Latest / Pharmacy Podcast Network / Precision in Practice; Real Stories, Real Results in Integrative Psychiatry | Precision Medicine Pharmacist Podcast

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Precision in Practice; Real Stories, Real Results in Integrative Psychiatry | Precision Medicine Pharmacist Podcast · Pharmacy Podcast Network

0:05
Speaker 1: You are listening to the global network of podcasters dedicated
0:09
Speaker 1: to the pharmacy profession.
0:10
Speaker 2: Welcome to the Pharmacy Podcast Network.
0:27
Speaker 1: Welcome back to the Pharmacist podcast Network. The Precision Medicine Pharmacist.
0:32
Speaker 1: In part one of our series Precision Psychiatry and Practice,
0:35
Speaker 1: a Pharmacist physician Collaboration, we explored how a collaborative approach
0:40
Speaker 1: can begin to reshape psychiatric care, building trust, aligning perspectives,
0:45
Speaker 1: and creating space for more personalized treatment. Today, we move
0:49
Speaker 1: deeper into what looks like real world integrative medicine incorporated
0:53
Speaker 1: into psychiatry. I'm excited to welcome back Saba our shot
0:58
Speaker 1: joined by doctor Kahn, as we explore their partnership and
1:02
Speaker 1: how it brings together different clinical perspectives to care for
1:05
Speaker 1: the whole patient, not just the symptoms, but a broader
1:09
Speaker 1: context of mental health, lifestyle, and individualized needs. In this episode,
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Speaker 1: Precision and Practice, Real Stories, Real Results, and Integrative Psychiatry
1:19
Speaker 1: will focus on the human side of collaboration. How do
1:22
Speaker 1: two clinicians with different training and strengths come together to
1:25
Speaker 1: approach complex cases, What does shared decision making really look
1:30
Speaker 1: like in practice? And how does integrate a model shape
1:34
Speaker 1: a better patient outcome with their patients. We'll walk through
1:38
Speaker 1: real patient cases, explore the dynamics of their collaboration, and
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Speaker 1: uncover how this partnership continues to evolve to meet patients
1:45
Speaker 1: where they are. If Part one introduce the foundation, today's
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Speaker 1: episode brings that collaboration to life, let's dive in together.
1:58
Speaker 1: All right, welcome back to our podcast series. For episode two,
2:03
Speaker 1: I would love for both my guests today to just
2:06
Speaker 1: kind of give a brief introduction to themselves that way
2:08
Speaker 1: you can get to know them a little bit more deeply.
2:12
Speaker 1: I'm going to start today with doctor Con if you
2:14
Speaker 1: wouldn't mind introducing yourself and just give us some background
2:17
Speaker 1: about your practice, and then we'll go back into reintroducing
2:21
Speaker 1: doctor Arshad as well.
2:23
Speaker 3: Hey, I'm dot Con. I'm an adult inchel psychiatrist. I've
2:27
Speaker 3: been in practice about fifteen years, ten years in private practice,
2:32
Speaker 3: and I also do a lot of integrative, holistic approaches
2:35
Speaker 3: to my practice and how I treat patients, and even
2:39
Speaker 3: more lately, I've been doing a lot more of precision
2:42
Speaker 3: medicine partnerships to bring in more of an individualized treatment
2:47
Speaker 3: approaches to my treatment care for my patients.
2:51
Speaker 1: Oh love that. Thank you so much for sharing that,
2:54
Speaker 1: and then that whole integration of precision medicine comes from.
3:00
Speaker 1: So Saba, please give us a reintroduction for those of
3:03
Speaker 1: you who haven't listened in on our first part of
3:05
Speaker 1: the series. For reintroducing now sure Hello everyone.
3:09
Speaker 4: My name is Samarshad. Thank you for having us again
3:12
Speaker 4: Melissa for this part too. I am a pharmacist and
3:16
Speaker 4: founder of my DNA Health. I have been practicing for
3:19
Speaker 4: over a decade, but I've been practicing Texas for about
3:22
Speaker 4: six years and my focus has always been not just
3:26
Speaker 4: formaca genomics, but looking at my pageent from a whole
3:30
Speaker 4: person perspective. And I'm so excited to discuss how we
3:37
Speaker 4: collaborated with doctor con and I hope you find it helpful.
3:42
Speaker 1: I'm certain that our audience will definitely find this helpful
3:45
Speaker 1: because there's it really has been more observed in the
3:50
Speaker 1: psychiatric space to really dive into more approaches to treatment
3:58
Speaker 1: and really allow for it to be unique to the
4:01
Speaker 1: patient and meet them at where there needs need to
4:04
Speaker 1: be mad Right, So I would like for you guys
4:06
Speaker 1: just to kind of give us an idea of what
4:09
Speaker 1: integrative psychiatry is, what holistic psychiatry looks like as far
4:13
Speaker 1: as a perspective from you both.
4:15
Speaker 3: I'm going to go first and I'll tell you a
4:17
Speaker 3: little more of where I believe it's more holistic.
4:19
Speaker 5: Right.
4:19
Speaker 3: For a long time, medicine has had a lot of data,
4:23
Speaker 3: especially internal medicine surgery, psychiatry is lagged behind in having
4:28
Speaker 3: that kind of data driven approach to treatment plans. Lately,
4:32
Speaker 3: we are kind of evolving in some ways in psychiatry
4:35
Speaker 3: to kind of look at things that we can support
4:38
Speaker 3: our patients and be more individualized, more resourceful in terms
4:42
Speaker 3: of AMI. I kind of use this common platform of
4:45
Speaker 3: saying treatment could be a pie thirty percent medication, thirty
4:48
Speaker 3: percent therapy, thirty percent environment and ten persons. Have my
4:51
Speaker 3: patient do the work. And when you kind of make
4:54
Speaker 3: it that individualized, then you look at what are the
4:56
Speaker 3: other holistic approaches that they can add in their life
4:59
Speaker 3: in terms of their environment, sleep, appetite. We all know
5:03
Speaker 3: lifestyle changes that are a big part of how you
5:05
Speaker 3: approach health. So that to me itself, sort of being individualized,
5:10
Speaker 3: being more holistic and seeing a whole body perspective than
5:13
Speaker 3: just seeing here is your symptom and year is the medication.
5:17
Speaker 3: So that's what I seem to call more of that
5:20
Speaker 3: holistic or integrative approach.
5:23
Speaker 1: Love that, and I have an interesting statistic around it.
5:28
Speaker 1: I found one saying that approximately thirty to fifty percent
5:31
Speaker 1: of patients with mental health conditions use some form of
5:34
Speaker 1: complementary or integrative therapy alongside their conventional care. So in general,
5:39
Speaker 1: it's definitely becoming way more common to utilize, and patients
5:43
Speaker 1: are really just looking for better when it comes to
5:47
Speaker 1: treatment for mental health. They're not always wanting to go
5:50
Speaker 1: on the medications first. Right, There's things that you need
5:53
Speaker 1: to do nutritionally, sleep management you were talking about, and
5:57
Speaker 1: you work with a lot of you said, adolescents because
6:00
Speaker 1: you're in child psychology, so I know a lot of
6:04
Speaker 1: the listening audience would love some better perspective with their
6:08
Speaker 1: own kids, especially when we're thinking about ADHD management autism.
6:13
Speaker 1: There's all sorts of things that can be addressed prior
6:17
Speaker 1: to even introducing the thought of medications.
6:19
Speaker 6: Right, that's right.
6:22
Speaker 3: I mean, if you mentioned ADHD, the way we approach ADHDS,
6:27
Speaker 3: we sort of start determining who needs to be on
6:30
Speaker 3: meds and who doesn't need to be on meds based
6:32
Speaker 3: on what the dysfunctionality looks like. And if you can
6:35
Speaker 3: have our kids, younger kids POPULAHED and do a lot
6:38
Speaker 3: more occupational therapy that's a way of building a sensory
6:41
Speaker 3: system and be part of that to build your brain systems,
6:44
Speaker 3: then maybe we can kind of approach it in a
6:46
Speaker 3: different way, just not with medication.
6:49
Speaker 6: We offer parent and child workshops, so.
6:52
Speaker 3: The parent needs to learn a little bit more about
6:54
Speaker 3: ADHD and how to kind of do that parenting with
6:57
Speaker 3: an ADHD kid, and then the ADHDK it gets to
7:00
Speaker 3: understand it ADHD a little more and see how they
7:03
Speaker 3: can build executive skills. So that's part of indicative approach
7:08
Speaker 3: we have for ADHD kids.
7:10
Speaker 1: Oh, you're speaking to my soul right there. I have
7:14
Speaker 1: a little guy, my son, he's ADHD, and I look
7:18
Speaker 1: for all ways before introducing any kind of medication with him.
7:22
Speaker 1: I'm doing all the things, so whether it be supplemental wise,
7:27
Speaker 1: fleet management, occupational therapies, those types of things. He has
7:31
Speaker 1: support at school and he's doing very well. So I've
7:35
Speaker 1: actually been very pleased with not having to even introduce
7:38
Speaker 1: medication with him just yet. But I know that there
7:43
Speaker 1: are times where it comes to that and I'm wondering
7:45
Speaker 1: kind of what your approach is when you think about
7:48
Speaker 1: determining the medications at that point, and how you incorporate
7:53
Speaker 1: SAVA into that whole relationship too.
7:57
Speaker 3: So you know, like I said, it's the level of dysfunctionality,
8:01
Speaker 3: and what defines the level of dysfunctionality is how far
8:05
Speaker 3: you're in trouble at school and at home. If it
8:09
Speaker 3: gets for me, as a child developmental expert, I say,
8:13
Speaker 3: self esteem is elementary school work.
8:16
Speaker 6: That's where all your self esteem gets developed.
8:18
Speaker 3: Who you are, who loves me, who does not love me,
8:22
Speaker 3: how much trouble I am, who's watching me, and all
8:24
Speaker 3: of that stuff. So for an ADHD kid who's constantly
8:27
Speaker 3: not sitting in a chair, being told to do the
8:30
Speaker 3: right thing, reminded multiple times, failing at directions is already
8:34
Speaker 3: affecting this self esteem, and then medication comes in if
8:38
Speaker 3: that dysfunctionality and that effect is lasting enough, that is
8:41
Speaker 3: affecting self esteem, affecting how he performs at school, he
8:45
Speaker 3: or she performs.
8:46
Speaker 6: At school, and where.
8:48
Speaker 3: They're doing with that depends on why we kind of
8:51
Speaker 3: decide medication be an answer, and when we kind of
8:54
Speaker 3: have approached all the other alternative therapies that I call
8:58
Speaker 3: like doing the parenting part the kids some tools and skills,
9:02
Speaker 3: getting to do occupational therapy, finding out more of a
9:05
Speaker 3: movement in.
9:06
Speaker 6: His life by doing martial arts.
9:08
Speaker 3: So we used to kind of spend that energy out
9:10
Speaker 3: what would that look like, and then we sort of
9:13
Speaker 3: end up deciding medication, and if medication becomes a part,
9:16
Speaker 3: then we start getting Most often if it's more of
9:20
Speaker 3: a complicated kid who has other multimerical comorbidities, that's when
9:24
Speaker 3: we sort of start looking into precision medicine. But more
9:28
Speaker 3: often we approach it with a very simplified as small
9:32
Speaker 3: those short access medications, and even if it is not
9:35
Speaker 3: as stimulant, it can be a non stimulant based on
9:38
Speaker 3: the age, weight and height and what that looks like.
9:40
Speaker 6: We make a decision.
9:44
Speaker 3: But if insteed in VALSABA, it would be really kind
9:46
Speaker 3: of doing a former genomics test and figure out what
9:50
Speaker 3: and that for a long time was not on the
9:52
Speaker 3: panel and now it's on the panel.
9:55
Speaker 6: So I don't think got something.
10:00
Speaker 1: Do you proactively test the Are you implementing the PGX
10:05
Speaker 1: testing right off the bats? That way, it's already done
10:08
Speaker 1: that way, you do need to integrate that or do
10:11
Speaker 1: you more kind of wait until it's determined that we're
10:14
Speaker 1: ready to move forward with that.
10:17
Speaker 3: So the cost effectiveness of PGX testing is always what
10:21
Speaker 3: determines if people are ready to get that done or not.
10:24
Speaker 3: Although insurance covers in a lot of cases, sometimes it
10:27
Speaker 3: does not. That kind of makes a huge part of
10:31
Speaker 3: do we really put it out there first? We do
10:34
Speaker 3: offer this to all our patients and say, hey, this
10:37
Speaker 3: is a good approach to stored with the limited evidence
10:40
Speaker 3: it has about the final end results, this might help
10:43
Speaker 3: us not have failed trials. Some parents are ready for
10:46
Speaker 3: the trial wanting to kind of spend that money and
10:49
Speaker 3: do it, and some parents and I actually have people
10:51
Speaker 3: come in because I do a lot of PGX testing
10:55
Speaker 3: compared to most of my peers in the community.
11:00
Speaker 6: So I get referrals because people say.
11:02
Speaker 3: Hey, here is her approach, and so I get a
11:05
Speaker 3: lot of refuls based on that too.
11:08
Speaker 1: And just out of your professional opinions, since you're utilizing it,
11:11
Speaker 1: how helpful do you find it? And oftentimes does it
11:14
Speaker 1: help really to determine things for you?
11:16
Speaker 3: So I wouldn't say particularly in ADHD cases, because sometimes
11:21
Speaker 3: you know, my thought on PGX testing is it helped
11:24
Speaker 3: with the pharmacokinetics and not the pharmacodynamics of it, so
11:27
Speaker 3: I can say the medication efficacy based on it. I
11:30
Speaker 3: can only say what somebody can tolerate and how can
11:33
Speaker 3: I avoid the side effects and high dosing or.
11:35
Speaker 6: Low dosing it. I often tend to use it.
11:38
Speaker 3: In my depression patients, my anxiety patients because that is
11:44
Speaker 3: a good way of looking at it. It's simplified, and
11:48
Speaker 3: the more we are data driven, the more people like
11:50
Speaker 3: to see it in red, yellow, and green blocks to
11:54
Speaker 3: understand it better. So for me, the use is more
11:58
Speaker 3: based on compliance because I think if you have more
12:02
Speaker 3: data to believe, if I had to walk more steps
12:05
Speaker 3: and I can see how those steps look like, it
12:09
Speaker 3: motivates me to be able to take it, or motivates
12:12
Speaker 3: me to kind of be compliant with it. So that's
12:16
Speaker 3: what is more of a value to PGX testing in
12:19
Speaker 3: my practice.
12:23
Speaker 1: SABA, have you had a lot of experience with just
12:27
Speaker 1: kind of helping to implement that on a larger scale,
12:30
Speaker 1: especially with the more complex patients.
12:33
Speaker 4: Yespecially with the same pharmacause genomics. You know, that's the
12:38
Speaker 4: same approach, you know, the same integrative approach. Whoever comes
12:41
Speaker 4: in it's not like I'm going to just order a
12:44
Speaker 4: test for them. Whenever we are doing wage industry is
12:47
Speaker 4: we have to determine the same thing, the cost effectiveness
12:49
Speaker 4: and does it really work for them based on whatever
12:52
Speaker 4: conditions or whatever diagnosis they have, especially in complex cases. Yes,
12:57
Speaker 4: it does help because there are a lot of drug
13:00
Speaker 4: drug interaction.
13:00
Speaker 5: There a lot of drug gene interactions.
13:02
Speaker 4: There are a lot of Unfortunately, every time I meet
13:06
Speaker 4: the patient, although it's like a follow up, I get
13:09
Speaker 4: to know more about them that they did not disclose
13:11
Speaker 4: in the first one, and then you understand, Okay, that's
13:13
Speaker 4: what them is, that's what them miss. So unfortunately, you
13:16
Speaker 4: know it least thirty percent of a US population takes
13:19
Speaker 4: three or more medications.
13:21
Speaker 5: And at least nine to ninety eight person of a
13:23
Speaker 5: population they do.
13:24
Speaker 4: Have a pharmacogenetic variant that could be actionable based on
13:28
Speaker 4: whatever evidence we have. So whatever, when I work with
13:32
Speaker 4: doctor Khn when we started at old Her, you know,
13:34
Speaker 4: I'm not going to go off like different labs, and
13:37
Speaker 4: I don't work with all of different labs.
13:39
Speaker 5: I work with ones that have validated gene panels.
13:42
Speaker 4: I'm not going to go with one that are testing
13:44
Speaker 4: like fifty genes because we don't have.
13:46
Speaker 5: Evidence for it.
13:47
Speaker 4: So told her was, when you work with me anything,
13:50
Speaker 4: any recommendation I put out on a paper that will
13:53
Speaker 4: be backed up by evidence, that would be EFT and
13:55
Speaker 4: Seapeck and me being a SEAPEG member has helped me
13:58
Speaker 4: to look I think the different, very different perspective because
14:02
Speaker 4: how we are included in all kinds of guidelines and
14:05
Speaker 4: all of these are being actively implemented at MIO Clinic
14:09
Speaker 4: and Saint Jude's and so many other research hospitals all
14:13
Speaker 4: over the country.
14:15
Speaker 5: So yes, I.
14:17
Speaker 4: Definitely agree we're talking about more complex cases. There's sometimes
14:21
Speaker 4: there are parents the same thing with ADHD. That's what
14:23
Speaker 4: we have seen because when I look at the pision population,
14:27
Speaker 4: it could range from early twenties to probably seventy eighties.
14:32
Speaker 5: In that range. So most of the times what I
14:34
Speaker 5: see is the same thing.
14:37
Speaker 4: With a lot of Doctor concaid and I love our approach,
14:41
Speaker 4: and that was one of the reasons I've both of
14:43
Speaker 4: us decided that it would be good for us to collaborate.
14:46
Speaker 4: A lot of the providers are using a very famous
14:49
Speaker 4: test out there and they would just look at the
14:52
Speaker 4: colors and just decide what is good for the patient,
14:56
Speaker 4: but not actually looking at the symptoms. And whenever we
14:59
Speaker 4: had conversation, you know, you should not be just looking
15:02
Speaker 4: even though the medication is probably in the yellow part
15:04
Speaker 4: or the red part as they would like to call it.
15:07
Speaker 4: So but we can always use those medications. We just
15:10
Speaker 4: need more monitoring for that patient.
15:13
Speaker 5: So so those.
15:14
Speaker 4: Are the things and what I loved about doctor Can's
15:16
Speaker 4: approach was, you know, she's always willing to give it
15:18
Speaker 4: a try and anything that works.
15:20
Speaker 5: She's always whatever recommendations I put out, I do give.
15:23
Speaker 4: My rationale and and I welcome any questions she has,
15:27
Speaker 4: and then we tape her based on you know, on
15:30
Speaker 4: the patient symptoms and what is there's one patient case
15:34
Speaker 4: that I would like to discuss as we go ahead
15:36
Speaker 4: in a discussion and yeah, and that would just you know,
15:39
Speaker 4: help listeners and everyone to understand how we both work
15:43
Speaker 4: and how we both kind of collaborate to basically improve
15:49
Speaker 4: patient treatment clinical outcomes.
15:52
Speaker 3: So yeah, I know, I mean that is interesting that
15:54
Speaker 3: by saying that, that is where while you take insurance,
15:58
Speaker 3: you're limited by the amount of time you have that
16:01
Speaker 3: you can really spend. Some times, even with non insurance
16:03
Speaker 3: patients there's so much you can cover in an appointment,
16:07
Speaker 3: which includes talking about your symptoms, really kind of doing
16:10
Speaker 3: the education part, explaining them lifestyle changes and all of this,
16:15
Speaker 3: and times, like Saba said, they miss out telling us information,
16:19
Speaker 3: they forget to put their.
16:21
Speaker 6: Labs in all together.
16:22
Speaker 3: And there's so much a doctor can sit alone and
16:24
Speaker 3: try to do it. And where I use Saba is, hey,
16:27
Speaker 3: this is a complex case, is on multiple meds. I
16:31
Speaker 3: do want you to kind of please look at this
16:33
Speaker 3: and review some of those things and give me a feedback.
16:35
Speaker 3: So it's all of this information that Saba takes in,
16:39
Speaker 3: spends a lot of time with them and gathers it
16:42
Speaker 3: and makes it comprehensive and precise for me to be
16:45
Speaker 3: more individualized with the achievement, And that itself is such
16:49
Speaker 3: a big benefit because I'm not thinking about reviewing that
16:52
Speaker 3: even if I ordered a PGX test, I'm not often
16:54
Speaker 3: sitting down with the same amount of time that Sabah
16:57
Speaker 3: would spend on explaining how those medications work in their
17:00
Speaker 3: body and how they interact with other meds. So now
17:03
Speaker 3: not only have I given this patient of precision individualized
17:07
Speaker 3: treatment option, I've also given this person a little more
17:10
Speaker 3: compliance opportunity, because you know, in psychiatry, the biggest struggle
17:14
Speaker 3: is not the meds, is a compliance in so many ways.
17:17
Speaker 3: People if they do not trust and believe in the medication,
17:19
Speaker 3: they're not going to take it. And if they not
17:21
Speaker 3: only hear from their doctor, they also hear from a
17:23
Speaker 3: pharmacist has reviewed all of those medications, the labs, the interactions.
17:30
Speaker 3: There's a lot more improvemented compliance with medication.
17:33
Speaker 1: Oh yes, And that's something I really want to highlight
17:36
Speaker 1: right here, is the emphasis on you having your own
17:40
Speaker 1: personal medication advocate within the practice that you can lean
17:44
Speaker 1: on to really dive deeply, because you're right, you are
17:47
Speaker 1: time constrained when you're visiting with these patients. There's only
17:49
Speaker 1: so much time that assurance insurance allows for for you
17:52
Speaker 1: to build for and that subsequently leaves you with less
17:56
Speaker 1: time being able to dive deeply into what some of
17:59
Speaker 1: these results can show. So I love that you have
18:02
Speaker 1: adopted this within your own practice, and I wish more
18:05
Speaker 1: practitioners would entertain this idea because this is time saving
18:10
Speaker 1: for you, this is patient safety, this is being more
18:12
Speaker 1: accurate with selection. I mean, I love this, So I'm
18:16
Speaker 1: so happy that I get to share this, I don't
18:19
Speaker 1: want it to be necessarily it's a unique relationship. I've
18:23
Speaker 1: wanted to be more prevalent all over. So that's why
18:25
Speaker 1: I want to share this with more practitioners where they
18:29
Speaker 1: see the utility of a pharmacist in their practice and
18:32
Speaker 1: how it can benefit them really support you and just
18:35
Speaker 1: lessen your burden in your load. And Sabo mentioned that
18:41
Speaker 1: you guys want to talk about a real patient case.
18:43
Speaker 1: So I would love to dive in right now into
18:46
Speaker 1: a patient case with you guys that you've been able
18:48
Speaker 1: to work through together and just kind of give me
18:51
Speaker 1: the details I want to hear about it.
18:53
Speaker 4: So this patient, I think we started collaborating in November,
18:57
Speaker 4: I believe doctor con and that was.
18:59
Speaker 5: A first patient. So let's say she's her.
19:04
Speaker 4: Name is Aby, a fifty four year old women and
19:09
Speaker 4: she was on multiple medications and the reason she came
19:11
Speaker 4: was the doctor carnt Refford was a polypharmacy. That was
19:15
Speaker 4: the biggest one because there were a lot of medications involved.
19:18
Speaker 4: So I'll talk mainly about the ones that we were
19:21
Speaker 4: able to change because they were there were a lot
19:23
Speaker 4: of them. The biggest one was she was on and yes,
19:27
Speaker 4: and she had generalized anxiety disorder.
19:30
Speaker 5: That was the biggest one.
19:31
Speaker 4: Plus other ones that I don't think it would help
19:34
Speaker 4: in discussion. So the ones that were were she was
19:38
Speaker 4: on a not trip pullin that was ten milligrams. She
19:40
Speaker 4: was taking it three times a day. Then she was
19:42
Speaker 4: an ambient.
19:43
Speaker 5: On extended release formulation.
19:44
Speaker 4: She was on metazapine, the extended release form because she
19:48
Speaker 4: had been probably saying.
19:49
Speaker 5: A lot of.
19:51
Speaker 4: A couple of psychiatrists through her to like to her lifetime,
19:54
Speaker 4: and then probably a couple of months back she started
19:57
Speaker 4: the doctor Khan and that's what I was able to get.
20:00
Speaker 4: Then she was also she was also on by oxidil
20:03
Speaker 4: and other kind of medications on weight loss medications that
20:08
Speaker 4: was Munjaro.
20:09
Speaker 5: She has been on a tesla for a while.
20:11
Speaker 4: She has also been using xanax that's one milligram three
20:16
Speaker 4: times a day or depending upon how she feels, like
20:18
Speaker 4: four milligrams per day, as well, also taking benadryl that's
20:22
Speaker 4: one hundred milligrams every night at bedtime. These were the
20:27
Speaker 4: basic ones, and yeah, then there were they were also
20:32
Speaker 4: on prapatha for a while and they have been like
20:36
Speaker 4: continuously using it, yes, yeah, and opin yes yeah, and
20:39
Speaker 4: cataphin as.
20:40
Speaker 5: Well, so they were on yes.
20:43
Speaker 4: So now I think she was She's on probably one
20:45
Speaker 4: hundred milligrams qhs. That's that's the recent one. Yes, yeah,
20:49
Speaker 4: that's the biggest one.
20:50
Speaker 5: And there was yes, yeah, we did Yeah.
20:54
Speaker 4: It was also ambient extended release. And what we did
20:58
Speaker 4: was yes, yeah.
20:58
Speaker 5: And what we did was we got her PTX test.
21:02
Speaker 4: It was interesting me, Lissa, let me, I do have
21:04
Speaker 4: everything here, so I don't mix anyone. So what it
21:08
Speaker 4: came out were her SIP to these sex Because at
21:10
Speaker 4: least twenty five percent of the medications, not just depressions,
21:14
Speaker 4: like beta blockers other antipsychotics, they do break down. It's
21:18
Speaker 4: not just the only chain, but it.
21:20
Speaker 5: Plays a major role, as you know. Right.
21:22
Speaker 4: So she was a pumatabolizer because due to a copy
21:25
Speaker 4: number variation. So that was another thing because most of
21:28
Speaker 4: the labs would not classify patients based on whatever, you know,
21:33
Speaker 4: what their genotype comes out. So that's why I love
21:36
Speaker 4: the lab that I work with. I can just reach
21:39
Speaker 4: out to them and just ask them, can you tell
21:41
Speaker 4: me how many copy number variations does the patient have
21:44
Speaker 4: or how would you think could be classified the patient?
21:48
Speaker 5: Right?
21:48
Speaker 4: And that's big most of the lab would just hand
21:51
Speaker 4: you and just tell you, okay, we can't just classify, which.
21:54
Speaker 5: Is the part.
21:55
Speaker 1: Yeah, it's difficult for when you're trying to identify penal
21:58
Speaker 1: conversion potential, especially with twod sex.
22:01
Speaker 4: Yes, and she was so she was a poor metabolizer.
22:04
Speaker 4: She was okay for two C one nine she was
22:07
Speaker 4: a normal metabolizer.
22:08
Speaker 5: Three or four was okay.
22:09
Speaker 4: Her two C nine she was an intermediate and two
22:13
Speaker 4: B six was normal metabolizer. So for most of what
22:16
Speaker 4: the basic thing to just keep it smaller. What we
22:19
Speaker 4: did was since she was a poor metabolizer for twy sex,
22:22
Speaker 4: what I did there were a couple of recommendations that
22:24
Speaker 4: had to keep it smaller for doctor Carnts so it's
22:27
Speaker 4: easier for her to review with the patients. So we yes, yeah,
22:31
Speaker 4: So what we did was I recommended to tape her
22:33
Speaker 4: down not triculine, and then doctor can she did a
22:36
Speaker 4: great job in tapering her off. It took a couple
22:39
Speaker 4: of weeks and now she's totally off. She also we
22:43
Speaker 4: tapered off her on metazipin odit she was eventually she
22:47
Speaker 4: just stopped. And an interesting thing was for the od
22:51
Speaker 4: ts and orally and disintegrating tablet.
22:54
Speaker 5: She was just taking it just like just with water,
22:57
Speaker 5: just as a tablet.
22:58
Speaker 1: So small, not allowing it.
23:01
Speaker 4: Okay, yeah, so that would Those were a few things
23:03
Speaker 4: we talked about, but doctor Khan was able to taper
23:06
Speaker 4: off those. Then we were able to stop her ambient.
23:11
Speaker 4: That was a couple of months back.
23:14
Speaker 1: Yes, she's amazing that.
23:16
Speaker 4: Then we finally convinced her to both of us, I
23:19
Speaker 4: would say, because she sees her doctor con every week
23:22
Speaker 4: and I think that kind of reinforces a lot of stuff.
23:25
Speaker 4: So we were able to take her off her weight
23:27
Speaker 4: loss medication because taking it once a month, because they
23:31
Speaker 4: have to be taking them consistently, so the concentration builds up, right,
23:35
Speaker 4: So finally she decided, okay, I'm gonna take it, and
23:39
Speaker 4: eventually she tapered off that as well.
23:43
Speaker 5: And currently there are a few challenges, but we are
23:46
Speaker 5: trying to still get her off her.
23:50
Speaker 4: Exex and some of the other medications that because there
23:53
Speaker 4: are the stressors in their life. So the best thing
23:56
Speaker 4: is we tried to take her off whatever we could,
23:59
Speaker 4: but with doctor cons you know, enforcement every week.
24:04
Speaker 5: So she has been doing a great job with her sessions.
24:07
Speaker 4: And still we but we do struggle with some of
24:10
Speaker 4: them and that will probably try to overcome the next
24:14
Speaker 4: coming months, hopefully as things kind of streamline in her life,
24:19
Speaker 4: so hopefully those things will also.
24:21
Speaker 5: But the best thing with this pasion, at least they're honest.
24:24
Speaker 5: So when I talk to them they do stop these
24:26
Speaker 5: that they do stop these, you will like, no, this
24:28
Speaker 5: is what is happening. So I can't just stop it
24:30
Speaker 5: right now.
24:31
Speaker 4: So the best thing is to actually acknowledge where the
24:34
Speaker 4: patient is and meet them or meet meet their goals.
24:37
Speaker 5: Where there are, where they're at.
24:39
Speaker 4: We're not just trying to push her to do something,
24:41
Speaker 4: but we're trying to take off things that we can
24:45
Speaker 4: or what is easier for her.
24:46
Speaker 5: And yes, if that helps.
24:49
Speaker 1: Huge improvement though, I got to say, I mean a
24:52
Speaker 1: lot of those medications I would think would bring some
24:55
Speaker 1: clarity and bring her out of a fog where she
24:58
Speaker 1: can do the work with doctor Cohn right in sessions,
25:03
Speaker 1: where she can actually start working on the things that
25:06
Speaker 1: are provoking the use of the medications. Right.
25:09
Speaker 3: I think she's a very brave patient right because to
25:11
Speaker 3: have that honesty and if you've had providers and multiple
25:15
Speaker 3: providers sometimes giving you different descriptions, and our clinic is
25:20
Speaker 3: very benzo opposed.
25:22
Speaker 6: I put that out really is.
25:23
Speaker 3: Benzos have a role, but it has a very short
25:26
Speaker 3: term role. But when patients are given by their family
25:29
Speaker 3: practitioners and things that they've been on it for years,
25:32
Speaker 3: it really is ineffective, but they are not able to
25:36
Speaker 3: give up on it because that's what keeps them going
25:38
Speaker 3: in a way. So having them to kind of engage
25:40
Speaker 3: in this what are we doing? Are we crippling you
25:44
Speaker 3: towards dementia or something when you're bogging you with all
25:48
Speaker 3: of these sleep aids, these benzos, multiple quali pharmacy, and
25:53
Speaker 3: I think sometimes it's hard to sort of just do
25:55
Speaker 3: it without you can tell this all day long, but
25:59
Speaker 3: if you have some that the patients can see. And
26:01
Speaker 3: had the conversation there was cigarettes smoking that was also
26:05
Speaker 3: affecting in her case, and how that interacted and how
26:09
Speaker 3: all of that pharmacrocnnectics played with all.
26:11
Speaker 1: Oh yes one A two activity, it can rapidly increase
26:16
Speaker 1: the metabolism of that, especially when we're thinking about psychiatry
26:19
Speaker 1: meds and psychotic therapies for sure, and if that was
26:24
Speaker 1: the case, she probably was seeing some reduced effectiveness with
26:27
Speaker 1: certain things in her life, if it was being utilized,
26:30
Speaker 1: if they're smoking consistently. That's something that people don't even
26:33
Speaker 1: think about, is the environmental factors that have an impact
26:36
Speaker 1: on these medications and how they metabolize in the body too.
26:41
Speaker 1: And the other one that was interesting is doctor kN
26:44
Speaker 1: I have a question about the GLP ones in terms
26:47
Speaker 1: of when patients are utilizing it and the mental health impact.
26:50
Speaker 1: Have you seen a lot of patients just having a
26:54
Speaker 1: rough go at it when they are on either the
26:56
Speaker 1: higher dosages or on long periods of time, because it
26:59
Speaker 1: can really that's with the gut microbiome, So I didn't
27:02
Speaker 1: know if that's something that you think about.
27:04
Speaker 3: You know, a lot of evidence is yet to be
27:08
Speaker 3: found on these medications and drugs, but as of now,
27:13
Speaker 3: there is room for some of that for kids who
27:15
Speaker 3: are actually having side effects with antipsychotics, especially the second
27:20
Speaker 3: generation antipsychotics, which seem to be very effective. But the
27:23
Speaker 3: weight gain is a problem, so we tend we tend
27:26
Speaker 3: to recognize that and talk about it. Nutrition is a
27:29
Speaker 3: big part of how your brain functions, So if you're
27:32
Speaker 3: not eating and what are you providing your body with,
27:37
Speaker 3: So certainly I think there's a lot more room to
27:39
Speaker 3: talk about it in so many ways. So there are benefits,
27:42
Speaker 3: but there are also so many cons with how it
27:44
Speaker 3: affects your gut microbium and what you're doing about it.
27:47
Speaker 1: Yeah, for sure. Well, I love that you guys were
27:51
Speaker 1: able to collaborate one another, really dive deeply into those
27:56
Speaker 1: medications for that patient and really just get them to
27:59
Speaker 1: a point where they're not on what was the total
28:02
Speaker 1: of medications? Was it more at well, anything more than
28:06
Speaker 1: seven medications or five medications with polypharmacy, So if we
28:09
Speaker 1: can get them more to that area, that would be great.
28:13
Speaker 3: I mean, if we've been able to drop one to
28:16
Speaker 3: three medications.
28:17
Speaker 6: Right off four, I know GLP one is that.
28:21
Speaker 3: Is motivation from the patient, the collaborative care that we've
28:25
Speaker 3: done to be able to drop four meds. And I
28:27
Speaker 3: remember being here in therapy session and she brought this
28:30
Speaker 3: whole bag of meds. It was big cathartic for her
28:32
Speaker 3: to say, I am going to drop this at pharmacy,
28:34
Speaker 3: and I'm so excited to drop all of this.
28:36
Speaker 2: So yeah, I'm sure I'm liberating, Yes, because after a while,
28:42
Speaker 2: when you when you're relying upon the medications, I don't
28:45
Speaker 2: like to say they're like a crutch or just like
28:47
Speaker 2: habitual sometimes, you know, like with patients with PPIs taking
28:51
Speaker 2: proton pump inhibitors, they just take them because it's just
28:54
Speaker 2: part of their daily routine and they may not even
28:56
Speaker 2: necessarily need to be on them anymore.
28:58
Speaker 1: Especially with You're right, it has to do with the
29:01
Speaker 1: patient and their openness to be able to do these things,
29:04
Speaker 1: because then their their mental mind shift is a lot
29:06
Speaker 1: easier to work with. I find.
29:09
Speaker 3: So that comes in, right, That's what testing comes in
29:14
Speaker 3: in a way of yes, you're not ready to listen
29:16
Speaker 3: to me, but here it is some data for you
29:18
Speaker 3: to review, and here's somebody will explain this data to
29:21
Speaker 3: you so you can actually follow through and understand this better.
29:25
Speaker 5: Oh definitely, that's true.
29:27
Speaker 4: And just a little like my two senses, I think
29:31
Speaker 4: a patient feels comfortable when the clinician is willing to
29:35
Speaker 4: not judge them and are actually willing to listen. I
29:38
Speaker 4: think that that's another thing. If doctor con would have judged,
29:42
Speaker 4: you know, just still she kept on prescribing them multiple medications,
29:46
Speaker 4: then she would have she would have ended up in
29:48
Speaker 4: the same way that she was in the last.
29:49
Speaker 5: Couple of years.
29:50
Speaker 4: So I think a lot has to do with clinicians
29:53
Speaker 4: not judging and actually listening to what the patient is saying. Yeah,
29:57
Speaker 4: it might not be it not be a lot of
30:00
Speaker 4: evidence to everything, but at least clinicians who are willing
30:03
Speaker 4: to go a little bit deeper.
30:05
Speaker 5: I think that's what that is what makes it difference.
30:09
Speaker 1: And that's why the relationship with a pharmacist is so
30:12
Speaker 1: important because you can break down that information for them
30:15
Speaker 1: because there is a stigma around pharmacogenomics and there are
30:19
Speaker 1: a lot of laboratories that test for genes that don't
30:21
Speaker 1: have high levels of evidence. I agree with you there,
30:24
Speaker 1: and that's where it deters a lot of them from
30:26
Speaker 1: utilizing it. But also the sheer, overwhelming information that comes
30:32
Speaker 1: on these reports. So for me, it's so crucial as
30:36
Speaker 1: a pharmacist whenever I'm interacting with any provider, when I'm
30:39
Speaker 1: counseling on the results, how they review the information is
30:43
Speaker 1: really just to simplify it and make sure that they
30:46
Speaker 1: feel comfortable with how to digest the information, but also
30:51
Speaker 1: know that they have a resource to come to when
30:54
Speaker 1: they want to more deeply dive into the information, because yeah,
30:57
Speaker 1: we're gonna you're gonna recall kind of the basics of
30:59
Speaker 1: it everything, but being able to have the time is
31:03
Speaker 1: a huge thing, and that's where the pharmacists can really
31:06
Speaker 1: lift that weight for practitioners working in collaboration with one another.
31:11
Speaker 1: So that patient case is a prime example of it
31:16
Speaker 1: being implemented to perfection. So I love that you were
31:22
Speaker 1: able to share that today with us for the audience
31:24
Speaker 1: because it just brings perspective on being able to work
31:28
Speaker 1: in a different way and not look to the Sometimes
31:31
Speaker 1: I feel like when there's interactions with pharmacists and practitioners,
31:36
Speaker 1: it's almost like combative. They feel like we're trying to
31:40
Speaker 1: encroach upon things that they have expertise in and that
31:44
Speaker 1: we're trying to not be helpful, I guess, And that's
31:48
Speaker 1: why I feel like highlighting a relationship like this is
31:52
Speaker 1: so brutal to really more practitioners embracing collaboration with the pharmacist.
32:00
Speaker 1: I'm just happy that you guys are having a good
32:02
Speaker 1: time doing it. I would assume you are.
32:06
Speaker 4: Yes, yeah, And I think that's where you know doctor
32:09
Speaker 4: Kahn's openness and her mindset comes in, and she's not
32:12
Speaker 4: Because I work with a lot of different psychiatrists and
32:14
Speaker 4: primary care providers and function as practitioners. So everyone comes
32:17
Speaker 4: with something but her openness and be willing to work
32:21
Speaker 4: with different things. But that I think that makes so
32:24
Speaker 4: very unique and not all of all the teinicians have it. Yeah,
32:28
Speaker 4: they're very stringent about their mindset.
32:31
Speaker 3: That's just experience in knowing that old models are not
32:34
Speaker 3: working anymore. Yeah, there's a lot of mistressed in the
32:37
Speaker 3: medical community. We all need to collaborate people like data.
32:43
Speaker 3: If we don't move into a different model that keeps
32:45
Speaker 3: our patients more individualized away from side effects compling to
32:49
Speaker 3: their medication, then we all need to collaborate more.
32:52
Speaker 1: Yes, and forgive me, I didn't start our conversation like this,
32:57
Speaker 1: but I wanted to know exactly how you two came
33:02
Speaker 1: together in terms of just working with one another. Did
33:05
Speaker 1: you guys know each other from just from school.
33:07
Speaker 3: Or are you I saw one of the transician friend
33:11
Speaker 3: of mine who had a son in my practice, bring
33:16
Speaker 3: Seba's report to my office, and that's how I got
33:19
Speaker 3: to find out about Sebah.
33:21
Speaker 6: She said, Hey, I want to get my.
33:23
Speaker 3: Kid the best of treatment, and I went to Cuba
33:26
Speaker 3: and had this test done, and then we ended up
33:29
Speaker 3: getting on a phone call, and that's.
33:31
Speaker 6: How I got to know Saba first time.
33:33
Speaker 5: That's true.
33:33
Speaker 1: Yes, yes, patient to see the patient brought it to
33:38
Speaker 1: you and that is a in my opinion, a great
33:41
Speaker 1: way for a door to open when trying to for
33:45
Speaker 1: a pharmacist get kind of getting in with a practice
33:48
Speaker 1: and giving them some awareness around the value add just
33:51
Speaker 1: kind of showcasing that in a medication action plan and
33:55
Speaker 1: giving you some insight into what they see as a
33:58
Speaker 1: perspective for you. I mean, I'm happy that you were
34:01
Speaker 1: open to it, because a lot of practitioners will shy away.
34:05
Speaker 1: So being able to highlight this is crucial for pharmacists
34:10
Speaker 1: to be able to be looked at as a collaborator,
34:13
Speaker 1: appear and truly a tool to help you in these
34:20
Speaker 1: types of situations when we have polypharmacy kind of coming
34:23
Speaker 1: on board, and even just moms. And I can't tell
34:26
Speaker 1: you how many times I've spoken with just parents about
34:29
Speaker 1: their children when it comes to just being terrified of
34:33
Speaker 1: starting medications. So they'll usually come to me to get
34:36
Speaker 1: testing first. And exactly the experience of you guys just
34:39
Speaker 1: meeting each other. It was brought to the psychiatrist, the
34:43
Speaker 1: practitioner prescribing and then that conversation was had and then
34:46
Speaker 1: it just took off from there.
34:47
Speaker 3: So that makes me tell you a random story. Actually
34:51
Speaker 3: it starts with training. Where do you train and how
34:54
Speaker 3: they integrate pharmacists. And this is funny. I trained at
34:57
Speaker 3: uty Southwestern Child Psychiatry Fellowship for to Boston now it's Dell.
35:02
Speaker 3: We had doctor Terrence Smith pharmacists with us surrounding in
35:05
Speaker 3: the mornings on a ink telling us how to interact
35:09
Speaker 3: with medications. So it really kind of it's odd she
35:12
Speaker 3: was doctor Smith too, Yeah, but it is she That's
35:17
Speaker 3: what I learned. She was part of our rounds and
35:19
Speaker 3: she would kind of go through all the meds the kids,
35:21
Speaker 3: and that was just part of the training we had at.
35:24
Speaker 6: You now Dell Med School.
35:28
Speaker 3: So that I think is seeing to be what the
35:32
Speaker 3: at a school level, I feel like it's being more implemented.
35:36
Speaker 1: I went to school in Colorado, but I live in
35:38
Speaker 1: Florida and I got to participate with Kaiser Permanente and
35:44
Speaker 1: that is a preverb provider network where everybody is all
35:47
Speaker 1: under one umbrella. All the practitioners, the pharmacists, the clinical
35:50
Speaker 1: pharmacists are actively working in ambulatory care. So alongside the
35:54
Speaker 1: physicians you were prescribing and making adjustments, So I get
35:59
Speaker 1: what you're saying. It's about training, where you go to
36:02
Speaker 1: school and what you solve yourself in. And older practitioners
36:05
Speaker 1: tend to be the ones a lot more apprehensive because
36:09
Speaker 1: they have their their ways of doing things and years
36:12
Speaker 1: of experience, which I totally get, but I don't want
36:15
Speaker 1: them to feel afraid of utilizing such a tool to
36:19
Speaker 1: just better equip themselves with managing their patients. So this
36:25
Speaker 1: just makes me happy that you guys have had such
36:27
Speaker 1: a great experience so far, and hopefully you guys continue
36:29
Speaker 1: to work with one another. I would see it working
36:32
Speaker 1: that way.
36:34
Speaker 5: That's true.
36:34
Speaker 4: That's true, And I think that the biggest thing is,
36:36
Speaker 4: you know, most of the people when they think of parma,
36:38
Speaker 4: could you know makes it's I think that's how portrad
36:42
Speaker 4: that's how it is portrayed.
36:43
Speaker 5: It. It's not a silver bullet, right.
36:45
Speaker 4: We are using it right at cool Right, there's so
36:47
Speaker 4: many other clinical decisions of what tools we use, So
36:50
Speaker 4: we use it as a tool.
36:52
Speaker 5: Not as something it's going to just come in and just.
36:54
Speaker 4: Change everything, and you wouldation you have to take, so
36:57
Speaker 4: I think said expectations in the right way, and the
37:02
Speaker 4: main thing for the clinicians just telling them what are
37:04
Speaker 4: the limitations, not just the good things, but the bad
37:07
Speaker 4: things and the other limitations that come with anything.
37:10
Speaker 1: M absolutely and really, one last question I have for
37:16
Speaker 1: you both is where do you see integrative psychiatry heading
37:19
Speaker 1: in the future. Do you see stronger collaborations with this
37:23
Speaker 1: integrative model. You guys are kind of pioneering together here,
37:27
Speaker 1: and what really excites you about continuing to work together?
37:34
Speaker 3: You know, the pendulum has swung too far away in
37:37
Speaker 3: integrative approaches in some ways, with all kinds of supplements
37:41
Speaker 3: with no data, non IFD approved, and that worries me
37:46
Speaker 3: more because I have now patients who are really suffering
37:49
Speaker 3: and on forty supplements and do not want to take
37:52
Speaker 3: antidepressants be more beneficial any kind of medication.
37:59
Speaker 6: Versus wanting to take forty supplements.
38:01
Speaker 3: Plus, you don't even know how many of those forty
38:04
Speaker 3: supplements are up to the standards, what kind of yes
38:08
Speaker 3: they have, and so there's no formulary that sort of
38:11
Speaker 3: checks on the quality efficacy of these supplements. I think
38:16
Speaker 3: the more we kind of look at integrative approaches, I'm
38:18
Speaker 3: excited that that actually has been looked into and maybe
38:21
Speaker 3: we'll find a medium ground on what that would look
38:25
Speaker 3: like in terms of, yes, there's more holistic approaches. How
38:28
Speaker 3: are we talking about lifestyle changes? What are we talking
38:31
Speaker 3: about sleep and appetite? Adults with screen times and.
38:36
Speaker 1: Like? So, yes, your sleep habits in general. Are you
38:40
Speaker 1: blaring at TV in your phone in front of your
38:42
Speaker 1: face right before you're going to bed. Yeah, that's going
38:44
Speaker 1: to impact how you've all sleep at night for sure.
38:47
Speaker 3: And then we can take three medications for it and
38:49
Speaker 3: five supplements to hope that that'll fix it.
38:51
Speaker 1: Mm hmmmm hmmm. No, I agree, I agree, but I'm hopeful.
38:55
Speaker 3: I feel like we're talking more about nutrition health, what
38:59
Speaker 3: the supplement it's mean, and which supplement is good for
39:01
Speaker 3: you and which is not, and be more effective with that.
39:05
Speaker 3: So I'm excited about what integrative psychiatry is going as
39:08
Speaker 3: it kind of balance finds this new balance.
39:11
Speaker 1: I'm glad you mentioned about the supplements, because you're right,
39:14
Speaker 1: so many people are trying to supplement themselves to death
39:17
Speaker 1: in hopes of curing things and helping with things. And yes,
39:21
Speaker 1: there's a time and place for certain supplementation. But my
39:24
Speaker 1: philosophy is less is more and being very targeted and
39:30
Speaker 1: very mindful of what you're taking and not just throwing
39:32
Speaker 1: the kitchen sink of supplements at yourself because they could
39:35
Speaker 1: also be causing issues for you. In terms of there
39:39
Speaker 1: is drug or drug interactions with certain things, Saint John's
39:41
Speaker 1: sport great one to bring up because that one does
39:44
Speaker 1: interact with a lot of the interpressants and things like
39:46
Speaker 1: and things of that nature. But also to three four
39:49
Speaker 1: in particular, so that's a big one we always learned
39:51
Speaker 1: in pharmacuy school. But in terms of see here, anything
40:01
Speaker 1: that you're excited about when working with each other Saba
40:03
Speaker 1: before we kind of sign off today.
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Speaker 4: I think I really appreciate her openness and mind us.
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Speaker 4: So I'm excited, do you know, help more people because
40:12
Speaker 4: I know we have so many people who are struggling.
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Speaker 4: So I look forward to working with doctor con on
40:17
Speaker 4: other complex cases so we can come back and tell
40:20
Speaker 4: you how many patients so that we were able to help.
40:23
Speaker 4: And yes, yes, yeah, so that's the biggest thing.
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Speaker 5: And yeah, I really appreciate the opportunity.
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Speaker 1: Amazing. Well, I want to thank you both for joining
40:34
Speaker 1: me here today on this episode and just thank you
40:38
Speaker 1: so much for sharing your story. Your collaboration with one another,
40:41
Speaker 1: your patient case. That was just so powerful to hear
40:44
Speaker 1: about in terms of being able to remove at least
40:48
Speaker 1: three medications off the roster. That's amazing, and just thank
40:52
Speaker 1: you for being here. I appreciate it very much more
40:54
Speaker 1: than you know.
40:55
Speaker 3: Thank you, Melissa, Thank you for doing this education podcast
40:59
Speaker 3: so important.
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Speaker 1: You're welcome, So you're so welcome. I'm so glad I
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Speaker 1: was able to have an MD on with me today
41:05
Speaker 1: as well as another pharmacist. So this is bringing perspective
41:09
Speaker 1: to all of my audience listeners when it comes to
41:13
Speaker 1: just utilizing precision medicine, looking things in a different way,
41:16
Speaker 1: and just knowing that it's helpful.