Interviewer(s): Interviewer
Interviewee(s): Respondent

Interviewer: Today is the 22th November 2019, and we are here in Echo room, paediatric ward- Mbarara Regional Referral Hospital to meet a Paediatric cardiologist, you are welcome doctor.

Respondent: Thank you.

Interviewer: So this study like I told you is to determine how to provide care for rheumatic heart disease patients and there are no wrong or right answers please be frank and share your opinions with us and the data we gather here is going to be very confidential we shall not link it to your identity and this is participant WH012, so doctor please tell me a bit about yourself, your age, don’t say the name, how old

Respondent: I am 35 years old

Interviewer: Okay, and qualification, and where you trained from?

Respondent: aaaah Paediatric cardiologist, I trained from Uganda Heart institute and aaah before that, undergrad, post grad was in Mbarara University

Interviewer: Okay, how long ago was that, how long did you qualify as a paediatric cardiologist?

Respondent: Like three months,

Interviewer: And how long have you been working in Mbarara regional referral hospital as a paediatric cardiologist?

Respondent: As a paediatric cardiologist of course I have just finished, but as a person providing paediatric cardiology services it’s been like, close to five years

Interviewer: Okay, so let’s look at the demographics of the patients we seek here, in terms of age and the common illnesses they present with.

Respondent: aaah generally here in the ward under paediatric we see children who are below 12 years that is our cut off, so most of the children I see are bound to be below 12 years and you know they have a specific demographic.

Interviewer: common illnesses that you see in them that cut across from neonates to...

Respondent: Of course there is the issue that they come with congenital heart disease and the acquired diseases and the patterns don’t change that much from what is being written most of them commonly are going to have VSDs and tetralogy of fallot being the commonest cyanotic disease and the commonest acquired heart disease being Rheumatic heart disease.

Interviewer: Ok...apart from heart diseases what are other common illnesses generally that are here on the ward?

Respondent: On the ward? On the ward there are many things, the biggest problem we have now we have neonatal diseases they contribute almost like 30 percent of the admission, then the other 30 percent comes from malnutrition then the other 40 percent cuts across in infectious diseases we have pneumonias they come in with meningitis, yah.

Interviewer: So tell me a bit about your training on rheumatic heart disease in school for example, did you have any training in school about rheumatic heart disease?

Respondent: In school, yah we used to have lectures about rheumatic heart disease

Interviewer: Post graduate?

Respondent: Yah we did a whole module on cardiology and we covered rheumatic heart disease under that.

Interviewer: So apart from the school time, have you had any specific training on rheumatic heart disease that is after graduation?

Respondent: what do you mean by specific training?

Interviewer: Let it be a workshop specifically about rheumatic heart disease

Respondent: Yah, of course in fellowships we had to study about rheumatic heart disease but there was also a time we had to it was like a workshop I think I have had like two when we are going to do school screenings so you start with a refresher course on what is expected.

Interviewer: When was that, and where and by who?

Respondent: aaah I don’t know whether I will remember the specifics all I know is we did the school training, I think like 2016, 2017 from Mbarara, yes and then we did one again in Kampala, yah the one I remember specifically was here, I think it was, what's her name, ... and Dr. ... and ... We did a lot, and mostly we have had like two, actually here in Mbarara we had two because we did the first school training and then we did again.

Interviewer: Ok...so now, how many patients of RHD do you see for example per day or per week or on a monthly basis roughly.

Respondent: there are two things that come in that, one, is that we have those that are coming back for review and those who have seen as new patients so for new patients we see almost on average like two newly diagnosed patients per week

Interviewer: okay, are those in patients or outpatients?

Respondent: They can be both, if they are coming for the very first time we do prior diagnosis and all that, the diagnosis for rheumatic heart disease and those who come for follow up

Interviewer: In a month, those who come for follow up in a month roughly, how many do you see?

Respondent: Maybe like ten

Interviewer: Okay, now I am interested in knowing what you were taught about rheumatic heart disease, for example in those workshops you talk about what do you understand is the cause of rheumatic heart disease?

Respondent: well, I mean rheumatic heart disease is more of an auto immune disease really, it’s a sequelae of auto immune disease that you get your valves damaged following Acute Rheumatic fever which is an auto immune, it’s a reaction of your body to group A streptococcal bacteria (door open)

Interviewer: Okay, are you aware of the link between a sore throat and rheumatic heart disease, what about it?

Respondent: Yah for you to get rheumatic heart disease, there must be a preceding sore throat which results into acute rheumatic fever and the recurrence of those sore throats and rheumatic fever which exposes you to rheumatic heart disease.

Interviewer: And what were you taught can be done to prevent rheumatic heart disease?

Respondent: One of course is the eradication of the strep which maybe, people have tried vaccines and all that, but also treating the sore throats and also once you get acute rheumatic fever, you prevent other recurrent acute rheumatic fever episodes.

Interviewer: Okay, how about the treatment options, what were you taught treatment options for RHD.

Respondent: The options, it depends I guess, one, if the patient is in heart failure you want to do the symptomatic management, managing heart failure then the definitive management depends on how sick the valves are whether they need to be replaced, whether you have to do a valve replacement, a valve repair, yeah.

Interviewer: So you are saying you manage them by surgery, that's what you are saying?

Respondent: yes, definitive management.

Interviewer: Okay and what do you understand about the long term prognosis of RHD

Respondent: From books or from...?

Interviewer: From your own experience.

Respondent: I think rheumatic heart disease has a very poor prognosis, that's what I have come across especially when there is no intervention, in our setting it is not very easy to come by the definitive management we all do give medicine for heart failure but we don’t know what’s causing it and if there are challenges in themselves, patients coming back for review, coming back for, getting their medications and all that, so most of the children actually die, that is one thing that I have noted, in this last month, we lost two children.

Interviewer: Oh, sad have you had those that you have treated and they have actually regressed?

Respondent: I hope one, okay, this one was, others regress and the disease becomes mild and they yah, and they just stay on Benzathine and we take them off the anti-failure medicine medicine, those ones actually we have seen them. There is one who came with severe martial regurgitation we were with them for almost like a year and a half and the symptoms regressed completely and they reached a point where they had trivial MR, we stopped all the anti-failure medicine and we just see them, they continued their injection, and we see them like once in a year because they come from far so we just tell them take your injection and they can only afford to come like every after 6 months or a year. They come from Fort, that side.

Interviewer: Okay, so now let’s talk about your encounter with these RHD patients, do you remember the very last patient you saw with RHD, the very current one, by age, how they presented, were they in school?

Respondent: Okay the last patient I saw, the most recent I saw this week, and this is when?

Interviewer: This is Friday

Respondent: This is Friday? Okay (Laughs) I saw them I think on Tuesday this week, yah six year old, first time presentation and the complaint were easy fatigability, cough that was persistent and the history of body swelling and they had had their symptoms for about four months. The child was supposed to be in school middle class but the child wasn’t attending school actually they had had to bring their exams to their home because the child couldn’t walk to school because of getting tired.

Interviewer: Okay, so In your own opinion do you think these patients are aware of the link between sore throat, acute rheumatic fever and rheumatic disease?

Respondent: No, they are not.

Interviewer: Why do you think they are not?

Respondent: I don’t know, they just don’t know the information, when they come the first time, they don’t have that information, so this particular one was coming from Ibanda- Ishongororo, it’s on the way to Ibanda, didn’t have an idea at all that there was anything related to sore throat, had been brought by a father, so, usually fathers are not good at giving history, was not even aware the child has ever got sore throat or has ever had joint pains or even fevers, yah most of them don’t have an idea at all, even those that you see when they have acute rheumatic fever and they are educated, university graduates, it has never occurred to them that sore throat can lead to rheumatic heart disease.

Interviewer: Okay, now, you said they describe symptoms, for this current one you said cough that had persisted, body swelling easy fatigability, how do others present?

Respondent: The commonest presentation actually is body swelling, it’s the commonest, and then these other things of cough, they stay home because they come and tell you, we been giving everything, they have given Amoxil, we have given antibiotics the cough is not going away but when the child starts swelling, that’s when they start actually thinking about; swelling, difficulty in breathing and easy fatigability but the commonest reason they come in here for check-up is because the child has started swelling.

Interviewer: Okay, and are they good at follow up and adherence with their medicines?

Respondent: No, they are not.

Interviewer: Why?

Respondent: They are not

Interviewer: what are the sorts of barriers they commonly state to getting care?

Respondent: The radius we serve as a hospital is really vast so and because it’s not like all of the patients we see come from Mbarara, they come from as far as Kamwenge, Kanungu, Kabale, think of all those far places, Kisoro whereby this is you have a child who is not a baby that the mother is going to carry, so transport becomes the first barrier, that is you need to pay two seats, so two seats if I use an example of someone coming from Kisoro to here, two seats, one journey is like 30,000 assuming that you are from the town, not including the journey where you are coming from, your home, and now going back is another 30000, 15000, 15000 that makes it 60000, its not common that a parent by the way, these peasant parents can afford a minimum of 60,000 every month, it becomes very difficult because remember, once you see them they have to do their monthly Benzathine and sometimes you are not very sure whether the health centres they have are going to be able to do that, it becomes very difficult. Two, they come here and you see them and you write medication and they go to the pharmacy and the medicine not there, so they have to buy this medicine and I can’t control I don’t even know the price I think maybe I need to find out but each pharmacy sells medicines at different price. So you don’t know how much money they charge them there, once you leave hospital and go to private pharmacies, so sometimes patients look at medicines and decide, this is what I am going to buy, I don’t know what determines their choice of choosing, you write medicines and after they say I am going to choose, some will choose the cheapest and that's what they will be taking, instead of being maybe they are supposed to be on an ACE inhibitor they are supposed to be on a diuretic and they choose one that is cheaper and they only take that so that so that next time you see them, they come back again in heart failure, you ask them what's happening , and they tell you, I have not had medicine in two weeks or when we left here, we didn’t have money we first went home, thou for those who were admitted, so you leave inpatient care and you go home without any outpatient medication and within two weeks you are back, so what do you expect.

Interviewer: Okay, so they are not good at follow up and adherence because of money for transport the distance and medication sometimes are costly so you what do you perceive is the barrier that is stopping them from getting the care that they want

Respondent: I think I agree with them that the distance is so, it’s difficult for them, that is what I think, yah.

Interviewer: Any other you are thinking, apart from those you have just said

Respondent: I don’t know whether I am not thinking even now but (laughs) because I see those patients myself, I don’t think it has to do with these other barriers of health workers because they know where to come you understand, they have my phone, sometimes I want to call you and ask you...”that see my patient and my child is swelling again”, but you cannot treat a swollen child on phone, it’s not like there is an issue with a health worker here, it’s like RHD patients have been one of those that have been protected I guess from the different studies that have been on, they had access to medical people but when it comes to having to deal with money issues, they actually don’t have.

Interviewer: Okay, so let’s look at the local healthy system barriers, I am going to mention some pieces and you tell me those that work for you and those that do not work for you. We are going to start with the administration here at the hospital and the leadership at the district, does it support you to do your work?

Respondent: (Laughs) I don’t know, I don’t think so because, I mean, this whole clinic as it were, its running and the equipment, didn’t come from the administration, didn’t come from the hospital, no. I am not even sure if the hospital is necessarily, they are aware that we have a cardiology service really but they are not interested in how it runs.

Interviewer: Ooh, why do you think they are not interested?

Respondent: And they give us reasons sometimes before that, you see this is a regional referral they don’t expect to have cardiac services so you can’t like ask maybe that the machine is down I need money to repair it, they will tell you we are not aware, such services it’s not in our protocol that we are supposed to have these things, so it becomes a bit difficult so whatever you do, you have to do it under the department and this is time of the complex department, we have university, we have hospital so finding the border line where this cuts into the other is a grey area which I myself never want to explore because you just get, you’re just disturbed for no particular reason. But for inpatients, they have drugs, some drugs, they have the IV Lasix, they have the IV Digoxin then sometimes they have Captopril but I don’t know how much on what they use to decide to procure but they know the patients are there but that's all I think, that's as far as it goes in their involvement.

Interviewer: So talking about medications, particularly Benzathine penicillin, is it available

Respondent: it is, Benzathine is available.

Interviewer: Anti- coagulation drugs?

Respondent: aaah No

Interviewer: Anti failure drugs?

Respondent: Some

Interviewer: Okay, and how about the diagnostics particularly echocardiogram is it available?

Respondent: We have the Echo.

Interviewer: Okay, do the patients meet it at a cost?

Respondent: No, here in paediatrics we do it for free entirely because the machine can as a grant, I mean some people gave us a choice of what we needed at the time and we asked for the machine so some of the terms and conditions are that patients are not supposed to pay for that machine so we do the Echo for free.

Interviewer: Wow, how about the funding for health care in general and RHD in particular

Respondent: I don’t know about the funding, eeh I don’t know, I have no idea about the hospital funds and how they allocate their money, no, I have no idea

Interviewer: How about the health care workers, particularly the numbers and the qualifications they have to do the job here as far as rheumatic heart disease is concerned, do you have enough numbers of the health workers, do you think you are fine with that?

Respondent: No, we don’t have enough numbers like I said this clinic is not necessarily should I say known, using the word in quotes by the hospital, so we do not have a nurse and me who runs the clinic, I am not under the hospital, I am running this probably out my own, I don’t know, passion because I am under the university so the man power that I tend to use are the post graduate students who you would say, you assign a post graduate student for their learning purposes so they have to rotate in the cardiac clinic see patients under your guidance and all that but we don’t have anything under the ministry in plans of that, no.

Interviewer: And how about the waiting time for our patients, do you think you are okay with that?

Respondent: The waiting time is fine.

Interviewer: Okay, the quality of care you give to them, are you fine with it?

Respondent: it’s me who gives, I won’t be a judge of myself (laughs) it might be difficult but I think I am comfortable with what we give, I mean I may not be able to provide you with the medicine but if I am able to explain to you what the disease process is, what it ought to be doing, how to take the medication and all that, I think on my part as a health worker maybe that's the best I can do, when it comes to you finding the medication I feel that that's not my problem really, when it comes to you going for surgery, the best I can do is to refer you, so the issue of ‘do I have the money? I don’t have the money,’ that becomes a different story yeah, but for these patients those we see, we manage to get some worked on, we send them to, those we really we assess and they need surgery like urgently, we send them to Mulago, we get touch with their representatives of Salaam centre they get surgery, some have gone to different places, to the US, so at least the best we can do is to tell you, the magnitude of your problem and then we tell you what the options are, we give you an estimate of what they are going to cost and then the next step is you deciding how I am I going to find the money, yah.

Interviewer: Okay so now how about the health information let’s talk about the medical record system, does it work for you here for both inpatients and out patients

Respondent: The medical recordings are a bit difficult especially if you are the doctor, you are the nurse, you are the one taking records, it’s just difficult.

Interviewer: Do we have specific registers for RHD patients here or ARF patients?

Respondent: Not in that sense, I mean everything is, under me, that if I see you, I type I do your echo I do your report but the ones I may record are the ones whom I think, the RHD we record I personally record their names and their addresses because the reason I want to be able to have a list in case people of Salaam centre come, they don’t come here but they come to Mulago and ask us where are many patients who need so if I have that list it makes it easier for me to just pick out names because you will get their name, their address the diagnosis and their phone contact and where they come from, like district of origin just like that so when such a thing comes I just get the numbers off but otherwise that other information is based on the Echo report that I have, which I keep in my computer.

Interviewer: Okay, let’s talk about the Salaam centre I have heard of it from you many times, what's this centre?

Respondent: Salaam centre is in Sudan, and it gives free surgery for RHD to patients.

Interviewer: Oh okay, wow, from Uganda only?

Respondent: I think they do other countries but I think I read they do from even other countries in Africa, yah.

Interviewer: So that surgery, where is it done when they come for these patients? Respondent They come for the patients, and select them and the surgery is done in Sudan.

In Sudan, Okay and, aaah so let me ask you again about these records, so If I came here to look for a certain patient for example who presented in rheumatic heart disease about three years ago, how can I easily trace that patient.

Respondent: It’s difficult but if he has been coming sometimes you know the patient but the best I can do is usually to trace like their serial Echos, because we do not one; all the records that we write for the patients information, the patient goes with them because we do not have a stationery where they are going write, so the patient buys their own book and we write there everything in that book every time they come, yah.

Interviewer: So there are no records here, that is it, how about the guidelines and protocols for RHD care, is that piece working for you, do you have all that it takes as far the guidelines are concerned to give care to RHD patients?

Respondent: I remember the guidelines I don’t have them pinned on a wall, but it’s like something I mean I have studied and it’s what I follow.

Interviewer: Alright, so we talked of these pieces we are just going to go throw them again quickly and then we see the pieces that work for you, Administration you said it’s not working, right?

Respondent: it’s not.

Interviewer: Funding for health care and RHD in general?

Respondent: It’s not working.

Interviewer: Health care workers as far as the qualifications and the numbers?

Respondent: it’s not working, but we don’t have the numbers so we cannot discuss their qualifications.

Interviewer: Okay, and then the medical records, that piece u said it’s not working, and then the guidelines you said that one is working for you.

Respondent: The guidelines are okay.

Interviewer: Okay, then let’s go on the last piece of questions now, generally do you think the patients get the care they need especially surgery?

Respondent: (Laughs) of course... this hospital doesn’t do heart surgery, No, it doesn’t

Interviewer: Why do you think it doesn’t?

Respondent: I mean it takes...,I mean how many cardio thoracic surgeons are there in the country to start with, and all of them are in heart institute, so here there are other things, I mean if you, heart surgery is something especially valve surgery, one it’s expensive, you need to find the valve, you need to have an ICU that is going to work for you or ICU I don’t know, that's a different story maybe it’s a story for some other time but it’s not like it has all these gadgets, they are also not probably stuffed, they do not have, we do not have bypass machines in the theatre, theatres are not prepared to do surgery here in Mbarara, so it’s not something that is done here, the only place that does surgery, cardiac surgery is Uganda Heart Institute

Interviewer: Okay, so they go to Uganda Heart Institute they are operated on,

Respondent: If they pay, it’s not free, the Uganda heart institute is not free, they have to pay, yah. And you can’t tell a peasant who has never held a million shillings in their hand that now you need to pay 19millions for surgery, it’s not easy, yah and children are a bit unlucky they don’t a lot of that support, they don’t own their own health care, I don’t know how adults do it maybe adults do go for surgery but children, if somebody has to get into their pockets to pay for you it’s not easier for them so they don’t want to know because they don’t feel your pain.

Interviewer: Alright and do you have any patients safety and quality of care concerns for example, have you had any preventable deaths here in the clinic?

Respondent: there are concerns that I have had actually I have been with Benzathine, we have had two deaths following Benzathine not because it’s anaphylaxis because these are the children who have been taking Benzathine for more than so many years but they have given them Benzathine and they just rested.

Interviewer: Okay, in your own opinion that do you think you would have done to prevent the death. Respondent I have never understood why they died but it’s, I think from literature what I have read they talk about neurogenic shock, they talk about the pain, the parasympathetic response and maybe it explains why, yah.

So talking about those two cases did you try to do some resuscitation or CRP and they didn’t come up.

Respondent: Yah, they didn’t come up, one was an OPD, was not a child, he was 19 but he was still under our care any way because he was a small 19 years, that was on OPD, he walked from home came in for his routine treatment and Benzathine because he was from Mbarara radius and usually he came for his Benzathine every month, the injection was given by a nurse who is trained who had be giving him the same injection and he just collapsed. Tried resuscitation, he didn’t make it. The second one died from the ward here he had been admitted but maybe had many issues and had surgery that was the most interesting thing, and had surgery but came in with issues that are not understandable but anyway we stabilized him, he was on the ward and was just receiving his treatment for heart failure, had come in with anaemia but I had had him on the ward for like a week, so his time for Benzathine found him here, so they give him Benzathine, he just died.

Interviewer: Okay, that was sad, do you think there are many people there in the community dying without actually presenting here at the hospital?

Respondent: Yah, there are many because there are those who come in and die in the hospital, they come in with heart failure and die, that means there are many who do not arrive here because they do not understand what the disease process is. So they have been everywhere and done everything, I think the community have a lot.

Interviewer: So putting into consideration all that you have said, so in your own opinion, what do you think are one or two most important things ministry of health can do to improve the outcome of the patients?

Respondent: The ministry needs to create awareness, really that these patients and their parents need to know that the disease is out there, it’s not something that is in our mind, it’s not there that is one two, there is need to make it easy for patients to access medication, patients can be stable because not all of them come in when they are so sick but because they have been getting their medication, they get worse during hospitalisation, so if say they could provide the medicine for these patients. Then the other issue I don’t know probably it’s not, I don’t think it’s that feasible would be for surgical options even if somebody needs a valve they should be able to get it, because without a valve, all these things we are doing we are just, maybe prolonging life but not prolonging life that is of good quality.

Interviewer: Okay, talking about this clinic particularly you said it’s not here because of the hospital administration and ministry of health, so supposing you left this university, probably you could go to another university in another world maybe not in this country, what do you think would happen to the clinic?

Respondent: It would stop.

Interviewer: Do you think there is anything that can be done to actually maintain this clinic running? Any suggestions?

Respondent: The suggestion would be to have somebody trained, to have more people trained that they can always come back, but it’s,.. like I said it’s not a clinic that is in structure so it becomes difficult especially if somebody is just doing extra work load without extra incentive like I said I run this clinic because it’s something I want to do, but there is a possibility that I will no longer want to do it, I will get tired, so if I get tired, I don’t know I will ever wake up and say, I no longer want to do cardiology, now I want to go into farming, currently there is nobody who can do that, because, one the training is very difficult, training for cardiology is your own initiative, you wake up and say I want to go and train. you don’t have anybody paying for your training, I was lucky that I didn’t have to pay for the fellowship, some people have to pay for the fellowship so unless you have somebody supporting to do that, it becomes difficult, the training is not here, you have to go to Kampala so if you have other commitments here it’s not something many people are willing to do, so even for everyone that suggests that you need to go and do the training they will ask you, for those three years “how I am I supposed to survive?”, I don’t have money, I won’t find a job that gives money, I have family, so the whole process of training becomes very difficult so unless somebody puts in efforts to train, either government or whatever it is ,so they train somebody that they have or ministry of health sends somebody to train who is attached to them, it can’t stay, I mean there are times when I am sick, the clinic closes because nobody is going to do the Echo, post graduates maybe be able to do drug refill and they may be able to say, identify that the child is in the heart failure and give heart failure medication but that's as far as they can go, yah.

Interviewer: Okay, Alright, so before we close do you have any other thing you would love to say to us?

Respondent: You as whom?

Interviewer: As acute rheumatic fever study team.

Respondent: I don’t know, I wonder acute rheumatic fever study team, when these things, your study ends, so what's going to happen, do you realise that, yes you have kind of maybe screened many patients, you are giving them review dates and all that, but when the study falls, where are all these patients going to go?

Interviewer: We hope to leave them here in your clinics.

Respondent: So, and that's where the challenge is going to come, you are going to leave many patients who do not have a really structured plan because you are working in a system where you have also come and must have realised the time you are here that you are there but the administration really doesn’t care, yah. They will not say maybe you should get somebody to train and understand what you are doing, or to get somebody to learn the ECG so that when you go maybe you leave the ECG behind or that V scan somebody can be able to use it, they are not, they are not really interested, that means that when you go, everything stops, and that burden that you have created, I think you are going to put a burden that you will not be able to deal with.

Interviewer: (Laughs) so doctor, do you think you can actually in your own capacities try to find out that maybe someone could be trained maybe?

Respondent: I don’t know the issue of training, like I said people do not want to get out of their comfort zone and you can’t get people out of here already they tell you, we have issues of under staffing we have what, so you have three nurses on the ward here, so you have three nurses, you have 100 patients, so whom do you take off to take for training, okay you understand, so that thing that I just keep wondering and okay I think I was going to say it on record (Laughs), but like I said the way this clinic runs it’s based on external funding the echo came from somewhere else, the ECG machine came from somewhere else, the paper came from somewhere else so we tend to depend so much on grants and good will and all that to sustain this, but I don’t know how long it’s going to sustain, there is time when this machines breaks down, you don’t have the machine for like two weeks but then the hospital cannot pay for all that then you have to go and see the ones who gave you the machine tell them that the machine you gave us, died, and we have had this machine I think for six years. yes we have had this machine for six years, so just imagine someone gave you the machine for six years ago and you have to call them again and say by the way the machine broke down so we need money to take it for repair and they tell you, you know lets first go and do a run for you, how much money do you need to repair then you say maybe like we need 1000dollars, that is like 3.7million and you have to go and do a run in their country and collect money and send here. These are things that we need to own up ourselves, but this is a government hospital you cannot make patients pay maybe the owners of the machines don’t want you to make patients pay, so it’s just.. you just do what you can do, when that time comes and people part ways, I don’t know probably will be, or we shall jump that huddle when it comes but the fact is that when I am on leave it closes until I come, yah

Interviewer: Alright doctor, thank you so much for your time, we appreciate.