Welcome And The Prehab Idea

Dr Andrew Greenland 0:00

So welcome to Voices in Health and Wellness. This is today I'm joined by Dr. Tammy Pen hollow, an osteopathic physician based in Arizona and the founder of Precision Med PRP, where she specialises in orthobiologics, including PRP and bone marrow therapies, particularly for spine and disc-related issues. What really stood out to me about Tammy's work is her philosophy around what she calls prehab, the idea that preparing the body through sleep, nutrition, and lifestyle optimization is essential before introducing regenerative treatments. As Tammy puts it, taking inflamed blood and putting it into an inflamed joint doesn't work. And that mindset really reflects a deeper, more systems-based approach to healing. So with that, Tammy, I'd love to welcome you to the show. Thank you so much for joining me today.

Tammy Penhollow 0:40

Thank you. It's an honor to be here.

Dr Andrew Greenland 0:43

So

From Pain Medicine To Regeneration

Dr Andrew Greenland 0:44

perhaps we could start at the top. Could you perhaps talk a little bit about your background and what led you into this space in the first place?

Tammy Penhollow 0:50

Absolutely. I'm traditionally trained in anesthesiology and pain medicine. And I moved into the regenerative medicine space because I saw where conventional care was falling short. I was practicing as a pain doctor in a very high-volume orthopedic-based clinic, and 15 minutes to see a new patient with two bags full of prescription medications is simply not enough. It was failing the patients, and I felt like a failure as a physician. So I completely stepped back, went into anesthesiology to pay the bills while I developed this practice from the ground up so that I could re-enter the pain space and do exactly what I love to do.

Dr Andrew Greenland 1:35

Lovely. So tell us a little bit about your practice. Obviously, we'll delve into it in a bit more detail, but just give us a sense of what your practice is at the moment.

Tammy Penhollow 1:43

I take patients who have spine, uh knee and shoulder pain mostly, but any joint, but those are the ones that find me the most who are trying to stay out of the operating room. They have been active in the past, or they are currently active and it's restricting their ability to do things from lifting the groceries to performing in pickleball leagues or golfing. And we work together, we partner together to get them ready to ultimately use their own cells. You mentioned platelet-rich plasma, bone marrow, adipose, or even dextrose prolotherapy to stabilize the ligaments, the joints, the systems that help them be active.

Why Steroids Can Backfire

Dr Andrew Greenland 2:29

And you just mentioned things like orthobiologics. So what drew you specifically into orthobiologics and treating spine and disc issues?

Tammy Penhollow 2:38

It was that we weren't using band-aids. We weren't using destructive. I can look at my life as a former pain doc using steroids. I now know steroids don't only destroy the cartilage within the joints or cause risk for tendon rupture in a tennis elbow or golfer's elbow, but it also tends to cause things like adhesions within the epidural space, the spine, my area. And it's it's something that's just like kicking the can down the road. Radiofrequency ablations to uh take care of the medial branch of the nerves that go to the facet joints, which are common in spinal stenosis, that kind of achy low back pain across the back, like you're wearing a Home Depot belt, denervates the multifidus and that further destabilizes the spine. So not only is it a band-aid to do the traditional things I was, it is something that is actually promoting the earlier development of arthritis and destruction, and it's leading them to the operating room. And I knew that was not the kind of medicine I ever wanted to practice. When we know as an osteopath, one of the first principles is that the body has the innate ability to heal itself when put in the right conditions, the right conditions then go back to that functional medicine that you deal with and I deal with as well, where if you optimize a patient's whole homeostasis and turn it up the notches where it used to be, then you can superconcentrate those cells and put them back into the areas that need the help and stimulate the body to do the work that it does have the innate ability to do.

Dr Andrew Greenland 4:29

Thank you. I love your philosophy because it's as a functional medicine person myself, it completely resonates with me. And I do um I have actually trained in osteopathy nine times, so I love this, the language of all of this. But um, I think you've kind of discovered that it's not just about the procedure itself, but the preparation beforehand. Was there a moment when that became real to you? Was it a patient experience or a particular thing on your journey when that really kind of clicked?

Tammy Penhollow 4:53

It was a combination of things, Dr. Greenland. It was me going to conferences like the Orthobiologic Institute or the IOF and seeing where others were getting some results, but not consistent results across the way. And everybody was chasing the numbers. Let's get a higher dose of platelet and assume that that also means all the growth factors, the anti-inflammatory cytokines. And they were chasing this number mark. But really, I could have the best kit and the best quality preparation. And this kit supposedly gets 90% recovery of the platelets, for example. But I could take two patients that have the same diagnosis and they would not respond the same, with me as being a controlled variable, my kit as being a controlled variable. I know what dose I'm giving them. And they were not responding the same because they were different bodies. And that made me take a big step back and say, of course, we are we're all unique humans. We need to optimize what we do have. So it was that that realization that I was watching others spin their wheels and just chase what I thought were the wrong, or I guess the two um elementary uh markers of improvement, and we really need to bring it back to the patient.

Dr Andrew Greenland 6:17

Thank

Prehab And Where It Comes From

Dr Andrew Greenland 6:18

you. And I suppose that leads us nicely on to this concept of prehab. Um, and where did the idea where did that actually come from? The idea of prehab and your your use of it in practice.

Tammy Penhollow 6:29

I work very closely with physical therapists for rehabilitation. I work with taking the person after the surgery or after a procedure or after all these interventions and know the benefit of that. But what about getting the person actually ready? As an athlete myself, I trained for marathons, I trained for the triathlon, I trained for the duathlon. That's prehabilitation, that's getting yourself ready for the event that you're getting ready to do. Similarly, as an anesthesiologist, I saw patients who had done some work, like they had even somewhat optimized their cardiovascular or their respiratory fitness. They had stopped eating junk food and started eating well before a big surgery. They tended to do better under anesthesia. And there's a whole group of people that are trying to focus on pre-surgical optimization. And that's from the orthopods who are doing, say, a rotator cuff repair, a knee replacement, they are seeing the benefit. So I think a lot of people at the similar times were coming around with why don't we start with a better substrate to work with and aren't we going to get better outcomes? So I coined the term quite some time ago, and I'm sure I'm not the original coiner of said term, but I've been using it for well over six or seven years now. So it's been a philosophy shift that I introduce to my patients when I meet them in consultation.

Dr Andrew Greenland 8:05

Thank you. And for somebody that's someone who's new to your work or a new patient coming in, how do you describe in patient terms what the philosophy is behind precision med PRP?

Tammy Penhollow 8:17

I say that right now your body is not in its optimum state. Right now it's working hard, and maybe we don't have the right uh fuels. Maybe we don't have the right system that is going to facilitate what you and I want to do together. I can liken it to using unleaded fuel and the regular versus the superoctane that you'd use in your performance car, and we're trying to increase your fuel to be that superoctane. If the person is already an athlete and a builder, then I talk about anabolic states and catabolic states. And basically, that right now you're in a breaking down state. We've got an injured tendon, everything right now is inflamed, and we need to be in a building phase. So that's the anabolic part. And we'll talk about how we use protein for that, how we make sure that their vitamin D levels are optimized. And I explained that we're going to get some baseline labs. We're definitely going to do the physical examination to include a dynamic ultrasound of the area. So it's not just them laying static in a tube or standing upright for those plain films. And we're going to have the ultrasound on as they're doing the motion that hurts, the overhead thrower, and I've got the probe on as they're doing the throw. So we know what's actually going on in dynamics and that we're then going to optimize that. Most people get that.

Explaining Prehab To Patients

Dr Andrew Greenland 9:45

Thank you. Um, so what does your um day-to-day look like now, both as a clinician and a business owner? Because you are a business owner, you're obviously running a clinic and it's a business. What does your day-to-day look like?

Tammy Penhollow 9:55

It varies based on the day. I have committed myself that as a business owner, I will work in the business and on the business. Um, Mondays are content creation. I am so big in education that I spend the entire day working with my YouTube channel, with LinkedIn, with the other platforms like Facebook, Instagram, and thought leadership development so that I can reach different people from that person who might be thinking about to the person who actually has an injury now, to my peers and my colleagues or other people that are considering entering regenerative medicine. And I focus on that. Um, Tuesdays through Fridays, I'm in the clinic and the schedule varies. I would consider a busy day four to five patients because I spend an hour to an hour and a half with each one, depending on what we're doing, even in a consultation, and then some of the prehabilitation treatments that we're doing. If I'm in the procedure suite, those are two and a half hour blocks for each patient because it's not just let's inject that whatever tennis elbow or that epidural space because you've got a radiated, you know, a herniated disc. Um, I look at things as more of the functional operative unit, the functional spinal unit, the functional joint. It's not just the shoulder, it's the rotator cuff muscles, it's the biceps tendon, it's the AC joint and the glenohumeral joint, etc. So it's very um patient focused, it's very in partnership and attuned to what they're going through. And there's a lot of high-quality touch points so that we are forming that team and I'm getting feedback from them and making adjustments on the fly if necessary, or if the labs aren't moving the way we want them to with the supplements that we've incorporated, then we make other adjustments. So each appointment allows for time to discuss that.

A High Touch Clinic Model

Dr Andrew Greenland 12:04

Thank you. And what shifts are you seeing right now in the orthobiologics and regenerative medicine space? I think you're probably at the forefront of this, but very interested to know what you're seeing.

Tammy Penhollow 12:14

Well, there is value. I'm seeing a lot in optimization. There are people publishing a paper on medical optimization before orthobiologics, MBOT or something. And so I think it's great that other people are waking up to this and coming around to it and trying to put a label on it. Um I unfortunately am also seeing that there's, you know, there's this difference between a person who is so frustrated with the current system and the declining reimbursements and the what am I going to do? I've got to infuse some cash into my practice and wants to bolt on regenerative medicine to their practice. They meet a rep, they get a kit, they decide how to draw blood, or they go to a weekend course to do liposuction to use MFAT. Um, but there's a difference between that and somebody who's actually addressing the underlying structures, looking at an entire system and targeting everything together. So I'm seeing a little of that, unfortunately.

Dr Andrew Greenland 13:25

Now you spent a lot of your time on Mondays doing content education, which I think is really fascinating and a massive commitment. Are patients now coming in with a clearer understanding of these treatments because of the kind of the messaging you're putting out, or is there still a lot of education that's required for these patients?

Tammy Penhollow 13:44

Yes and no. There is more education. I do get a lot of people who've already done extensive AI research. It used to be we we would jokingly say they visited Dr. Google first, and now we might say they visited Dr. Chet GTP first or Dr. Claude first. Um, so they are more educated in the basics. They are asking the kind of questions that I put videos out on what system do you use? How much blood are you going to draw? Are you going to use image guidance? And I love that. Where I still am doing a lot of education is dispelling the myth that PRP is a just a process, uh, excuse me, a one-time injection, that they're looking for towards that rather than the prehab. The it's going to depend on you. I can't answer your question when you first call me and say, How much is PRP? Because I don't just do PRP. We work together to address your issue within a system of prehabilitation through possibly an intervention and everything that that goes with rehabilitation.

Dr Andrew Greenland 14:56

And in terms of the messaging and the content you put out, what is working in terms of the stuff you put out, in terms of the feedback that you get and the patients that come to you? What kind of messages are really resonating with the patients?

Tammy Penhollow 15:08

I think that one that I just mentioned where I did the video on the questions to ask, because I have people specifically calling, asking those questions. So I love that. It's empowering to the people. I also have done something as simple as KT taping for medial knee pain, KT taping for lateral knee pain or for the patella. And I've had people come in with that KT tape already on and just ask me to confirm. You know, is this something that is right for me? Did I do this right? Is this part of what you would have done for me anyway? Um, there are still uh this last year I took a more of a foundational approach and I addressed quarter one as laying the foundation on what works, what doesn't, what does you know, failed standard of care mean and how that's uh very discouraging for patients. And what it really means is we didn't get it right. It's not you, it's us. And I think that people relate to that. Um, that seems to be working, but people come to me at totally different levels if if we talk about it from the marketing standpoint. They, I still am getting people who inquire at the top of the funnel, but by the time they see me, they're closer to that middle to the bottom of the funnel, and they've done a lot more research. And some of it is not the way I practice. It's I expect that you're gonna take blood from me three times and we're gonna do this on the date of the proceed, on the date of the consultation, and then I'll never see you again. So I do still have to dispel myths because there's a lot more people than me putting content out there.

Dr Andrew Greenland 16:50

Thank

PRP Myths And Better Questions

Dr Andrew Greenland 16:51

you. Um, in terms of the expectations between patients who have done the prehab work versus those that haven't, what are you seeing as a difference between them?

Tammy Penhollow 17:00

Oh, they're so much calmer because they know what to expect. They have had that many more touch points with me. We've gotten to know each other. They um would sometimes come in with a list of 20 questions and and expect them all because I've got to get it all in because it's the only time I'm gonna have with you. And now it's they come in because they know we're seeing each other once a week for four weeks to do this rehabilitation. That, oh, by the way, I just read this. What do you think about that? And I've done what you said here. I wanted to let you know I modified it a little bit. And is that okay? So we're having much more, I guess they're bought in and much more engaged and calmer patients because they aren't trying to get it all in in that very first meeting out of desperation. They really feel like we're moving together on a I guess uh scientific side. I've compared actual bone marrow concentrate because I send out every specimen. I can't do a bedside test for it because it needs to be culture plated for two weeks to count the total nucleated cells and the uh, excuse me, the colony forming units per mil on bone marrow. And that's the standby or the equivalent of a stem cell. And I've had people that say they did the prehab and people that I know have done the prehab, or I had a person who this is I consider a failure early on, but I wanted help so bad. I'm a veteran, he's a veteran. It was one of those things where everything came together, where the kits would have been donated, and I donated my time, and he just simply didn't want to do the prehab. And I knew the moment I drew the bone marrow that it looked like a creamsickle. You could see the fat in the blood. It in the bone marrow, and there's some peripheral blood. It was lipemic. It was uh, I knew at the time um I got the results back, and it was the lowest I've ever had, and he's one of the youngest patients I've ever had, versus you know, a third, the fifth, the seventh the total number of stem cells of an 80-year-old that I have worked with. So that flies in the face of all of the literature that says your stem cells go down as you age. Well, yes, I agree with that, but I believe that we can prehabilitate and optimize a patient to the level where I can show you results from my 80-year-olds and results from my 50-year-olds, and you wouldn't be able to say that's gotta be the 80-year-old because the numbers are lower.

Proof Prehab Changes Cell Quality

Dr Andrew Greenland 19:57

And thinking about the industry uh more widely, do you think um the industry as a whole underestimates the importance of the preparation before treatment that you embody in your practice?

Tammy Penhollow 20:10

I do. Um I think maybe it's two-pronged though, that I think most docs get it. I think they understand that an optimized patient is going to do better. Maybe they are an orthopod and they've seen their patients who come into surgery and they've done work like they've stayed in the gym or they've done the PT ahead of time and they've stabilized the quad muscles, for example, before a knee replacement, and they've seen that person postoperatively and see that they actually have done better and they can extrapolate in their minds, it'd probably be better if they're high protein. It'd probably be better if they were vitamin D3 replete. It'd probably be better if, but maybe the current system constraints where we're trying to potentially merge these things. I'm still a high-volume orthopod who's seen patients at three to five minute intervals. And yeah, it'd be great if somebody else can handle that, fine. But my job is to replace the joint, or if I'm going to augment with the biologic along the scar within the soft tissues, I'll do it. But right. So I'm not, I'm not sure that there's been that paradigm shift, that mindset change. I don't think you can practice traditional pain management and orthobiologics to the same degree of precision if you don't make that shift.

Acute Pain Without The Quick Fix

Dr Andrew Greenland 21:48

Got it. I'm thinking about the patients now who have probably got a really acute problem going on. There must be I I expect some of the patients have got a call, they want a bit of a quick fix because of the acuity of the situation. But how do you balance that with the work that you want to do in the widest sense, which is probably more time consuming?

Tammy Penhollow 22:05

Sure. And that happens all the time. You know, I I work under constraints with athletes, a high school swimmer who has a rotator cuff tear, and they've got a meet where they're going to be scouted for college. Or I mean it could be everyday athlete too, right? I've got I've got plantar fascia inflammation, and I'm I walk for a living. I go between offices, I'm a drug rep. And we've got to temper that. Um, the Playlor rich plasma or bone marrow doesn't work instantly anyway. So I tell them that this is really not for an in-season sport athlete at this point, but there are things that we can do right now to start addressing the acute inflammation. And that's where we can rely on things, not in SEDs, because those are not indicated in this situation. And they actually, you know, start a clock on where I can't move forward with orthobiologics until they're out of your system, or even a corticosteroid, which is the band-aid. I haven't used a corticosteroid in my practice since 2014. So there are other things we can do by immediately addressing the inflammation other ways, like the rest, like using appropriately topicals, other medications that can help and bringing the diet down immediately. Um, if there are markers, uh, widespread anti-inflammatory markers, nonspecific, the CRP, the ESR, some of those other body markers, then we immediately dive into that and say this is only going to help. And I do start the physical portion of that. We can release the fascia, we can look at the mechanics, we can get an insole in to the shoe if that's an issue. We can correct the pelvic obliquity from an osteopathic standpoint if there's a one-sided issue and it's down that IT band and into the medial aspect of the knee. For example, I've used prolotherapy early on because it's not inflammatory in the lower concentrations. So we can do things immediately while we're getting them to the ultimate.

Blending Functional And Structural Care

Dr Andrew Greenland 24:20

Now, I'm a functional medicine person. I'm just curious to know how functional medicine more widely has helped your work and your mission with your approach.

Tammy Penhollow 24:29

Oh, there's so much value there, especially in optimization. That is the ultimate in prehab. So I do utilize that. There are labs. There is the talk about the gut, there is the talk about the sleep, and optimizing both of those and um not a specific stack of supplements, but talking about those and what should just about everybody be on, and how do we move towards a more anabolic building phase with your macros, um, big endo protein? And that's going on at the same time as I'm addressing the structural issues. That's where I've I've sometimes seen if they just go that functional route and the structural issue isn't addressed, then they might plateau. So when we combine the structural and the functional, then we see the kind of results that the patients really deserve.

Dr Andrew Greenland 25:23

That's really

Building Direct Care Without Insurance

Dr Andrew Greenland 25:24

gratifying to hear. So I'd love to shift to the business side a little bit because you are running what sounds like a very high-touch concierge style practice. When you look at the business today, what's working really well? What are you most proud of?

Tammy Penhollow 25:37

Um I'm proud of the fact that I've been able to stay 100% direct care, have not needed to fall back onto, oh, well, I'll just take a couple of insurances so I get the patients coming in or the volume. Um, that to me would have been a complete failure for me, knowing that that's the kind of resist the system I repel that I ran from and I said I would never do pain management again unless I came back into it on my own terms. So because of the way I've structured it and have had that backup with anesthesia, I've been able to build the business slowly and create those kind of systems without scaling in chaos, I guess you'd say, trying to keep that measured control of things and develop the systems as they come up and address things. So I'm I'm proud about that.

Dr Andrew Greenland 26:36

Wonderful. And on the other side of the coin, what are the sort of challenges or bottlenecks which are most impactful in the business at the moment?

Tammy Penhollow 26:44

Uh finding people who can represent this high-level medical practice without being clinicians. Um, because in my model, the first conversation is actually part of the care pathway. So having somebody that can answer the phone as well as I and represent the brand and the philosophy as I do.

Dr Andrew Greenland 27:07

And how do you find those people? What's the secret source and what are you looking for in the person?

Tammy Penhollow 27:13

I haven't found the secret sauce yet. I'm still working on that. I'm looking for somebody who is bought into the model of how exciting is it that we can work with somebody, not in a transactional fashion, to help them get back to what they want to do and what they love to do. I believe qualities are more of a um hospitality industry. You don't have to have potentially that medical background, but the people pleasing, the people caring, and the great listening aspect of hospitality is what I believe is ultimately going to be the secret sauce.

Dr Andrew Greenland 28:05

Now you wear lots of hats in your business because you're a frontline clinician, you do a lot of work behind the scenes. But what's your biggest time drain in terms of takes you away from the things you'd rather be doing? Or other things you'd rather be doing?

Tammy Penhollow 28:20

Uh the day-to-day aspect of knowing that when I do bring on the next clinician or the the person that manages the entire business, that I need to have the systems in place. And so it's developing those systems, uh, writing SOPs, um, those kind of things kind of drag me down. Day-to-day bookkeeping, although I still do my own QuickBooks at the end of the month, but day-to-day things, running those kind of reports is something that's not my favorite thing to do.

Dr Andrew Greenland 28:55

Fair. Um, if you had a magic wand and you could fix one business, one thing in the business tomorrow, what would that be? I mean, you might already have mentioned it, but I'm just curious to know what you would what would be the one thing that you would fix.

Tammy Penhollow 29:08

I'm still in growth phase. So I would have all AI point people who have knee, joint, uh, shoulder, and back pain to me in my area. So they would uh call me and let me uh work with them and take care of them.

Dr Andrew Greenland 29:27

Thank you. Um, obviously, you mentioned growing and scaling, we're all trying to grow our clinics. But if you had a massive surge of patients next week, what would happen? Would anything break? Hopefully, not you. What would happen?

Tammy Penhollow 29:39

Sure. At this point, I could absorb it onto the schedule. Um, I ultimately need that first teammate that is going to be able to be that high-level concierge person who answers the phone and can take care of the patients from the moment they are the lead through their on the schedule and then for subsequent. So I think it would expose the fact that I'm doing this all.

Dr Andrew Greenland 30:05

If you were starting again tomorrow with everything that you know and the journey that you've been on and the career and the training and everything that you've learned, would you do anything differently?

Tammy Penhollow 30:19

I don't think I would because then I wouldn't have the lessons that I do. I thought about would I ever have done a traditional pain practice in the beginning? I I would actually, because it shows those choke points. It shows the issues with that system, the band-aids, the destructiveness. So my first instinct was to say I would have gone into regen first, but I wouldn't have appreciated what it is if I hadn't lived in the system before.

Dr Andrew Greenland 30:52

Very, very honest, that's very true. I mean, I think I'd probably say the same thing. Everything has been a learning journey, and I don't think I could have um, I don't I wouldn't want to miss out on that because everything has been a valuable learning. So I completely concur with you. But

Ethical Regenerative Medicine And Growth

Dr Andrew Greenland 31:05

what but thinking about the next six to twelve months, what does um what does that look like for you and uh precision med PRP?

Tammy Penhollow 31:14

It looks like continuing to build the practice, um honing in on patients who are maybe in that confused state. I've developed a guide on the re you know, the patient's guide to ethical regenerative medicine, and that's kind of a prequel to a book. So I'm really thinking more on that patient education side and trying to protect them from a lot of the I call them scam cell clinics. That's not very nice, but it is uh what it is. Um, so just more, I'm leaning more towards that so that I can affect more people, help people who are far from me and wouldn't have the opportunity to work with them one-on-one, that I can maybe help protect them from some of the things out there in this growing field that is sometimes not as clear as it could be for patients who are trying to navigate it.

Dr Andrew Greenland 32:17

Thank you. And you mentioned growth a couple of times. Is that more patience, more leverage, more support, something else, all of the above, none of the above? What does it look like for you?

Tammy Penhollow 32:28

All of the above. Um, more patience to fill the schedule with um those who I now are are consistently working through at different places in their optimization through rehabilitation, that then allows me to bring on people that can help me with that so that it's not me being the operator in every situation, um, somebody that can help decompress that from me, which allows me to then do more outreach. Um, I teach and I speak, and doing that I think also helps with growing the practice, excuse me, the practice in general, not my practice, but the practice of regenerative medicine in an ethical fashion, teaching other physicians who are interested in um bringing that into their practice. So, yeah, growth in all aspects.

Dr Andrew Greenland 33:23

And I obviously love your pre-hab concept. I know you weren't necessarily the first person to use it, but I I like the way that you embody it. But how scalable is it if we think more widely?

Tammy Penhollow 33:33

I think it's very scalable. Um when we look at developing kind of baseline parameters, are there certain labs that are for everybody that we want to know? Is there a certain functional evaluation that we want for everybody with a shoulder gets this, everybody with the knee gets that, everybody with the spine gets that? And then developing the protocol based on are we repleting this person? Is this person 100% in all these areas? Is this person got an A1C of 7.5? And we really know where we need to dial in there. Um, I do believe it is scalable without rigidity, that you might not be able to take all these people in the same cohort and put them in the same room unless they are coming in for education and we're at high-level education, and then you're one-on-ones with the nutritionist, or you're one-on-ones with me, can dive into your specific issues.

Dr Andrew Greenland 34:37

With that,

Final Takeaways And Thanks

Dr Andrew Greenland 34:38

Tammy, I'd love to thank you very much for joining me today. It's been such an insightful conversation, especially around the idea of the prehab model. I love it. Um I think it's something that a lot of practitioners will resonate with, you know, outside of this particular niche, but more generally. Um, so thank you very much for joining. It's been a really great conversation.

Tammy Penhollow 34:54

Thank you again. It's been a pleasure.