This week’s guest is Dr. Steve Daviss, a consultation laison psychiatrist. He joins Brett to talk about pandemic psychology, addiction, ADHD, note taking, and a bit of making music with code.

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Transcript

254 Steve Daviss

[00:00:00]Brett: [00:00:00] [00:00:00] This week’s guest is Dr. Steve Davis. He’s a consultation liaison psychiatrist. Hi Steve.

[00:00:07] Steve: [00:00:07] Hey, Brett. Uh, thank you for a vitamin onto your show.

[00:00:11] Brett: [00:00:11] Oh, absolutely. Uh, tell me what a, uh, consultation liaison psychiatrist does.

[00:00:18] Steve: [00:00:18] Uh, that’s a great question. Um, so. Uh, consultation, liaison psychiatrist. Uh, the words in that phrase, essentially refer to psychiatrists who work in typically medical settings. Um, often hospitals emergency room. Sometimes it might be nursing homes, um, and. Uh, the focus is really, I’ve got somebody here with some sort of problem, and I need a psychiatrist to, uh, evaluate and see if they have a psychiatric problem that might be contributing or, uh, the person has [00:01:00] psychiatric symptoms.

[00:01:01] We think it might be XYZ, depression, bipolar disorder, schizophrenia, uh, alcohol withdrawal. Um, but we know we want a second opinion. So that’s, that’s really what we do. We work in hospital settings generally. Um, and that’s where I spent most of my career, I guess, working in either hospital settings or other kind of primary care setting.

[00:01:24] It’s like a FQHC federally qualified health center or primary care offices. Um, so that in essence is what a cl psychiatrist, uh, does. Uh, I’m also, uh, an addiction psychiatrist, um, frankly, It’s hard to do psychiatry without also doing addiction. Uh, and I’ve done a lot of, um, uh, work around addiction. In fact, I’m currently the president of the Maryland DC society of addiction medicine, which is a chapter of the larger national main addiction [00:02:00] organization, which is a, or the American society of addiction medicine.

[00:02:03] Brett: [00:02:03] So you do a lot more, um, uh, consultation than actual long-term seeing of patients, at least in your capacity as a consultation liaison, then.

[00:02:14] Steve: [00:02:14] Um, I had been, um, my career has kind of, um, O taken a winding path. I, you know, I started off doing, uh, actually frankly, schizophrenia research way back in the day. Um, and. Uh, I wanted to go into, uh, research, uh, primarily because it that’s what attracted me to psychiatry and medicine in the first place. I, um, uh, growing up, I had a, um, uh, family members who developed schizophrenia at a young age in their teens, uh, which is oftentimes when it develops and the.

[00:02:54] Uh, just to see, you know, these loved ones of mine transform [00:03:00] with hallucinations and seeing numbers floating in the air. And it just kinda made me made, you know, I was younger than them. I was probably 11 or 12 and made me wonder how does the brain do this weird stuff? Um, and I was kind of a geeky kid to begin with.

[00:03:15] Uh, so that just was something to focus on and, um, I never let go of it. I mean, that’s really, what’s driven my. My, my career is how does, how does it happen that the brain gets broken like that and how to fix it?

[00:03:32] Brett: [00:03:32] do you think it’s a typical fo it surprises me that you’re still fascinated now by what you were fascinated by when you were 12.

[00:03:43] Steve: [00:03:43] yeah, well it reminds me of, um, you know, so I, so I went into. Uh, kind of a research research career. I actually started out as an MD PhD candidate. Um, and then, uh, [00:04:00] Uh, when I was driving around to, um, residencies, you know, you go to four years of medical school after college, four years of medical school, then internship and residency for psychiatry, which is, uh, uh, typically four years.

[00:04:15] Um, and then maybe a fellowship or, or start your career. And as I was driving up to Dartmouth, um, and New Hampshire, um, for my interview on the radio, Um, there was an NPR, a story about how they found the gene for schizophrenia. And, um, I remember kind of shouting, you know, and exclamation as I’m driving. Um, Oh, this is great.

[00:04:42] And then my next thought was, Oh, well, I guess they solve that problem. Maybe I won’t go into research. Um, as we know, it’s never as simple as it seems. Uh, there are, you know, a bazillion genes that seem to. I have something to do with, uh, schizophrenia and, um, [00:05:00] it remains, uh, mental health in general, um, remains, uh, to me a very interesting, challenging area.

[00:05:09] Um, although over the years, my interest have gone from research, you know, causes it, how to treat it, um, to more mundane, but probably much more important things like, uh, we know what good care looks like. We sometimes don’t know how to get it to people. You don’t know how to get it to them, where to get it to them, how to make it affordable, how to make it effective.

[00:05:36] So a big part of, um, psychiatry nowadays is often, uh, uh, implementation research, how to. Get people, the care that they need, it’s a little sad, um, that it is like that. Cause we don’t seem to have as much trouble getting diabetes treatment to people and blood pressure treatment to people. Uh, but it continues to be a problem.

[00:05:57] Brett: [00:05:57] Do you, I think that, uh, I mean, there’s been a lot of [00:06:00] talk over the last couple of years about mental health, especially mental health in America. Do you feel like things are changing, uh, that there actually is more of a light being shined on those problems?

[00:06:12] Steve: [00:06:12] I do. Um, you know, it’s been something that’s been changing, I think over the years, but, um, over the past, I would say five, eight years or so there seems to be an increasing. Recognition of the centrality of mental health and by, and when I say mental health, I mean like mental health and addiction, I, I, a lot of people split those two things separately.

[00:06:39] I think of them, many of us think of them as, as together, it’s all brain stuff. Um, and so, uh, the, uh, th the recognition that if you don’t. Address those issues, then somebody’s health, physical health suffers as well. And so you’ve got to [00:07:00] do both and if you don’t do both, you’re not going to do a good job.

[00:07:04] If you’re just focused on physical health, like diabetes, you won’t do a great job with that, unless you’ve got the mental health stuff under your control.

[00:07:12] Brett: [00:07:12] So you talked about, uh, genes for schizophrenia and I, over my life, heard a lot about, you know, the various mental illnesses being passed on genetically has, has that kind of research resulted in any, um, actual therapies? Um, it does knowing that it’s genetic help in treatment.

[00:07:36] Steve: [00:07:36] um, it, it’s not a direct answer to that. Um, overall, you know, a blunt answer would be, um, not greatly, uh, but, uh, there’s more nuanced answers. So. Um, knowing that the target of the gene. So what does that gene do, you know, does it code for, uh, a certain neurotransmitter receptor [00:08:00] or, um, some other piece of the receptor, uh, ecosystem?

[00:08:06] Um, if you will. Uh, so there are different things in the, in, in the neuron, in the brain cells, um, that either make neurotransmitters and neuro-transmitters are generally the, you know, the messenger. Um, uh, the lingua franca, if Frank gua rank God, if you will. Um, and, uh, so knowing about what is broken, you know, if a gene has an error in its code, um, that helps you understand, well, maybe we should design a drug or find a drug.

[00:08:41] That targets, that particular receptor and tries to work around the defect. So it does, it does help to define the targets, the, uh, the drugs that, uh, drug companies, um, uh, think about and look for. When they’re trying to figure out, okay, what, what else will work? [00:09:00] Um, so that, that does drive. Um, those, those types of genetics do drive some of the research, but there’s still, I think a lot more that we don’t know then there is that we do know.

[00:09:13] Brett: [00:09:13] So what’s, uh, what’s new and exciting and the field of addiction and psychiatry.

[00:09:21] Steve: [00:09:21] Um, so those, those things. Um, certainly as I said, go together. Um, and, uh, what’s new is, is what’s really old, unfortunately. So, um, we talk about whole person care. Um, you know, uh, whether it be physical, uh, mental, uh, addiction, uh, but there continues to be a lot of separation. Between those three things. And even between addiction and psychiatry.

[00:09:53] So some of the new stuff is, uh, finding models of care that knit [00:10:00] these things together in a way that where you can get treatment for both types of conditions, uh, mental health condition, and, uh, addiction condition, and ideally even your physical health, all in one place. That’s the big, um, The, the big thing right now is putting all that together.

[00:10:19] Um, so that there are not these silos or, or wrong doors. It used to be instilled as sometimes where you might go to, uh, your doctor or to mental health clinic and say, Oh, I’ve got this problem with, uh, opioid use. You know, I, I wanna, I wanna, I wanna have that taken care of, um, And be told, Oh, well, we don’t do that here.

[00:10:43] You got to go somewhere else. Uh, which is pretty frustrating. Um, same with, if you go to your primary care doctor and you want help for depression. And she says, um, Oh, I don’t treat depression. You have to go to somebody else. Um, so trying to, [00:11:00] uh, put these things together so that you can get your treatment for all your conditions from one place.

[00:11:07] And they can bring in specialists when needed. Um, uh, that’s uh, unfortunately that’s kind of a new thing. Um, relatively new, but people are starting to pay for it. That’s the key is, um, insurance companies, Medicare. It wasn’t too long ago that Medicare, um, did not cover, uh, treatment for mental illness more than.

[00:11:31] You know, a small amount, 20 visits a year or something like that. Uh, and then they didn’t put limits on other, you know, conditions, uh, that, that has gotten better. So, uh, so these are, these are new things. Um, you know, there’s always some new medications. Uh, there are some sexy things I would call that sexy, I guess.

[00:11:51] Um, new interventions, like TMS transcranial magnetic stimulation. It’s been around a while, but it’s still, it’s newer compared [00:12:00] to other treatments, but it’s a non-medication. Form of treating various conditions. It’s approved for treating, uh, treatment resistant depression. So depression that doesn’t respond to medications after, you know, a decent trial, uh, and, um, TMS involves essentially a big electromagnet that gets essentially held over your, your, your head, your scalp, and a certain type of physician, um, positioned in a way that, uh, they’re deep narrow beams of magnetic.

[00:12:33] Energy, uh, that in a focus way, try to go to parts of the brain that are involved in depression. Um, and, um, uh, I don’t know, uh, zap them, if you will. It’s you’re not killing anything. It’s just, you’re sending a magnetic pulse that causes a current flow, um, uh, an electrochemical current flow. And we don’t know exactly why that.

[00:13:00] [00:13:00] Helps. I mean, I’m sure there’s lots of theories and so forth, but, um, it’s a bit of a, Oh, you know, um, there, there’s a far side cartoon with a wooly mammoth laying dead on its back. And there’s a single arrow, like in his stomach somewhere. And I think the caveman says something like let’s write down where that spot is.

[00:13:21] Brett: [00:13:21] um,

[00:13:21] Steve: [00:13:21] of like that,

[00:13:22] Brett: [00:13:22] there’s so.

[00:13:23] Steve: [00:13:23] yeah, go ahead.

[00:13:24] Brett: [00:13:24] There’s like a whole pseudo science around magnets, which I feel like, uh, having actual clinical uses for magnets is only going to lend strength to this craziness with all these magnetic, uh, like necklaces you’re supposed to be able to buy and they’ll fix your life.

[00:13:42] Steve: [00:13:42] Oh, yeah. Um, yeah, so there there’s some good research to show that these strong, um, uh, electromagnets. Um, do something, but these are strong. Like if you, if you turn on the magnet [00:14:00] and you’ve got, uh, something metallic, uh, um, uh, near you, it can, it can hurt you. I mean, it can fling across the room. This is, uh, a serious, um, uh, uh, type of, uh, uh, electromagnet, um, that costs you can buy these machines, these transcranial magnetic stimulation machines they cost about, I guess, a hundred thousand dollars.

[00:14:24] Um, and it’s not something that, um, you’d buy and keep it in your house next to your treadmill. Right. Uh, but, um, uh, there are certainly plenty of psychiatrists that are using it and it’s pretty effective. It does require though. Um, daily treatment about five days, five days a week. Um, you know, for most forms of it, there’s a couple of different forms forms of magnets now, but the most common one you’re getting this treatment for about 35, 40 minutes, five times a week for about six weeks.

[00:14:57] That seems to be the dosage that, [00:15:00] um, makes a difference. But I have definitely seen people who have not responded to your usual types of treatment. Um, who do respond to this? It’s not a magic bullet. Uh, it’s about a 30, 40% or so response rate. But if you’re in that 30 or 40%, you’re going to be pretty happy that it works.

[00:15:21] If it does.

[00:15:23] Brett: [00:15:23] So I’ll, I want to offer some background before I ask this. Um, like I, in, uh, in my late teens, early twenties was addicted to all kinds of things. Um, like to the point of homelessness. And, uh, when I got, uh, diagnosed for bipolar in my twenties, Uh, that wasn’t the turning point, but at the same time, like as part of getting my life together, I started going to N a and I found that, um, mentioning my addictions to my [00:16:00] primary care physician led to, uh, bad things happening to my care, uh, mentioning or trying to treat, uh, addiction via my psychiatrist was just, she would just refer me to.

[00:16:15] He at the time would just refer me to a, like, they didn’t want it. They didn’t have any solutions for me. It all had to go through 12 step programs. So what I’m really curious about is this is 15, 20 years ago. Uh, w what would there be help for me now, if I were in a position, uh, that I, if I were actively abusing drugs or was recently clean, Would psychiatry have new answers for me?

[00:16:49] Steve: [00:16:49] they would have better answers. Um, some of the, some of them are new. Some of the answers are new, uh, 12 step programs, you know, uh, those, those [00:17:00] started back in the 1930s, um, by, you know, a couple of guys, uh, I’m sure, you know, the story, um, and really focused on, on alcoholism. Um, and. Um, that sort of, uh, social support.

[00:17:15] Um, and there are a number of factors. I think that, that make that helpful, but, um, there are treatments that are more effective even than say 12 step. Um, so for example, as we learn more about the biology of addiction, which is actually pretty well mapped out, um, What you learn is that there are types of treatments, either.

[00:17:40] Some of which are medications, some of which are more, some people will call them psychosocial treatments, um, like, uh, motivational enhancement therapy. Um, there are, um, The, the, the [00:18:00] medications for it though, I think are pretty helpful. You know, this is the United States. Everybody wants to take a pill to fix a problem.

[00:18:07] Um, and, um, we look for those things, but for some types of addiction, we, you know, there are medications that have been shown to be effective. More effective than placebo, at least. Um, and, um, an example of that would be for, for alcohol, the main medicine for many years was, um, deisel for, or an abuse. And, you know, that’s a medication that mucks up your liver’s ability to break down alcohol and kind of blocks the pathway so that a certain chemical builds up and makes you really sick.

[00:18:47] I mean, it makes you feel lousy, vomit and so forth. Um, and, uh, that was more of an adversive type of

[00:18:56] Brett: [00:18:56] Positive punishment.

[00:18:57] Steve: [00:18:57] treatment. Yes. Yeah. Um, [00:19:00] you know, I’ve, I’ve used that some, um, it’s not the most popular as you can, as you might imagine, but I’ve had people tell me that, um, without that they wouldn’t have been able to stop.

[00:19:10] Um, but even that is kind of, I would say fallen. More out of favor, um, for, uh, you know, other substances like other medications. Uh, now Trek zone is a good one. Um, now Trek zone, um, also goes by the name of Revia or Vivitrol. Um, it is a opioid antagonist, so it blocks the opioid receptor. Um, and in, so doing, um, if you were to take.

[00:19:41] You know, like oxycodone or heroin, um, it wouldn’t have much of an effect because you’re blocking that receptor and, and the opioid that you took would not be able to bind and do its thing. Um, so. Taking a medication that blocks that, [00:20:00] um, also helps with alcoholism because when you drink your body releases, you know, your own internal, um, opioids, the endorphins that you’ve probably heard of, um, and those endorphins make you feel good about drinking at least early on.

[00:20:18] Um, and so by blocking those receptors, then when you drink. You don’t get quite the same, feel good out of it. You don’t get the same buzz out of it. And because you remove that kind of reward, then, um, you develop a habit of, ah, you know, I don’t care so much about the drinking. That’s the thinking behind it.

[00:20:41] And it seems to work, but it doesn’t work for, for everyone.

[00:20:44] Brett: [00:20:44] so like the, the thing that got me. Was, I could get off of any given drug and I could go completely clean and sober, but my addictive behavior would show up in completely non related areas of my life, [00:21:00] like, uh, obsessions and, um, unhealthy behaviors, uh, that had nothing to do with, you know, sticking needles in my arm anymore, or, or even like drinking, like completely non drug related.

[00:21:11] Uh, and it seems like all of those treatments that you just mentioned were very much about the physical. About turning off like pleasure centers. Is there, is there anything new in the area of actually treating the, uh, not the chemical dependency, but the addiction.

[00:21:32] Steve: [00:21:32] Um, yeah, so, you know, addiction is sort of a S a cycle. And in fact, if you look at the. The, the, um, reward systems in the brain. You’ll see, it actually looks like a circuit, um, you know, uh, kind of a three-way circuit, if you will. And so the trick to treating and stopping addictions is to block that circuit because it’s this pathological feedback loop.

[00:21:59] Um, that [00:22:00] just kind of spins and spins and spins, and you’ve got to do things to block it. So some of the things that people do would be to, uh, use a medication to block that cycle, but there are non-medication. Ways to block those cycles. So, um, learning, um, essentially how to, uh, change your behaviors, you know, uh, you can learn as I’m sure you already have.

[00:22:27] You’ve probably learned that there are certain things that if you, if you do those things, they might be more likely to facilitate, uh, escalation of an addiction.

[00:22:40] Brett: [00:22:40] yeah.

[00:22:41] Steve: [00:22:41] Um, you know, and for some people that’s, uh, uh, go into a bar and hanging out with their friends. Oh no, I won’t drink. I won’t drink. I’m just going to see here, sit here in the bar and be with my friends.

[00:22:53] Well, you know, um, our brain associates senses things, um, seeing, [00:23:00] seeing the, uh, people drinking, uh, hearing the clinking of glasses. Um, back in the day when people smoked in bars, you know, cigarettes smoke all these sorts of cues and these cues, um, train your brain to go, ah, I want the thing, the feel-good thing that’s associated with those cues.

[00:23:19] So just learning how to block that cycle by avoiding those cues and, um, you know, a big part of the problem sometimes is. Just teaching people how to identify those cues in the first place. Uh, you, you probably hear of, uh, you know, in 12 step, they talk about people, places and things. These are all, um, you know, things that you associate with with using or with feeling good while you’re using substances.

[00:23:48] Um, and those things require changing, um, to, uh, break, break that cycle. So it is a combination of. You know, uh, the, the best treatments probably [00:24:00] try to hit that cycle pattern in multiple different ways, you know, uh, like, uh, uh, let’s say for opioid use disorder, um, buprenorphine, Suboxone, that is a medication that, uh, is an opioid itself.

[00:24:19] Um, but it is, uh, it seems to be associated with less. Um, uh, less of a reward feeling from it. Um, it has a bit of a ceiling effect, so you can’t like take more and more and, um, feel better and better. Oh, that reminds me that, um, the other thing that the brain is really good about, uh, although sometimes that good can be bad is, um, if it starts to see.

[00:24:47] Um, experience, uh, a, let’s say, um, you know, some sort of opioid on an ongoing basis while your, your brain already makes its own endorphins. [00:25:00] Um, but if you are supplementing that on a regular daily basis, then your brain starts to go out. I don’t need to make those endorphins anymore because I’m just getting too much as it is.

[00:25:11] So I’m going to stop that. Well, if you were to then stop. Using your opioid. It takes a little bit of time for your brain to kick in and go up. I see. I’m not getting any of that anymore. I better start making more of those endorphins. Um, and then you’re going to have a deficit of those endorphins. And when that happens, that can be an uncomfortable feeling.

[00:25:32] Uh, the other thing that your brain will do is, uh, because the, the endorphins or the heroin or the opioid that you take, um, Uh, does its thing by binding to receptors. The other thing that the brain is really good at is going, Hmm, I’m getting too much of these opioids. I’m going to make less receptors. So that way I’m not getting stimulated so much.

[00:25:57] Uh it’s too much hyperstimulation. So I’m going to [00:26:00] tone down those receptors and make fewer of them. Well, that’s fine. As long as your dosage of opioids always stays the same, um, Uh, but what will happen is if you’re making fewer receptors and then you take away the opioids, it takes about two weeks to make new receptors.

[00:26:20] So that means for two weeks, you’re going to have, you’re going to your, brain’s going to be starving for what it’s used to getting. And that’s what go through withdrawal and, you know, shakes and tremors. And, um, it’s a very extreme vomiting, a very uncomfortable feeling. Which is why if you’ve experienced, you’ll know that, um, people will do just about anything to avoid feeling that bad.

[00:26:46] And that’s that cycle of addiction that gets you, you know, the brain, the opiod is really hijacking your brain and its own regulatory processes. Uh, and doing it in a way that you’ve lost control. Once you get to that [00:27:00] point, it’s really hard to, to regain control. Some people are able to do that. Um, without a lot of intervention, I think those people are.

[00:27:09] Far and few between, um, others need more help. Um, and still others just never quite get to the point where they get the help. And I’ve seen people who are, you know, using opioids off the street for, you know, 30, 40 years or so. A big problem nowadays of course, is that we have a toxic drug supply. Um, With the fentanyl that’s out there.

[00:27:31] It’s, you know, it’s, fentanyl’s super strong. It is easy to a small amount. It’s easy to get in to the country from different places. Um, and, uh, if you’re in the business of, uh, of being a street dealer and selling, um, opioids, usually it’s heroin. Most of the heroin that’s sold on the street now has no heroin in it.

[00:27:54] It’s fentanyl. And then a bunch of like sugar and other white stuff.

[00:27:59] Brett: [00:27:59] Yeah, I’m [00:28:00] glad I got out when I did, I guess. But, uh, so you, you, I don’t mean to stick on this topic forever, but you T you talked about opioid disorder. Um, and the way that it was always presented to me, mostly through 12 steps is that there aren’t different kinds of addiction. It’s all just addiction. Are there different?

[00:28:21] Are there different kind of, uh, brain patterns between different types of drug users?

[00:28:28] Steve: [00:28:28] um, more, I, I’m not a, an expert on, on the, the fine points of, you know, the, the brain’s reward system with respect to different types of addictions. But I, I do know that, um, Those addictions are much, much more alike than they are different. There may be some differences, like for example, cocaine addiction, um, is much more focused on the dopamine reward system as opposed to the, [00:29:00] um, endorphin the opioid receptor system.

[00:29:03] Um, so there might be some subtle differences, but much more alike than they are different. Absolutely. And that goes with other types of addiction too. People are, have sexual addictions. Um, some people gambling, um, there’s a lot of, a lot more similarity there than there are differences.

[00:29:20] Brett: [00:29:20] I cured my cocaine addiction by starting to use heroin. Um, I feel like I’m, well-versed

[00:29:27] Steve: [00:29:27] Well, and, and so that is very old school because back in the late 18 hundreds, early 19 hundreds, that’s exactly what people did. You came in with cocaine addiction. We will treat it with heroin. You come in with heroin addiction, we might treat it with cocaine, um, or cannabis, or, you know, um, you know, if you go back far enough, they were using all sorts of things.

[00:29:52] Um, Uh, lead for example, or I think maybe I want to say arsenic was [00:30:00] also used sometimes. So, uh, of course that those were the, there were days when, I guess it was, uh, leeches and all sorts of weird things.

[00:30:09] Brett: [00:30:09] humors. Yeah. Um, so how has, uh, I’m gonna, I’m gonna try to get off my, uh, my obsession with the addiction thing. How has, uh, how has COVID affected your, your life, your daily job?

[00:30:25] Steve: [00:30:25] Uh, for, for me, um, uh, personally, I mean, it certainly it’s disrupted the whole country, the whole planet, um, and in various different ways, um, you know, the work that I do. Uh, right now, I’m not doing direct care. Um, I, uh, I guess in December of 2019, I started working for, um, an insurance company. Optum. I’ve never worked for a payer before.

[00:30:53] Um, but they had a contract to do, uh, take care of, uh, people with behavioral health problems, um, in [00:31:00] Maryland who are, uh, who have Medicaid and, um, I, you know, I’m the sort of person that I like to know how things work underneath the infrastructure, the gears that make everything turn, which is probably what attracted me to psychiatry and to, uh, research initially.

[00:31:18] Um, but that’s true with all sorts of systems. I like to know what makes everything, um, uh, tick and we’ve got a lot of problems in our healthcare. Um, if you haven’t noticed, and some of those problems, you know, aside from COVID. Um, just again, the whole, um, how to implement a treatment to people and get those, those services, um, you know, available to them.

[00:31:48] Um, that whole system just isn’t working well here. So I decided, well, let me, you know, the job opportunity came up to, um, to work on the payer side. And I think a big part [00:32:00] of it is how. Healthcare is financed and paid for and the incentives they’re in. Um, so I wanted to take this job to learn what’s going on on the payer side.

[00:32:12] How does that work? Cause I had my, my vision I’ve, uh, I’ve cursed out insurance companies for enough, enough of my career that I decided, well, let’s see if I can figure out what’s broken on that side. Um, and uh, so I can do my work. Uh, remotely, um, you know, I was driving to work, um, every day, uh, March 16th, they think was the last day, last year.

[00:32:36] And haven’t been back since, other than maybe sometime in the summer, I went and got some, some things there. You know, when we left, we didn’t, we didn’t know that we would be gone for a year. Uh, so, um, I’m able to do my work remotely at home. So I’m blessed that. Uh, th that I can do that. There are a lot of jobs where people cannot, um, but the [00:33:00] impact on people has certainly taken a toll.

[00:33:04] Obviously there’s the physical toll, if you get COVID, but, um, a lot more depression and anxiety, uh, we’re certainly seeing during COVID, um, uh, addiction and use of substances has gone up. Um, you know, it’s like, well, some people have a lot of time on their hands. Um, others are self-treating maybe, uh, the rate of alcohol consumption has gone up tremendously.

[00:33:32] Um, and so that has had, you know, a very significant impact. I think just the loneliness. There’s a lot of people that are lonely, a lot of social disruption. Um, obviously all the other. Negative consequences of COVID financial problems, loss of jobs, um, you know, kids in school, um, people going to college and kind of uncertainty about all those things, uh, losing friends and family to [00:34:00] COVID, uh, people that, that have died.

[00:34:02] Um, so these are a lot of, um, uh, consequences that are hitting us, um, kind of in, in, in the brain, if you will. Um, I think, uh, you know, some groups are hit harder than others, uh, indigenous people, people of color, uh, people that don’t have access to a broadband, um, you know, uh, it used to be before COVID that you could not provide treatment just over a regular phone, um, and get paid for it.

[00:34:37] Uh, and that changed with COVID and we’re still trying to figure out how are we going to keep that change? Uh, you know, I would argue that we should, there are lots of people that even without COVID, um, have limited access to treatment, if you’re working three jobs, uh, just to keep, um, your family fed pre COVID.

[00:34:57] Um, you don’t have a lot of time to [00:35:00] take three buses to get to the doctor’s office for your regular, you know, medical checkup. Um, and so having other ways to do that, um, ways that are more convenient, um, uh, I hopefully will go a long way. It certainly seems, it certainly seems that way. Um, so we’re, we’re, it’s, it’s odd though, that something so terrible has caused such. Positive changes in our healthcare system. It shouldn’t have to take that, but it did.

[00:35:29] Brett: [00:35:29] Yeah. W do you think that, uh, as things quote, unquote, head back to normal, uh, that there will be. Uh, w we’ll we’ll the things we’ve learned in the advances we’ve made in medical care, uh, move forward or what they revert your prediction.

[00:35:49] Steve: [00:35:49] I predict it’s going to be hard to put that genie back in the bottle. Uh, so I think that, uh, tell the, all the telehealth, um, advances that we’ve made. Um, [00:36:00] I think most of them will stay with us. I think that, um, we will see much more. We’re seeing it now, um, uh, digital therapeutics, uh, different words for it, but essentially using technology, um, and, uh, data population, health concepts.

[00:36:22] Um, using those sorts of tools to, uh, get help to people identify who needs help, um, make them available. I think we’re gonna see a lot more of that in COVID we’ve had to, we’ve had to change gears. Um, otherwise there’s no way to, uh, get people the help. Um, I think it will be overall positive changes. I sure hope.

[00:36:48] That we’ll see a reduction in the cost of care. You know, uh, our country spends, you know, two to three times more than any other country does, uh, per person on [00:37:00] healthcare. And a lot of that goes to, you know, well, some of it at least goes to like administrative costs and so forth. There’s a lot of overhead.

[00:37:07] Um, and it’s long been argued that we spend, you know, for what we’re getting we’re spending way too much. Um, But it’s been hard to figure out. Okay, well, where are you going to cut without losing quality, without losing access to care. We’re kind of forced to figure that out now.

[00:37:27] Brett: [00:37:27] yeah. All right. So last question, before we get to some top three picks, uh, I assume that as a practicing psychiatrist, you take a lot of notes. What is your favorite way of taking notes?

[00:37:44] Steve: [00:37:44] Uh, for, I don’t know how long it’s been. Um, so you, your product a and V out. Uh, actually I use notational velocity before, um,

[00:37:55] Brett: [00:37:55] be clear. This was not me fishing.

[00:37:58] Steve: [00:37:58] I know, but, but, but, [00:38:00] uh, you’re, you’re going to get the fish anyway. Um, you know, uh, I use that every day. That is my main note taking tool. Um, you know, so I use Mark I type in Mark down.

[00:38:16] Um, so I use a lot of asterisks and other, um, uh, markdown tools. Cause it just makes a lot of sense. Um, to me and, uh, uh, what I, what I really like about it is that, um, you know, I’ve developed kind of a workflow for note taking, um, and, uh, that workflow has certainly evolved over the years, but having some kind of tool that allows me to immediately, um, find all the notes that have certain words or phrases in it.

[00:38:50] Um, is, uh, incredibly helpful, um, as well as having a tool that allows me to hyperlink between notes to connect [00:39:00] those threads. Um, so, you know, th th the concept of a Zettel Castin, uh, is something I certainly read, uh, a fair amount about and learned. You know, picked up some tips about, um, how to write notes in a way, you know, back in, uh, medical school.

[00:39:19] So here’s, uh, uh, you know, you’ve talked about your, um, uh, your ADHD and how that has affected your life. Um, so, you know, I have been diagnosed with ADHD as well. Um, I’m not taking any medications for that now. Uh, but, uh, I have had, you know, uh, I’ve been, uh, kind of, uh, a high performing kid, um, and never at least in high school and college didn’t really need to work too hard.

[00:39:50] I’m not trying to brag. It’s just kind of how I found it to be. Um, I nearly flunked out of medical school, uh, because of, because of this, the F uh, [00:40:00] in, in the first year of medical school, I used the same stuff. Poor study habits that I had in college, which was, um, a lot of last minute cramming, um, uh, procrastination, um, uh, you know, being in a lecture, listening.

[00:40:19] I learned a lot from that, um, reading, um, I, you know, I would sometimes get into it, but I, it was just very easy to get distracted. And so I had poor study habits. Um, and in medical school your first year, you’re, you’re like, you know, a typical, uh, semester in college is like, um, 15 credits, five classes, right?

[00:40:44] Uh, uh, three hours a week. And in medical school, instead of taking like five classes, it’s more like taking 20 classes. Um, all at once, all through the same time. Um, and I use the same techniques I use, I [00:41:00] used in college and that failed me terribly. Um, and I started to do poorly and it really took, um, uh, you know, kind of a, okay.

[00:41:10] Either figure it out or you’re out of here. Before I finally said to myself, okay, I’m doing something wrong. I’ve got to change. I’ve got to do something. Um, and at that time I wasn’t thinking it was, um, it was, um, ADHD or anything like that. I just thought I had, you know, uh, bad habits, bad study habits. I just needed to try harder, try harder.

[00:41:32] And so that’s what I did. I tried harder to try harder. Um, and. And that did work. I mean, I, but it meant that I always had a book in my hand. I was always writing notes. I wasn’t typing notes back then. I was, everything was handwritten, a lot of highlighting and so forth. And I just overdid all of that stuff.

[00:41:53] Um, just to, uh, you know, finally, um, uh, succeed, but I was eight, but I [00:42:00] was able to, um, and, and after I, but, but I had to do some sort of. Mental gear shifting. And I can’t even, it’s hard for me to define what that was, but that’s what it, but that’s what it took. Um, and, uh, you know, I have tried, um, uh, myself, a few of the medications that are used to treat.

[00:42:20] Um, ADHD, um, at times in my life when, um, I thought, well, maybe that would help. Um, it did help, but I did not like how it made me feel. I felt very speedy, kind of wired feeling on stimulants. Um, you know, I, I tried, uh, some other medications like, uh, uh, Wellbutrin or bupropion, um, Effexer, which has Venlafaxine’s, which are sometimes used to treat these conditions.

[00:42:47] And, um, they gave me kind of odd side effects that I didn’t like. So, you know, after I tried a couple of years different medicines, but I just didn’t find that I was too, uh, too helpful. [00:43:00] Um, w w w tell me about, you know, your experience with those types of medicines and side effects.

[00:43:06] Brett: [00:43:06] this is really funny because the question was about notes, but I’m happy to talk about this. Um, so like as a, uh, former. Cocaine. And at some point meth addict, uh, the idea of feeling speedy wasn’t, uh, I’m not sure reverse to that. Um, I definitely, I S uh, I was on a med called Vyvanse for a long time, and Vyvanse did not give me that speedy feeling, but it also wasn’t terribly effective.

[00:43:38] Um, The, the drug that has been the most useful to me is Focalin, which is closer to, uh, uh, Ritalin Vyvanse is in the Adderall family. Um, so like I don’t function without, uh, ADHD medication. And [00:44:00] part of it is, uh, it’s combined with bipolar depression. Um, I just, plus when I’m not medicated for ADHD, my addictive tendencies, uh, I have lower impulse control.

[00:44:12] So that leads to just general problems. Even if it’s not drug abuse, it’s just addiction in general. Um, so I’ve been willing to accept the kind of physical side effects of ADHD medication because they allow me to function the way I see everyone else functioning. Which

[00:44:33] Steve: [00:44:33] Well then. Yeah. Um, so the, the connection to me with the note taking is that I find that. Um, like I did back in medical school by focusing on the process of making notes, writing notes, typing notes, um, that, that becomes almost like a focus for me and [00:45:00] helps me pay attention more and improve my memory.

[00:45:03] Cause if I write something down, if I’m typing something, um, um, especially if I use it soon afterwards, Um, I find that I remember it better. And that was one of the tricks that I learned in medical school was just by doing more of this kind of note-taking highlighting, make things yellow and pink and so forth.

[00:45:23] Um, it, it, for me, it kind of built a bit of a mental map, like a geographical map almost and helped me, like I could envision a page and where certain words were on the page and that somehow helped me. Help me remember, um, uh, what it was I was trying to learn. Um, and so using those types of these types of, uh, tools, like, you know, uh, like envy all for example, and by the way, okay.

[00:45:52] I’m going to, uh, envy ultra, which is like your, how, I don’t know how you would describe it, but, um, [00:46:00] is that something that’s going to be coming out?

[00:46:02] Brett: [00:46:02] I should hope so it, so, I mean, basically right now, uh, Fletcher my partner on this. Is, uh, he’s going through a lot of stuff that is not related to NBA ultra, uh, in addition to being an ER doctor in the middle of a pandemic. Um, so things are moving slowly, but we are absolutely like on the precipice of release.

[00:46:26] Uh, I just need him to find a little more time and, uh, and we’ll get that out there. We are pretty much anyone who directly asks me to be on the beta at this point. We’re not mass adding anybody, but. You and anyone else listening who wants to be on the beta? Just email me and we’ll get you up and running with NBA ultra.

[00:46:48] Steve: [00:46:48] Well, that’s cool that the name is funny, cause it makes me think of a certain CIA

[00:46:52] Brett: [00:46:52] I know MK ultra it’s. We, we did the, they was supposed to be a code name. It was just supposed to be a [00:47:00] temporary envy envy ultra wordplay code name. We never found a better name for it, or I should say we never agreed on a better name for it. I thought I had some great ideas. He thought he had some great ideas.

[00:47:12] We couldn’t, we couldn’t come to a two person consensus.

[00:47:20] Steve: [00:47:20] Um, um, uh, that, that is something that I’ve been in fact, I’ve, I dallied with a couple of things. Um, uh, I thought I thought Rome was gonna, um, kind of fit the bill, but, um, I, I haven’t found that I got very frustrated with it and, um, it hasn’t been easy to use. Uh, and I think they, they’re not using text-based notes.

[00:47:42] Um, you can’t just save a bunch

[00:47:44] Brett: [00:47:44] They’re not actual files. Right.

[00:47:46] Steve: [00:47:46] Yeah. Yeah, yeah. And, and the whole idea of getting something, you know, I’ve gone through, I don’t know how many computers, um, in, in my, in my life so far, but, um, uh, you know, to have things on, in formats that [00:48:00] down the road, uh, I won’t be able to access is just not something I’m willing to

[00:48:04] Brett: [00:48:04] Yeah, that is very much the philosophy behind notational velocity and VL MBL. Is this, this idea of portable portable notes in regards to what you were saying before. I have a hundred percent found that if I take notes on something while it’s happening, I rarely even need to go look at my notes because just the act of taking the note helps me remember what happened.

[00:48:26] Steve: [00:48:26] exactly. I find, I find the same thing, um, as well. Uh, and, uh, I, in fact, I sometimes will. Uh, like I might be listening to a podcast, um, and somebody is talking about something and I’ll pause it and go, you know, do what I need to do so that I can take some notes about it. Cause just listening about it. Um, you know, I’ll hear it and I’ll think, Oh, I wanna check that out later.

[00:48:52] But if I don’t write it down, it’s out of sight out of mind and it’s gone before, you know, it. So I’ve got to stop and [00:49:00] do something to capture it. Just that capture is almost like taking a picture and then I have it.

[00:49:05] Brett: [00:49:05] you use mind maps at all?

[00:49:08] Steve: [00:49:08] I’ve tried to mess with mind maps a number of times. Um, I can’t get into it. I don’t know why. But it, cause you would think from some of the things I’ve said that, uh, um, that would work well. Although most of the, my maps I’ve done have been, um, you know, like on a computer rather than on a piece of paper, I’ve done it on a piece of paper and I get frustrated cause I run out of room.

[00:49:32] Brett: [00:49:32] Sure. Yeah, Tony, Tony Pizan was a huge proponent of like, you have to do it on paper, up until. Uh, probably the mid two thousands, but like I never enjoyed doing it on paper because I like to be able to move things around. That’s part of the magic for

[00:49:50] Steve: [00:49:50] Yeah,

[00:49:50] Brett: [00:49:50] is as I choose to like jot down these notes and dump out ideas and, and, and concepts that are coming up, I just.

[00:49:58] I can just dump them [00:50:00] onto the screen and then I can organize them and then I can start to make the connections and see what relates to what, and like it’s perfect for me. And it’s very much, uh, it’s uh, there are two kinds of people. There are people who mind map and people who don’t. And for some people, like I would never push mind mapping on anybody because it just doesn’t seem to click for some people the way it clicks for me.

[00:50:27] Steve: [00:50:27] Yeah.

[00:50:29] Brett: [00:50:29] All right.

[00:50:29] Steve: [00:50:29] Uh, I I’m, I’m conscious of the time. And, uh, top three picks.

[00:50:35] Brett: [00:50:35] yes. Let me do a quick sponsor break.

[00:50:38] Steve: [00:50:38] You got it.

[00:50:39] Brett: [00:50:39] Actually. I’m just going to add that, edit that in later, but all right. So now top three picks. Tell me what you got. Uh,

[00:50:47] Steve: [00:50:47] Um, so, you know, it changes every time I think about it. Uh, so the first thing I thought of, um, is something I keep coming to, so I do, uh, [00:51:00] photography, I’m a hobbyist, um, but, um, uh, really enjoy, um, photography, mostly landscape. Um, nature, um, you know, some street photography and, uh, I came across, um, a book by photographer, David Lubbers, um, and the book is called persistence of vision.

[00:51:23] You can, if you just Google it, you’ll find some, some of the pictures out there. And what he did in this book was. He found he’s a, you know, a professional photographer. He makes his living doing photography. And, um, he went through his photographs and he found, uh, you know, dyads of photographs to photographs.

[00:51:47] The technical word for this is dip tick, um, and, uh, put. Them, uh, one on the left and one of the rights. So each time you flip a page, you’ve got a new set, a new pair of photos [00:52:00] and the one on the left and one on the right. Um, Jay, what he does is, um, matches photos that have elements that are very similar, but they’re different photos or like from different times, like different years, different locations.

[00:52:18] Um, but there might be, for example, on the left, there might be an S curve of a stream. And on the right, there might be the same exact location, everything S curve, but of sand, um, in a desert. Um, and it’s a series of these pictures. And what I really like about it is that he doesn’t tell you what’s the same.

[00:52:41] So this is really something that the observer, the reader is looking at and noticing, Oh, Oh, look, there’s a rock over here and there’s that same type of rock over here. And, um, you know, it, it makes you think, um, and it makes me think I’ve got, I don’t know, [00:53:00] probably 30,000 photographs, um, all on, all on backed up hard drives, so I don’t lose them.

[00:53:06] Um, uh, but this concept of finding photos that are similar. Um, and tell a bit of a story is just fascinating to me. So I started to try to do something like that myself. So, um, uh, any photographers out there? Um, I would suggest take a look at his book.

[00:53:26] Brett: [00:53:26] nice. Um, it’s kind of like those, uh, those funny pages spot the difference between the two photos, but opposite.

[00:53:34] Steve: [00:53:34] Yes. I remember going to the dentist and reading highlights.

[00:53:39] Brett: [00:53:39] of course.

[00:53:40] Steve: [00:53:40] Well, there were some things in highlights like that, where you’re trying to find what’s changed.

[00:53:44] Brett: [00:53:44] Yup. Yup.

[00:53:46] Steve: [00:53:46] Um, okay. A second thing, um, is, uh, something kind of more general, uh, the internet archive, the way back machine and all the other things that are associated with that, [00:54:00] um, you know, just in the past week, Um, I went in there to, you know, I, me and two other psychiatrists did a podcast for several years called my three shrinks.

[00:54:12] And I think we’ve got about 70, um, episodes. Uh, we haven’t done them for a number of years, but, uh, I had, you know, I didn’t, um, renew the, um, the domain and then all the files went away. And where are my files while they’re on some hard drive somewhere? Well, it turns out, um, uh, way back, caught them all, including the audio files.

[00:54:36] Um, and, um, I, uh, I’ll share a link with you, uh, so that readers that they want to listen to any of them, they can, but that got me digging deeper into what is on the internet archive. Um, and, uh, some of the, you know, so during COVID, um, there were, they’ve really doubled down on. Um, [00:55:00] get making more books available, um, through, uh, the archive.

[00:55:05] And so there’s a lot more, um, uh, uh, books, I think there’s, you know, there’s obviously it backs up webpages like nobody’s business. I think there’s like a half a trillion web pages on there that are all searchable through keyword searching and so forth. Um, and, uh, lots of audio recordings, music spoken, word sound effects.

[00:55:26] Uh, Podcasts, uh, videos too. There’s old, you know, movies and things like that. Um, there’s just so much there. Um, and it’s a, uh, it’s truly a treasure trove. Uh, and if people don’t know about it, um, uh, you know, we’ll, you’ll put a link in the show notes too, that, but, uh, there’s just amazing stuff in the internet archive.

[00:55:51] So, um, that definitely deserves a, a strong mention.

[00:55:54] Brett: [00:55:54] Absolutely. I, uh, when I first, this, this podcast started on the five [00:56:00] by five network and not to malign anybody, but, uh, within a week of me moving to a different network, Uh, the first a hundred, some episodes were just gone from the internet removed. And, uh, I went back a couple years later and realized that they were all in the Wayback machine and I was able to retrieve.

[00:56:21] So the, the website’s current pot, uh, podcasts, current website at, uh, system, what is it? Systematic pod.com now has like the full archive. And it’s only possible because of the way back machine.

[00:56:35] Steve: [00:56:35] It saved our podcast too. Um, really, really, uh, you know, really amazing that that’s there. Um, and, uh, uh, just awesome. And lots of, um, uh, I, you know, like for example, I think there’s, they’ve got, um, Several million books, a lot of Saifai. Um, although it’s curious, they had, so I looked at for Isaac [00:57:00] Asimov, right?

[00:57:01] Um, at least a hundred of his books are in there. Hi, uh, Robert Heinlein, none. Why is that? I don’t know. Uh, so it’s got some quirkiness to it. Um, but, uh, uh, very useful. And I think I also found. Did I find that there? I think I did, um, our, you know, so the two psychiatrists, I mentioned, um, uh, Diana Miller and Anne Hanson.

[00:57:27] We also, you know, we, we had, uh, a blog, which we no longer write for, uh, which was called shrink wrap. Um, and then came the podcast, uh, my three shrinks, you see a theme here and then, you know, Diana had this great idea. Well, let’s take the hundreds and hundreds of blog posts that we did and make a book out of it.

[00:57:48] Um, and, uh, if you ever tried to do something like that, it doesn’t work the way you think it would you, she thought, Oh, you just stitch stitch them all together and it’d be fine. No. Uh, and [00:58:00] three of us, you know, um, arguing about, uh, okay. Uh, writing what we’re going to put in, what we don’t put in, but that book.

[00:58:08] Is, um, also, um, in the way back machine. So if you want it to buy, it’s still, I think it’s still, um, there’s some still print copies that are, um, um, out there. Uh, it came out in 2011, uh, but I was very pleased to see that it’s also right there. Um, you know, uh, in the Wayback machine, well, it’s actually not even part of the Wayback machine.

[00:58:29] It’s part of open library.org, uh, and, uh, they allow you to borrow a book for an hour. So it’s really interesting to see that the three that even on the internet and the Wayback machine psychiatrist, um, you know, are doing their thing one hour at a time. I had to reach for that one. Sorry.

[00:58:53] Brett: [00:58:53] all right. What’s number three.

[00:58:55] Steve: [00:58:55] Uh, number three is Sonic PI. Do you use your [00:59:00] musician? Have you used Sonic by.

[00:59:01] Brett: [00:59:01] I have not. Is PI P I or P I

[00:59:05] Steve: [00:59:05] T I, yeah, it’s not Python. It’s PI like the Greek letter. Yeah, Sonic I, um, it is a, a downloadable executive bowl, um, that, uh, allows you to, um, make music by coding. So you’re essentially, um, writing code that, um, uh, spits out music. And as you tweak the code, the music changes. Um, if you’ve ever used like, um, uh, like a Jupiter notebook, it’s something like that.

[00:59:40] And the sense that by changing it, it, uh, the output immediately, um, um, comes out. And, uh, the, I think the guy that, that, that wrote it is Sam. Aaron, I think is his name. And he’s got a number of, um, YouTube videos. Of him, you know, jamming with his computer, uh, [01:00:00] music, people dancing and so forth. Um, and you know, what I like about it is that, you know, you’re using code and mathematics to, uh, right to make sounds.

[01:00:12] And, um, there are some folks who have used Sonic PI to turn data into sound. Uh, and that concept just fascinates me. I haven’t quite figured out what to do with that. That’s a patient, but it’s just asking for something, check it, check it out. I’d love to, um, I’ll bet that you’ll get turned on by this and, um, want to do something

[01:00:35] Brett: [01:00:35] Yeah, I’m worried. I’m worried that you just killed between one and a hundred hours of my productivity.

[01:00:40] Steve: [01:00:40] w well, that’s why I got into it one weekend and, and, um, haven’t been back to it yet because it. It’s hard to stop once you start. Um, there’s uh, on the, um, are you familiar with the calm app? So in that I there’s a, um, I [01:01:00] found a segment of, um, there’s an astrophysicist by the name of Matt Russo who took, uh, kind of the data of the stars and when they come out at night.

[01:01:14] So when they become visible as. Dusk settles tonight. Um, and, um, took a file with all of the star information and the intensity and the color. Um, and, um, when they come out, you know, kind of as, as it gets darker and darker and darker and created. Um, essentially there there’s one of the sound system sounds, I think it’s called and the call map is that recording.

[01:01:44] And so for an hour, it starts off with a little thing Thing as stars become visible. And then over the course of an hour, it becomes kind of this Rawkus white noise sound. Um, but as [01:02:00] it’s, as it’s unfolding, it just has a very calm, soothing feel to it. And so, you know, taking data and making sound and music out of it.

[01:02:09] I love that, that concept. I just want to do something with it.

[01:02:12] Brett: [01:02:12] awesome. I’ll have to I’ll let you know how it goes. I’m absolutely going to play with

[01:02:17] Steve: [01:02:17] that. Yeah. Yeah, it’s hard. It’s hard not to, once you start messing with it.

[01:02:22] Brett: [01:02:22] All right. Well, if people want to, uh, learn more about you or reach you, where can they look for you? Yeah.

[01:02:30] Steve: [01:02:30] Um, Ooh, probably the best way the best places are. Um, uh I’m so I’m on LinkedIn. I’ll put a, uh, a link in the show notes for my LinkedIn page. Um, and I’m on Twitter. I’m hit shrink. Those are the best two places.

[01:02:46] Brett: [01:02:46] All right. Cool. Well, thanks for your time today.

[01:02:51] Steve: [01:02:51] Really great to, uh, to have this extended conversation with probably one of my favorite software artists. So, yep.

[01:03:00] [01:02:59] Brett: [01:02:59] Thanks for putting up with my, uh, my, my addiction obsession and the, uh, in the questions.

[01:03:05] Steve: [01:03:05] My, my pleasure. Some things you want to feed.

[01:03:09] Brett: [01:03:09] all right. And thanks everyone for listening. We’ll see you again in a week.

263: The One With Victor

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