Interview with Dr. Rebecca Cunningham

Rebecca Cunningham, MD, is a Professor in the University of Michigan (U-M) Department of Emergency Medicine; Vice President for Research, U-M Office of Research; Director of the CDC-funded U-M Injury Prevention Center; Professor in the Department of Health Behavior and Health Education in the U-M School of Public Health; and Principal Investigator of the Firearm Safety Among Children and Teens Consortium (FACTS). Her expertise is in ED-based research on substance use, violence, and other negative outcomes, particularly among children, and the development and application of behavioral interventions in the ED setting.

Dr. Cunningham spoke with Dr. Nidhi Garg (RSI Section Chair) in January 2020 about her career and her advice for early stage investigators.

Dr. Garg: Thank you for doing this for the Research, Scholarly Activity, and Innovations Section. We are very excited to have you with us.

Dr. Cunningham: Thank you for the honor.

Dr. Garg: I am Nidhi Garg and I am the section chair. I work at Northwell. I am a clinical researcher and my area of interest is congestive heart failure. My first question is about how your research journey started. Where were you in life that prompted you to do ED based research on substance abuse and violence, especially in children?

Dr. Cunningham: I did a three-year residency at the University of Michigan in emergency medicine, and at the end of that I went ahead and applied for a NIH T-32 fellowship to do research. During residency, I got really interested in injury prevention by going through life experiences, seeing patients come in and out of a trauma bay who had alcohol misuse and suffered from cocaine induced chest pain and learning how to take care of them clinically.

Our job in residency is to learn how to be good clinical doctors. I knew I wanted to do more than that, and in addition to thinking about the patients that were right in front of me. I wanted to think about how to make a difference in injury prevention, and in keeping people from needing our clinical services in the ER.

I knew I didn’t have the skills to do that right out of residency necessarily. I had been involved in some research projects in residency, but very early on – doing a literature review with a senior faculty, or being in a lab for a month or two with medical students, but had no significant understanding of how to dream up a research study, what path to take to conduct that or how to get any money for it. I needed different kinds of training than what I had in residency alone, so with that, I did a research fellowship funded by the NIH as part of the T-32 program.

I applied to be a fellow to get that postdoctoral fellowship. That fellowship gave me the mentors, the direction, and really the time, that one doesn’t have in residency at all, to really sit and learn from people who are spending their days looking at data, dreaming up research questions and what that process looked like, including how to meet people, and think of ideas together and form teams.

Dr. Garg: So, regarding the fellowship application, how did you choose where to go and what program would fit your needs? My second question is about choosing your area of expertise – was your area of expertise the same during fellowship as it is today?

Dr. Cunningham: During my last year of residency, I started looking around and asking senior faculty what options were around for doing this research that they were doing. And they started pointing me in the direction of some opportunities. There was a violence fellowship in California that I considered that was funded by the Injury Center out there, as well as staying here in Michigan where I was trained. They had a fellowship program available in a different department of emergency medicine. In fact, the year that I graduated it was a brand-new department at Michigan in 1999.

So, we didn’t have any fellowship programs within our department, but the department of psychiatry had a T-32 program, and the job of that program was to train researchers across different disciplines. With some support from my own department, I became a joint fellow between the department of emergency medicine and the department of psychiatry funded NIH program. I worked towards getting some examples from senior faculty and filling out the forms, and the interview process involved in taking one of the spots they have available, which was a two-year spot to do that training.

My initial interests started out to be very clinically based, which I think are a frame of reference certainly as clinicians and clinicians right out of training. At the start, I was trying to understand what happens to people – it was the thesis of my work both then and even now- and understanding what happens to people before and after the trauma bay. In our clinical time in residency, we spent a lot of time learning how to manage people in the trauma bay and understanding what happens to people before they got there that brought them there, and then working on understanding what happened to people after they left, who did well, and who didn’t do well.

I started doing very basic work at that point - trying to understand survey data, surveying patients who came into the emergency department about what their experiences were with violence, and with substance abuse before they came into the hospital. That grew into doing longitudinal studies of patients once they were in the trauma bay, or if they had come in for trauma at all in a time period of one or two years after.

In later years, I had been out to run NIH longitudinal studies that were about 800 youths who were seen in the emergency department for violence and to examine what the trajectories detailed in a very scientific, methodological way. I called it the Flint Youth Injury Study, and we learned that about 1% of those kids who came into the emergency department with any kind of violent injury, even a minor injury, go on to die. Over the subsequent two-year time period from the ED, we went on to understand how many become involved with firearm violence and recurrent partner violence that helped lay the foundation for another interest of mine.

As emergency physicians we do like to take numbers and measure them – so in addition to measuring what some of the factors were for people before and after the trauma bay, I was also very much interested in clinical intervention and what we could do to alter their course. That led to partnering with people outside of the department of emergency medicine.

I am a big believer in interesting work that happens in boundaries between fields. I partnered with folks in the department of psychiatry and public health to develop an intervention called the SafERteens Intervention, which people can find at saferteens.org. It is an intervention we developed that was meant to be a 30-minute intervention for kids aged 14-20 who come into the emergency department who are at risk for violence, either because of the neighborhood in which they live, or they’ve had some fights in the past months. We developed a 30-minute theoretically based counseling session for them and went on to study that with funding that we got from the NIAAA over the next couple of years, and found that the intervention we developed in the emergency department decreased the amount of fighting those kids had over the subsequent year period. And for every eight youths to receive the intervention, they had one less violent encounter over that subsequent 12-month time period. We also found that it decreased for kids who had experience with dating violence or partner violence in their teens before this. We also found that counselling sessions that we developed in the ED decreased violence for kids that have had some experience with dating violence or partner violence in their teens before this. So those were some really powerful parts of my work right after my fellowship in early residency.

As you are learning how to become a researcher, I encourage people to work and contribute to other people’s studies. An early study that I worked on was with senior researcher Dr. Brenda Booth, who at the time was studying chest pain cocaine patients – patients who came in with cocaine and who were staying in observation in the emergency department. We realized we had patients with major substance abuse problems who were sitting in our emergency department overnight and about to go back out, and there was an opportunity for us to figure out more about their cocaine use and to see if there was an intervention we could develop to help them become less engaged with substance use after they leave the ED. Instead of just treating them for their chest pain, what could we do for their substance abuse that they were dealing with at that time? So those were some of my earlier studies.

Dr. Garg: I would say those were very brave attempts because in my experience, ED physicians have a very cross-sectional approach to everything because we meet patients at certain points, and we don’t know when we are meeting. My fourth question is how you made that experience and learning from cross-sectional to longitudinal, and how it was not just quantifying and actually intervening.

Regarding this 30-minute intervention which you did – who were the people who were doing this counselling and what were the ED physicians’ attitude towards this study? Did they have a pessimistic attitude? Did the people roll their eyes?

Dr. Cunningham: People are really starting to have a much different attitude about the role and lane that physicians work in, in preventing violence, and now specifically firearm violence, and you know with the national movement now, they say this is our lane and we need to care about violence and the public health problems.

We are in a much different place, but I can transport you back to the timeframe of the late 1990s and early 2000s. Even though we are the safety net of health and public health more than any other specialty, there is definitely the idea that we are treating people for what they have and it’s not so concernable to take care of all these other messy social issues, such as substance use and partner violence - the things that are making it more likely for them to have problems later on. And certainly, as a busy emergency physician for many years in my career, I understand I can’t do everything in a busy ED. And with the patients that have decisions to be made, we don’t always have time to dig into all those pieces.

One of the things I would say is I am a big believer that the emergency department is a really great place to address a lot of these issues for patients because they arrive there like no place else in society, and it impacts their health dramatically. If you want to think from a health system’s approach, you have to think about some of these prevention aspects for patients who are meeting them where they’re at and after the emergency department. With that being said, that doesn’t necessarily mean that whoever I am asking heavily believes it has to be the physicians who are doing all the interventions. We simply don’t have the time; we have to go see the next patient who comes by or the next patient in the trauma bay.

When we first started our study, SafERteen, we had research counsellors who were paid on the study to do the work. I have always been very cautious about being careful not to disrupt the flow of patient care - even if it’s for something important like this counselling session. So, it’s a 30-minute session that happens in passing; for example, when a patient is needed to go out and get an x-ray, get their ID, blood drawn, or whatever they need. Patients have an awful amount of downtime, and so we worked with that downtime that they had, and we were mindful of prioritizing clinical care.

Initially, the physicians and staff and nurses didn’t wind up needing to engage them; we were mindful and respectful, so we didn’t have to engage them directly in this and operated around the edges. We moved on, and multiple studies showed that this counselling session worked. It has become CDC’s best practice of care in terms of prevention of youth violence. We started moving it to implementation studies and how we can engage the staff more broadly.

Initially, I had a lot of eye rolling. As long as I didn’t mess up people’s clinical practice and care, the thing we were doing with the patients wasn’t paid attention to, and I didn’t get a lot of grief about it, although nobody thought it would particularly work and potentially was a waste of my time. People always said, “Rebecca, shouldn’t we be studying something that is more meaningful?”

There is certainly a shift in culture overtime since then. Once we moved on to doing this as implementation studies, we had to work on integrating this into clinical care a little better. We met clinicians and staff and nurses and techs and tried to figure out who would be best, when we didn’t have research counsellors anymore to provide these sessions, and a couple of options came up.

In one hospital we do administer the program with child life advocates who are already there, and are well integrated into care and trained to do these sessions. In other places social workers have picked up some of the sessions, although they are very busy and very understaffed in our study. So those are two of the options. In some study situations we had nurses trained to deliver the sessions to reserved patients, but we haven’t made this for physicians who we know don’t have 30 minutes to sit with individual patients, in the same way I don’t have time to draw my own blood and do my own x-rays, so we have a team approach and that’s what works.

We found ultimately from a cost-saving analysis that we did and published years ago that  the SafERteens intervention costs less than a bag of IV saline prevented incidences of violence over the year, so from a full cost benefit perspective, the impact was substantial.

Dr. Garg: To point out what you said earlier, the times have changed now and the EDs have a very different approach. I remember when I was a resident, if somebody would ask for a Metformin prescription, some people would eye roll. This is a different world now, we are doing a lot more public health than we did before and ED’s have really expanded their role.

The other thing I want to ask is that these people are challenging as it is to begin with - there are a lot of issues around wrong documentation, false identity, or undocumented patients - so did you face any of those issues with your population? How did you even longitudinally identify them if they may give a fake name and they may be undocumented?

Dr. Cunningham: For longitudinal research, we identified people when they came into the ED, and asked them if they wanted to be a part of the study. We didn’t find fake names necessarily to be an issue, but people are hard to follow, and housing isn’t stable often, and they’re moving around and such. With that it is difficult to track patients longitudinally for research studies. Tracking patients, particularly substituting patients who are violent or have complex social lives involved, is difficult to do longitudinally, but we were able to do this. We actually wrote a methods paper on exactly how to do this and we published it in Academic Emergency Medicine called “Tracking Longitudinal Patients,” (and that’s not the exact title), to share our experiences. 

We really pulled from literature that has done this well in other fields, and I remind your listeners to think about that, most of the methods that you have a hard time with, other disciplines may have figured out in other specialties. The psychiatry fields have figured out a long time ago how to track patients that are difficult or complicated, and we pulled from their methods to be able to do that. Now we have research funding to do this project so with that we were able to pay people for their interviews every six months for the two-year study that we did. We were able to retain 85% of our original sample, and that took a fair amount of effort.

When you are going to follow outcomes from ED patients, it generally doesn’t work trying to sit there in an office and trying to call them between 9 to 5. You have to be willing to try to contact people on weekends and on evenings. We sent letters to their homes, we sometimes do home visits to follow up with them to be able to find them and continue the survey project that we have going on for the longitudinal study.

We detailed all those methods exactly for that reason because we realized it is difficult, but I also caution people you can’t have, it’s really important especially when we’re doing public health research in emergency departments – we have to be able to study the outcomes. We have to be able to decide which programs are valuable or not. You can’t comment on the outcome for studies that have a response rate after that is 50-60%; they really just wind up not being valid. Both our group and other groups have demonstrated that the highest that you get in the responders in that time period after, unless you have a representative sample of 85% or so, is simply leads to mis conclusions. So, it’s important to really dedicate the resources in your project that are needed to do that version of the follow up to get that outcome and response rate that is needed.

I would say also that these studies, and that particular study, was not completed twenty years ago. In fact, we are still following that cohort, and we have just recently picked them up in a certain spot. We now do a lot of contacting and following patients when we’re going to interact with them in the ER, we are going to follow them after, we do a lot now with text messaging and social media and making sure we have multiple ways to contact them, and have approval and IRB approval to contact them through all of those different methods, which are often better and more reliable than phone.

Dr. Garg: That’s amazing, and my guess is when that all this started there were no phones or text messages.

Dr. Cunningham: We didn’t have text messaging, but our team moved pretty quickly and we now make sure you have to get approval for people to get their Facebook, get their Instagram accounts or whatever means we have to get to contact them, and then for those you have to be able to set up a chat that is private so they are not identified in the study when you are trying to contact them. These methods have been done by others, and it is a valuable way to think about tracking your patients. Whether you are doing heart failure studies or whether you are doing violent studies, and you want to have the outcome after the ER, you have to be able to track people.

Dr. Garg: I’m glad you mentioned that because we had a similar discussion regarding our heart failure patients and for different reasons that is a very difficult population as well. So, personally, this is very enlightening for me and I am learning a lot. So, my next question is, this is a very difficult topic and what motivated you in life, or was there any particular event, which led you on this path?

Dr. Cunningham: I grew up in a household that had a fair amount of domestic violence in it and that really shaped a lot of my childhood and early years and views of the world. I was fortunate enough to go on to medical school to be able to help take care of other patients down the road. But it did give me an appreciation of early on of how violence impacts people’s lives and also the difference that interventions and caregivers can provide during that time. I think both those life experiences as well as the interactions in medical school and residency and taking care of patients really motivated me.

I think one of the things that really motivated me in residency and early on is looking to identify the problem. One of the problems I saw early on was that in the late 90s early 2000s we had a pretty good understanding of other kinds of violence, so there were good practices in place even for partner violence that still have a long way to go, but a basic medical student then knew and knows now that if you see somebody or see a woman that has an injury that is inconsistent, there are questions you should ask and services you should offer.

There is also a mandate around child abuse, and we get lectures on how to manage that, and what to look for. I found it really striking that taking care of other types of trauma patients, peer violence specifically and street violence, that we didn’t have any similar understanding of how to change the course of those folks lives and it was our goal to do that. We were really just treating and treating them, and I found that to be incongruent with how we managed other kinds of violence, and also just unsettling that we have 14 and 15 year olds who come in and they get shot on the leg, and 95% of those will go home the same day from the ER. We sort of just wish them luck and follow them up with wound care without any regards to their emotional and mental health around the injury, or necessarily what environment we are sending them back out to- that they’re not going to be shot again in retaliation. And that’s where I found the greatest need and focused my early research efforts on first trying to understand that, what do we know about it.

When we first started, it wasn’t clear when people came into the ED for violence, how many came in for partner violence versus street violence versus other kinds of violence; where those injuries were happening – were they happening at home or were they happening at work? So even just dissecting that and describing the problem better helped identify ways that we could move forward. And that’s a good tactic for residents and early fellows – you have to be able to describe the problem, and that’s what you mentioned, that’s where the cross sectional work comes in often; simply understanding what the problem is and what else is known about it and describing it clearly can lead to help identifying what the research questions are.

People run to sometimes solving the problem; solving requires addressing the issue like trauma and trauma care and preventing violence that may take an entire career. You have to identify the individual questions first. So, one of the first questions I asked early in my career is how many people come into our ER with violence and what kinds of violence they have. How many people have both partner and peer violence, and how should we start to think about who is at risk and who is not?

One of the other things that has come up that more hospitals are becoming cognizant of is the concept of trauma informed care. It has to do with the way that we as providers address and interact with the victims who come in of violence. It’s also something perhaps worthy of a journal club down the road, but we actually started doing some of the studies following the longitudinal patients who came in with violence and people often say to me, “you’re not going to get any real answers, people aren’t going to tell you, they’re just going to say they were sitting on the porch, and they got hurt minding their own business.”

And we actually didn’t find that at all. We found that over and over again with studies that when you sit with patients respectfully and confidentially and you are not judgmental and you seek to understand actually what’s going on, that people are very open often with you.

Now obviously some people are worried about criminal sanctions, and that has to be sorted out and respected, but an overwhelming amount of people will speak openly and are incredibly grateful for the opportunity to discuss what is inevitably a very traumatic event for them in a way that isn’t blaming them for how they wound up. Whether they were the perpetrator or whatever it is that happened, this person in front of you is injured and has suffered this trauma. Thinking about it from a different lens, also from the ways that we set up our risks that led people to wind up where they wind up in our trauma bays is understanding them a little bit more fully leads to a different type of care that could be beneficial to our trauma patients.

Dr. Garg: I think the new generation of residency education, specifically in emergency medicine, has to open up the horizons for what we can, especially trauma and firearm injury and teenage violence because that’s a big way to make the world better.

Dr. Cunningham: Emergency physicians are some of the only providers who wind up seeing firearm violence. In rural areas, they don’t even wind up in an ER often because of suicide and they die on scene and then in urban areas the numbers we pulled from both kids and adults – 89% of victims who get shot go home from our ER. Sure, some wind up being seen by trauma surgeons up in the hospital, but most don’t, so they come in and out of our ER. Our specialty keeps an interest in their care and their outcome and the prevention – they simply don’t interact enough with the rest of the health system and the rest of the health and medicine office to be able to really impact public healthcare. We are the interaction.

Dr. Garg: I’m going to dial the needle a little bit back towards the research and the collaborations. How did you secure your first grant? What were the collaborations you needed?

Dr. Cunningham: Again, both then and now, an awful lot of research knowledge and information is not here, we are a new field still. It’s really critical to get mentorship both within your department and within your specialty but also out of your specialty. I knew I needed mentorship in public health and psychiatry for the counselling component. So, I partnered initially with people who had that expertise and I got mentorship in injury prevention broadly.

And in terms of first publications and grants, I think there’s two really good models for mentorship you need: you need mentors who are senior to you, but you also need peer mentorship. I developed a group and a cohort by doing the fellowship. The other fellows who were struggling with some of the same questions that I was, and how to write manuscripts and how to look at the data and what these different p-values meant when we were first starting out, and we were able to support each other through some of those times and questions and also seek senior mentorship. But it was a very multidisciplinary approach. It also made for good grant writing later on because we were all emergency medicine physicians all studying the same idea, and when you go to write grants or papers, you all have the same focus, but you also have the same role on it.

Most keen scientists prefer for people to have some differentiated roles, and so it wound up being very good for writing other grants later on because I could bring in a clinical perspective about this particular component of the research and the psychiatrists knew this part and the data person knew this part, and it led to keen scientists having a clear role that was different.

Dr. Garg: I heard psychiatry and social work and life advocates being involved in your research, was there any role for trauma? Was that a collaboration at that time?

Dr. Cunningham: Interestingly, not so much at the time. It certainly would’ve been logical. I had good collaborations with them, but my mentorship and team didn’t want to involve the trauma service. I was also mostly working with people who didn’t come in to the hospital. An overwhelming percent of the group were people who come into the ER, and most of the ER goes home. Especially with injury- unless you’re really severely injured, and I was looking at folks across a spectrum of injury, so I didn’t get to interact with much of those folks. I had developed relationships with them later on – they have all kinds of great data across trauma systems. The American College of Surgeons and trauma surgeons right now are some of our best collaborative partners across the country in firearm violence because they are the other specialty that really sees this the most.

Dr. Garg: So, how did you secure your first grant? Was it very tough? Was it a unique topic? Or was it relatively easier?

Dr. Cunningham: After some internal funding from the university, the first grant we really wrote was the SafERteens grant and in terms of our level NIH grant, we didn’t have to pay. But even so, this has been as true then as it is now, we submitted that grant four times. So, roundly rejected completely the first two, it got some scores that were reasonable the third. The point here being the magic of research being successful and research has to do with persistence and knowing there’s an idea in there somewhere and being open to the feedback. It’s the rare person I meet that submits a grant and magically everyone thinks it’s a great idea and funds it.

The next longitudinal study that I told you about, the Flint Youth Injury Study, I submitted that grant three or four times. It was roundly rejected the first two, and I managed to get it funded after the third full re-write, complete reconfiguration of it. It turned into this six-year cohort study and still lives on today as a study, but the reviewers were quick to tell me how awful it was the first two times we put it in. So, you need a thick skin and an ability to really accept rejection and re-tweak things.

Many, many, many other grants that we’ve put in that I’ve submitted two or three times have never been funded, and I’m a big fan of people who put forth their CV of failures and having a long CV of grants and papers that were rejected or failed. But the key to successful scholarly research work is really just to continue your writing and continue seeking outlets and seeking agencies to support your idea and keep receiving feedback and how to get better. It’s rarely a straight path that requires continual submission. If you don’t submit things, you don’t get them, and if you don’t submit them often, you will have to get rejected. That is research.

Dr. Garg: That’s a sign of resilience and persistence. Thanks for telling us and reiterating this information, it gives people a lot of courage.

Dr. Cunningham: You have a couple of days after someone tells you how bad your grant is to be sad about it, and then after that you have to pick yourself up and re-write it. You have to keep putting your ideas out there.

Dr. Garg: So, I have one last question for you, and it may sound a little political, so if you don’t want to answer it or answer it in the most non-political way please do. I want to ask you your opinion about firearms in current school shootings, especially by teenagers. For example, the Parkland School Shooting. As a factful researcher, how do you think the trends are involving this – are they getting worse?

Dr. Cunningham: I say this as the principal investigator on firearm safety among children and teens, which is the largest funded grant currently from the NIHCD to study firearm violence amongst children and teens. The facts say that firearm injuries are the second leading cause of death for kids over a year old until the age of 18. It is the thing they are most likely to die from other than car crashes. In my state of Michigan, overall, guns have killed more people than opioids in the past decade. This is true for many states across the country and it is a fact that is not very well known. Deaths by firearms have increased by about 33% since 2016 for kids and teens, and these are straight up the CDC numbers on death rates. We published in the New England Journal about a year and a half ago on the cause of death amongst children and teens. School shootings have also increased in ways that children and teens die by guns by about 40% more. Those are by suicide; close to 60% are by homicide, and 2-3% are by mass shootings, the kind you are talking about in Parkland and in other schools, and 3 or 4% are related to unintentional deaths in where a kid or teen finds a gun and it goes off. Those are roughly off the top of my head. All of those across the country, except for unintentional injuries, have been increasing steadily over the last four years. For teens, over the age of 14, guns killed more teens than cars now do, and that’s been a change over the past couple of years. So those are significant increases and trends that have been studied year over year and really are not debatable; those are just the death counts.

Dr. Garg: Why do you think it’s increasing? Is there any change overall that has happened over the last four years that has triggered this change and pushed towards firearms? What happened?

Dr. Cunningham: If you look at the data across demographics, pretty much every demographic across the country and every age group across the country has increasing gun deaths.  There’s a health affairs paper that we published in October of this year that details that out by date for you, as well as by demographics by state.

For example, for my home state in Michigan, firearm death rates are upped most substantially among older white men and have been pretty horrible, but steadily high, among teen boys and African Americans. They haven’t been tremendously increasing but they have been steadily very high. So, the rates of it increasing altogether over the last several years – there are a lot of hypotheses about that, I don’t think we have a lot of answers exactly why.

We have not changed in our country in improving our methods and changing the culture storing gun safely and safe storage at the time when gun availability and access and numbers have increased across the country. Part of the work that our force is doing is trying to understand how we can help gun-owning families secure the firearms that they have more safely and more consistently safely.

Dr. Garg: That precisely answers my question, and I think it is a very difficult question and we hope to find more answers in time and get this trend better

Dr. Cunningham: It’s a good time for you to ask. Congress has just allocated 25 million dollars, which is historic, this past month for the specific focus on firearm injury prevention to the CDC and the NIH. That’s really a modest amount of funds for what probably is overall needed. It’s a really important signal to emergency medicine physicians out there. This is a very legitimate field of study that we need to spend as much time on as sepsis and MI and stroke. This is the number two killer of kids and teens in the country and kills almost 40,000 people in the US every year and EM physicians are on the line for it. Now there is money increasingly available and I really encourage people to think about it as a place to put their research efforts and time. There’s a lot of unanswered questions over the past twenty years and there’s a lot of work to do.

Dr. Garg: Thank you, Dr. Cunningham. Are there any closing remarks you would like to make for the audience? We learned a lot- it was a fabulous interview and I personally learned a lot.

Dr. Cunningham: I would say as emergency physicians, the skills that we learn from our training and the breadth of types of patients we take care of makes for a really strong research skill. And the skills that we have from our training are really very applicable, so the views that we have from interacting with other specialties and the ways we naturally get along with many other specialties based on the kind of work we do tends to make for a very good research skill. We need emergency medicine researchers out there doing more and more work. I can’t encourage your listeners enough that this is a worthy path and there’s a lot of great questions to be answered in emergency medicine research. And don’t give up!

Dr. Garg: Thank you again for your time.