $20 or $30 or $46 item, they're telling you it's 200 something and it's no longer covered. And you're like, wait a minute, it was last month, and now you're in this complete scramble.

Dr. Shaker: And what I see is, you know, I'll see somebody and I'll say, oh, you know, the guidelines have come out, and we have these new great therapies. There's a great therapy for asthma, Budesonide Famoterol. Budesonide is an inhaled steroid, anti inflammatory. Famoterol is a quick, long acting bronchodilator. We now use this type of inhaler as a single maintenance and reliever therapy. There's a cute little acronym called smart for it. I'll see a patient and I'll say, oh, this therapy is going to make a big difference for you. These are the advantages, these are the disadvantages. What's important to you? Is this something that you might be interested in? We have kind of a shared decision making conversation. Some patients say, you know what, actually, that's not the therapy for me. I want to take this alternate approach. But for many patients, this fits the bill, and we'll come up with an excellent plan. Patient's comfortable with it. It fulfills guidelines, it fulfills principles of shared decision making. And no, that's not what to be able to get covered. Well, we could talk a little bit about pharmacy benefit managers, but one of the major pharmacy benefit managers in the US in 2024 decided that they were not going to cover any drug that contained Famoterol. And so that eliminated any smart base therapy. And instead they decided they were going to cover a drug that they thought was the same. It contained a drug called salmuterol, which is similar but not the same, because salmuterol has slower onset of action than formoterol and can't be used as a reliever therapy. It's not recommended in any of the us guidelines. It's not recommended in the international asthma guidelines. And so this has led to a lot of these type of appeal letters that we've been writing referencing the guidelines. And I'm happy to say that for the most part, when insurers realize what guideline based care is, they allow those prescriptions to proceed. But there is tremendous delay in that process while that happens. And it shocks me that a major PBM in this country allowed that to happen without an awareness of the guidelines. And so that's what I think. If we can do anything to try to improve the situation and the healthcare we have, it can be as simply as making sure that the pharmacy benefit managers and the payers understand what current guidelines are.

Caroline: You know, and we're going to talk about that in just a little bit because I am going to ask you about how, what can a patient do? But this is just mind blowing to me. I just feel like you just lifted the veil completely on that. There are these practice parameters in place that us as patients could access and then go back to our insurance companies with. But then also, how do you recommend a patient handle this with their physician? So, like, say, you know, I go online and I see the food allergy parameters, how can I use that to best help my doctor visit when I go see my doctor?

Dr. Shaker: So it's a partnership. You know, you mentioned team based care earlier. You know, a good example is the atopic dermatitis parameter. You know, so the atopic dermatitis parameter is an outstanding grade based parameter. And it has 29 recommendations that are beautifully illustrated in a figure, a two page figure. But in addition to that, it has tools to translate these recommendations to action. It has patient instruction, instructional materials. And so the guidelines not only provide recommendations, but they can also provide suggestions on how to translate the recommendations into actionable things that families can do. But it's important that the guidelines, they're not self help manuals. They really are written for clinicians to understand best practice. And so it's kind of like a situation where I think there needs to be some caution in reading through it. I think that it's important that all of us as patients are as informed as we can be and as we choose to be. And different families will want to have different levels of engagement in that kind of parameter. Some of it's fairly technical, and so I don't know that there's necessarily a need to do pre reading, so to speak, on the parameters before the visit. But they are available if people do want to look through them. I think that perhaps one of the useful aspects of knowing that they're there is to realize that there are practice guidelines for clinicians, and those can be applied to these struggles that we have helping payers understand what is guideline based practice. And it's important to say that it's a partnership. And so these guidelines are used in partnership and the guidance and care of your allergist, immunologist.

Caroline: This is great advice and thank you. And listeners. Just so you know, I am going to put in the show notes all the links to all these websites that we're talking about, and then I just want to make sure everyone's on the same page and understanding that insurers and payers, those words are kind of interchangeable. I think maybe from our patient side, we'll say insurance companies, but they are the payers. And we all know it's such a barrier for so many of us, right, when we get something denied if it's our epinephrine, auto injectors or asthma stuff. And so this conversation is really important because I think this is giving us information on what we can do.

Dr. Shaker: Carolyn, you know, the other thing that is just kind of jaw dropping is in 2021, Scott Bickel and colleagues in the Journal of Pediatrics published an article. It was called impact of payer initiated switching of inhaled corticosteroids on lung function. And it probably won't surprise you, but they looked at 58 patients who were initially on one inhaled steroid but were mandated to switch to another. And they actually found that insurance formulary changes leading to a different inhaler device had a detrimental impact on pediatric lung function. And I just think thats such a striking example of the kind of harms that we see from time to time situations where somebody with asthma, they need an inhaler, they need the recommended therapy, somebody with food allergy or anaphylaxis needs an epinephrine auto injector. Right. And so it gets prescribed and then it gets held up. And you say, why is this held up?

Caroline: So on that note of what you're just saying, you mentioned in previous discussions the need for advocacy on all levels to provide each patient with the right care at the right time in the right place every time. And that is such a powerful statement. I just can't put a bigger emphasis on that. So then how can a patient, a parent or a caregiver for joining us today make this all happen? How do we take action now?

Dr. Shaker: Well, the name of the episode is patients are not commodities. It's part of the realization that whatever our role is, either in healthcare or society, we're all patients. And if we're not patients now, we're going to be patients someday, some of us sooner than later. And we all have family members and loved ones who are patients. So we're all in this together. And I know it seems intuitive and idealistic and even naive, but my opinion is that anyone in the healthcare sector really bears a fiduciary responsibility to work toward better health in society as a common good. But evidence contradicts this, at least to some degree, that as market forces are kind of undermining this aspirational goal, the study by Bickel I mentioned on lung function due to insurance mandates the situations that I think myself and a lot of other clinicians struggle with, with step therapy, and there are unintended consequences here. So step therapy, for instance, this is the idea that an insurance company will pay for therapy, but only after you have had therapy one and two and three. Omelizumab, a biologic just approved for food allergies, actually been approved for asthma for the past 20 years. So if you have a patient, say an adolescent who just started driving, and let's say this adolescent has been hospitalized for asthma, let's say they had an intensive care unit admission, let's say that it was severe, and now they've been prescribed an inhaled steroid. Say it's a smart therapy that we talked about. But this adolescent, they're 16, they don't take their medicine like they should, right? So they come in and they're not well controlled. Their *** is not well controlled. And so you say, hey, as the clinician, hey, I think a biologic may be a nice option for you. You can come in, you can do it at home, or you can come in, you can get the injection, it'll probably be pretty effective at controlling your asthma. And you might not have to get this injection, but every month or two, and they say, you know what? That sounds like a great idea. I think that's going to work. You write the prescription. The insurance says, wait a minute, they are not adherent, they are not taking their inhaled steroid. We are not going to pay for this medicine until they take their inhaled steroid. Well, the challenge is that that really challenges equity, because we have very good data that adherence relates very closely to health literacy. And health literacy is not uniformly distributed across the population. So what I say to that is if you're discriminating by health literacy, you're discriminating. And so this idea of step therapy, this idea where the payer says, prove that you need it, what the patient hears is, you haven't earned it. And what clinicians realize is that efficacy, which is the word we use in clinical trials, which means that something works, is not effectiveness, which is the word we use in the real world, which is that we don't live in a clinical trial. We live in the real world. And so it ties back to the conversation I had earlier with, look, we need flexibility. I understand that pbms generate market share by not having flexibility, by choosing one medicine and generating large rebates or use of spread pricing so that they can generate margin that's not passed through to patients. And in order to do that, they need to restrict access. But that's completely counterproductive and counterintuitive to guideline based care, which really indicates shared decision making, is the key across these conversations. And the answer probably comes down to policy on some level. I think part of it is these kind of conversations where we all have an awareness of it, but we all need to advocate within whatever spheres we have. We need to realize that across the healthcare sector, many of us are being treated as commodities, and nobody wants to be a commodity. Policy is key, and there can be some simple solutions. There can be some simple solutions. Some medicines that are currently prescription would probably be better over the counter. The smart therapy I mentioned earlier, we did a cost effectiveness analysis on what it would look like if this budesonide femoteral inhaler was over the counter. We found that if budesonide formotorol was over the counter and not prescription, even at current prices, it could save $70 billion, prevent nearly 15 million severe exacerbations, and save close to 12,000 lives just if it was over the counter. Some of this relates to the expense of some of these medications from the pharmaceutical companies. Should any medication cost tens of thousands of dollars a year? It seems a bit excessive to me. Some of it relates to the way that the pharmacy benefit managers negotiate prices, and some of it relates to larger policy issues. But, you know, hospitals are not immune. There's also a situation called white bagging and brown bagging and clear bagging with how medicines are supplied to hospital pharmacies and there are different margins that are generated from each of those. There are situations where health systems try to leverage that, and that can lead to restricted access as well. I don't know that we have enough time to get into that, but I think it comes down to this idea of stewardship. You know, as a clinician, you know, you asked about my practice philosophy. It's just about making sure people can get the care they need.

Caroline: Well, I think we're definitely going to have to have another podcast to dive deeper into this brown bagging and all these, these other concepts. And again, these examples are so relatable and so perfect for us to get a better understanding. So then what can a patient do? Like right now, like hearing about this and getting a better understanding. Now, what can they do to make change? Like, do they reach out to their legislators? Should they talk to their doctor to see what's going on? Is there national organizations that maybe they can support and engage with? But how can someone listening who says, wait a minute, like, this is not okay, I've got a little extra time to volunteer. What can I do to advocate?

Dr. Shaker: I guess there's two ways to think about that. One is there are resources when you're not able to get your medication. And, you know, I think it's always worth if an insurer denies your medication, look at some of the pharmacy websites that have come out, some of which are kind of bypassing these PBM situations a bit. You know, there's Goodrx, there's cost, plus there's Amazon. There are different new models within the market that are emerging. Try to help with this, and perhaps we can post that in the show. Notes, I'd like to hear your experience, too, Carolyn, because I know you have quite a bit of experience with this, too. But more broadly, as I think about it, and I don't have all the answers here, I wish I did, but I think part of it is to have these conversations, realize what our common values are, speak to our common values, try to design systems that work. I mean, every system is designed to get the results that it gets. The problem is our systems just haven't been very well designed. And then, you know, advocate. Advocate locally, advocate globally. Speak with your HR department. You know, when things aren't acceptable, you need to say, this is not acceptable. Otherwise you get the same old, same old. I think that once we realize that many recommendations are conditional and they demand shared decision making. So when insurers and third party payers and pharmacy benefit managers restrict shared decision making, they're restricting guideline based care, but more largely. And the easier argument to make is when they refuse to pay for things like smart therapy, single maintenance and reliever therapy by excluding medications from formularies, they're definitely outside the balance of formula of guideline based care. And so part of realizing where guidelines make certain recommendations and holding payers accountable to support current medical practice and current medical standards, it seems that nobody should be in a situation where their insurer will not provide for evidence based, guideline based care.

Caroline: Oh, absolutely. And kind of going back to what you're saying, you know, experiences, and I'm just speaking now as a parent of kids who are in their twenties who dealt with asthma and food allergies or continued to deal with, as I think you said it so well, when you were saying, say something. Throughout the years, we've had almost all our medications rejected and even doctors appointments rejected and so forth. And what I've learned from all of this is exactly what you're saying is go back to your physician and say, okay, this is happening. What can I do? Is this the correct medication? Is there a different medication? Can you speak to the payers? Can I speak to the payers? And like you said, in the meantime, though, while you're having those discussions, go to those resources like Goodrx. My family still uses Goodrx. Cause our insurance sometimes doesn't cover. And again, listeners, I will make sure the links are in the show notes. And these are really wonderful websites that you can go and get discounts, discount codes. Some of them even give you direction on how to find advocates and people to help you. And I think that's the big key, is to say something. Speak to your doctor, speak to a social worker, speak to whoever is in your realm and say, I'm not getting my needs met. You know, use your voice. You have a right to that. You know, if you're taking care of your family or, you know, a spouse, a loved one, anybody else, this kind of information that we're receiving today is just so powerful to make sure that you are getting your needs met and you're keeping yourself and your family safe. And I just can't agree with you more. You know, doctor Shaker, you're just amazing.

Dr. Shaker: Well, I appreciate that. And I'd like to hear more about your experience, too. I think that there was a time where folks on the other end of the phone were more responsive. It seems like, you know, more and more, it's hard find somebody on the other end of the phone that's responsive, and it almost makes me wonder. It seems like there's an avenue missing here, right? That there's a. There's a. There's a gap for some sort of vehicle to provide more global advocacy. And again, I don't know the answer, but I'd kind of like to hear your perspective. I know you've had some experience in.

Caroline: This, too, you know, with my family, and again, our insurance, we own our own business, so we have individual insurance, which isn't necessarily the strongest that is out there. And our first plan of attack is either go to Goodrx or these different sites just to make sure we get some kind of medication on hand. I will also call around to different pharmacies because each pharmacy has a different price. Sometimes, you know, the big box store pharmacy has the best price, then sometimes, you know, it's the little individual monpa pharmacy down the street. So, believe it or not, I write a list of the pharmacies that are within a decent driving range. Or even if I'm traveling, this sounds really bad, but even if I'm traveling, sometimes I will check those pharmacies as well. So I try to find where I can get something affordable. So I might call around. And then I will definitely go back to my doctor to see what I can do to figure this out. Or I've at times gone to my state. I live in Nevada, and so state of Nevada has different departments that handle insurance and hospital care and different things like that. And I will actually call them and ask to speak to an advocate or someone who can guide me if I feel that I'm really having issues. And I actually just recently had an issue not related to allergies and asthma, you know, just for me personally, where some pathology wasn't covered because it was sent out of state. And so I reached out and was like, wait a minute. I didn't know that was gonna happen. And the payer actually took it off my bill. But what I think is such a challenge is you have to have the time to do that right to call somebody. And I just felt that was a little unequitable, because what if someone's working two jobs, like, you know, how do you get that lunch hour break where you just gotta call and get in there? But I think, again, that goes back to what doctor Shang is. You've got to use your voice and just start speaking up. It's a very odd space. But I'm getting hope from this conversation, because now we know about these practice guidelines. We're all getting tips now on how to take care of our families even stronger. So again, I'm just so appreciative for this conversation today.

Dr. Shaker: It's great to hear your variance and it does challenge equity. I would just say for me, it's just such a privilege to take care of patients and to work with with patient partners. I mentioned patient partners. Patient partners are also involved in our guideline development because the patient voice is key. Otherwise we can really get off base and we really don't understand necessarily the implications of everything. So patient partners are key. As I said, top to bottom, patients have to come first. Patients have to come first. Otherwise, why are we doing this? Everything I've said today, not on behalf of the JTF, not on behalf of the Academy of college, just my personal views talking with my friend Carolyn about some really important issues close to my heart. Again, I don't have all the answers, but we're fellow travelers in this and it's nice to kind of get together.

Caroline: And chew on it together and we're exploring together.

Dr. Shaker: That's right.

Caroline: Well, doctor Shaker, time just went so fast. Definitely look forward to speaking to you again because we have so much more to talk about. But thank you so much for your time. This was such a powerful moment of sharing and exploring and you left me with a lot of hope. So I'm hoping our listeners are left with a lot of hope. And again, listeners, please check the show notes. I will have every website link on there for you.

Dr. Shaker: Likewise, Carolyn. It was nice to have a chance to visit with you and talk about these issues. I sure appreciate everything you do with this podcast. It's an outstanding effort, very valuable. Appreciate everything fact is doing and their advocacy for our patients. It makes a big, big difference for our community and really for our society. It's these type of patient groups that I think will really be the change in the future.

Caroline: Well, thank you and we really appreciate your support and your kind words today. Before we say goodbye today, we just want to highlight one more time, FAACT's National Gold sponsor, the National Peanut Board and we would like to thank them for their years of continued support and partnership. Thank you for listening to Facts Roundtable podcast. Stay tuned for future episodes coming soon. Please subscribe, leave a review and listen to our podcast on Pandora, Apple Podcasts, Spotify, Google Podcasts, iHeartRadio and Stitcher. Have a great day and always be kind to one another.