A system with a soul or the humanisation of medicine. Episode 16

Monika Rachtan
Good morning, I welcome you to another episode of the podcast "Patient First", which has been a programme for several editions now. Today my guest, but above all your guest, is Father Dr Arkadiusz Nowak. A warm welcome to you.

Arkadiusz Nowak
Good morning, ladies and gentlemen, welcome.

Monika Rachtan
Mr Arkadiusz, you are the president of the Institute for Patients' Rights and Health Education, which talks a lot about the humanisation of medicine and which is also a partner in this project. I am glad that we were finally able to meet on the programme.

Arkadiusz Nowak
In fact, it took some time.

Monika Rachtan
You were a little long in coming to us, but I am very happy that you finally did. I ask each of my guests at the end of the programme what the humanisation of medicine means to them. I get different, but always interesting answers. I will ask you about this in a moment, but I have a habit in this programme of collecting questions found on Facebook groups or other places on the internet and asking for a short comment. Would you agree to comment on these questions?

Arkadiusz Nowak
Yes, of course.

Monika Rachtan
The subject is a patient statement in the context of the lack of specialists in oncology. The patient wrote: "It is not true that there is a shortage of specialists, it is just that there is no one to deploy them correctly. Imagine that there are these so-called specialists driving around small towns and communes and there they make sledges. Whatever the disease, the patient will die anyway, it's just a matter of time, and the cash doesn't stink."

Arkadiusz Nowak
Well, yes, but these are comments that are hard to address because I don't know what the author meant. In fact, as far as the shortage of specialists is concerned, we know that there are not enough of them, not only oncologists. Yes, oncology is a priority in the health care system, but this does not change the fact that it takes a long time to educate an oncologist. The DILO card, after all, shortens the time from diagnosis to proposing a specific treatment.

Arkadiusz Nowak
And things are different, as I recently spoke to a close friend who was impressed by the speed of the response after the DILO card was issued. It took only three weeks from the moment he contacted the coordinator to his father's surgery. But I confirm, there are not enough oncologists.

Monika Rachtan
And do you have to go to a big city to get a good specialist?

Arkadiusz Nowak
No, not necessarily. There are fantastic specialists in smaller cities and even in counties and municipalities. It is not only Warsaw, Gliwice or Gdansk that have the best and competent oncologists.

Monika Rachtan
Here is another comment on oncology. The essential question: 'Does the health service want to treat us or is it just making appearances?' My husband is suffering from prostate cancer. We have been struggling to get a test since January. The appointment for the test is six to eight weeks, and the wait for the result is another two weeks. And so on with each subsequent test. There are signs hanging in the cancer centre saying 'Rapid oncology treatment'. This is a fairy tale. Anyone dealing with them should not believe this nonsense. The situation could be saved, but the staff don't care. A cancer patient is just an object to be put away somewhere else. The ladies at the registration desk act as if they are working for punishment."

Arkadiusz Nowak
Indeed, I would like to make two points. Firstly, any generalisation is hurtful to situations that are exactly the opposite. This example I gave about a friend of mine completely contradicts what the author of this statement says. However, the author of this opinion has certainly experienced something like this first-hand. You can see how different cases are and it is not legitimate to say that the system does not want to treat us. You have rightly pointed out that the staff, e.g. the registrars, behave as if they do not want to work. This does not change the fact that there are also some staff who deserve praise.

Arkadiusz Nowak
A patient, especially an oncology patient, expects to be treated seriously and empathetically from the start. And the beginning is usually the registrar or secretary, who should welcome the patient with empathy and a willingness to help. Organisationally, this is possible and we don't even have to focus on whether the doctor is empathetic, although this is also important. Because the patient can then judge the whole system based on the first contact with the registrar. And this is sad. I often emphasise that at the very beginning of this journey, the patient needs to be and feel taken care of. This doesn't require a lot of money, just proper training of frontline staff.

Arkadiusz Nowak
It is possible that these people earn less than they would like and work under stressful conditions. But if they are on the front line, they should have the right aptitude for this type of work.

Monika Rachtan
I will now ask about the humanisation of medicine.

Arkadiusz Nowak
Well, that's something we've talked about quite a bit.

Monika Rachtan
Exactly, but I would like to ask in a general way. Apart from what has already been said at the beginning, what else do you mean by the humanisation of medicine?

Arkadiusz Nowak
There is a problem with the humanisation of medicine. It is a concept that is currently gaining in popularity. I often use it myself too. But it is worth asking ourselves at the outset whether medicine really needs humanising. Medicine as a science, as a very broad field that is relevant to every human being, is directed towards the human being and actually works with him or her all the time. Medicine itself does not need humanism, but its representatives do. I am referring here to the health care system with which patients collide. They do not collide with medicine itself, which often offers them modern therapeutic solutions, technologies or medicines.

Arkadiusz Nowak
The problem arises when we run into a systemic wall. In this system, we have many stakeholders: the medical profession, various treatment entities like clinics, hospitals, care facilities and hospices, and patients. And in between, there are still authorities, such as the National Health Fund and the Ministry of Health, who create legal and legislative solutions. All these stakeholders have their own interests and, paradoxically, they all claim that the welfare of the patient is the most important thing. But when you take a closer look, it turns out that often the well-being of the respective stakeholder is also important. This is why we do not want to see professional bodies constantly invoking the good of the patient, when in reality they are looking after their own interests.

Arkadiusz Nowak
You talk about the welfare of the patient, but often under this slogan you demand an increase in funding for your salaries. What does the gingerbread have to do with the windmill? There are many patient organisations in Poland that can make their voice heard. The patient in Poland is not like a goose that has no voice. He or she can express himself or herself through these organisations, and their voice is increasingly heard. So we do not need advocates in the form of corporations that supposedly fight for the good of the patient, but in practice look after their own interests.

Arkadiusz Nowak
The humanisation of medicine is, in practice, a focus on the direct relationship with the patient. This includes both the communication skills of medical professionals towards patients and an ethical approach to their mission and profession. It is also about respecting the rights of the patient and the culture of medicine, which covers a wide range of behaviours from the medical secretary to the clinic director.

Arkadiusz Nowak
In practice, patient relationship skills are nothing more than an empathetic approach, understanding, genuine concern expressed in a clear and communicative way. It is also the ability to have a basic dialogue with the patient and to give them the feeling that they are important to us, perhaps even the most important. And these are skills that can be learned. Even if someone does not have them initially, they can be trained. This also applies to personal culture, which can also be learned. But that is one thing, and the humanism of medicine in the context of the healthcare system is quite another.

Forget everything I asked and requested earlier. below is an excerpt from the transcript of the podcast "First the patient". The guest is Rev. Dr. Arkadiusz Nowak. Your task is to read the text and correct the sentences to make them understandable and easy to read, but to keep the current form of the conversation and the names of the speakers. You may not create any new content or make up any new ideas. Remember that you are a proofreader, not an editor. Communicate when you have finished and reached the end of the passage you have been given to process.




Arkadiusz Nowak
I always pay a great deal of attention here to the creation of legal acts and to the so-called spiritualisation, if you like. If I may say so, of institutions. Yes, if we assume that the Ministry of Health should be a ministry with a soul. The National Health Fund should be a fund with a soul, and not only deal with counting, statistics, processing numbers. While these are undoubtedly important, let us nevertheless remember that behind each one. Behind every number, behind every figure, behind every benefit counted, is the drama of a specific person. A concrete person. And coming back to this law-making, it is difficult to say that the Minister of Health. As here he is the author of legislation. He acts. He does not act in the interest of the patient, he acts in the interest of the patient and in creating legislation in health care also. However, for a patient who is not familiar with the system, this is not the most important thing, because he or she will be confronted, firstly, with the lack of availability of health services, or he or she will be confronted with improper provision of these services, sometimes contrary to medical knowledge, sometimes in violation of his or her rights. Finally, they may be confronted with the fact that once an adverse event occurs, they will have to wait a long time for a resolution.

Arkadiusz Nowak
From the point of view of patient safety, the most important thing is access to health services, so short waiting times, then the provision of these services in accordance with the latest medical knowledge and the whole spectrum of behavioural culture. And finally, the third important point, should something happen, is that there should be a rapid route to redress. This is all served by legislation. But the average patient will say I'm not interested in that. I'm not going to read any law, any regulation, because what am I going to get out of it? I want to go to the doctor and get quick, competent advice. For patient organisations, on the other hand, these are the key things, because patient organisations are already a level up. These are leaders who know the system and know very well that also this legislation, all these laws, the law on as quality and safety, recently so widely discussed, it serves the patient. And now, in the Council of Patients' Organisations under the Minister of Health, we are discussing the fact that the voice of patients' organisations should be taken into account already at the stage of drafting legislation, because legislation is written by lawyers for whom it is important whether to put a comma here or there, or whether the word or and rises to the level of being very important.

Arkadiusz Nowak
For us, it is important that the life and experience of the patient is reflected in the proposed legislation. The humanisation of medicine concerns the relationship between doctor and patient, but also between medical professional and patient. It is also an important issue in the context of the system as a whole. To this end, the ongoing experience of patient organisations is essential. I am glad that their representatives are now represented in various bodies at the Minister of Health. Lawyers, doctors, nurses, but also always a representative of the patient organisations should be there.

Arkadiusz Nowak
In conclusion, the humanisation of medicine must be considered both in the context of the individual relationship with the doctor or professional and the system as a whole. I recommend Professor Jan Taton's publication 'The Culture of the Medical Profession in the 21st Century', available online. Although the title talks about doctors, it applies to all medical professions. We can really learn a lot in this regard.

Arkadiusz Nowak
As far as portals like ZnanyLekarz.pl are concerned, the ratings there often concern whether the doctor was nice, polite and empathetic. The effectiveness of the treatment or the appropriateness of the methods used are less often assessed, as patients are often not competent to assess this properly. What is important to them is whether they will be treated with respect and culture by medical professionals.

Monika Rachtan
That is a very good word. I will now ask you about the authority of the doctor, or maybe not just the doctor, but also other health care professionals. It used to be that a doctor was really a person who was respected - in a particular locality, in a particular family. Today, this authority of doctors is much lower than it was a few or a dozen years ago. What, in your opinion, has caused such a decline in the status of the profession?

Arkadiusz Nowak
In my opinion, it is the pauperisation of the medical profession. It used to be that the doctor was indeed a special figure, treated as part of the elite. It can still be said to be a profession of public trust, but it used to be even more pronounced. People had full respect for what the doctor said. Although it must also be remembered that doctors talked less often to patients than they do now. There was more ethical paternalism on the part of doctors. They were not expected to explain much to the patient; their knowledge and authority were sufficient. Today, this philosophy is already outdated. We expect a dialogue with the doctor, we expect to be asked for consent for different procedures.

Arkadiusz Nowak
Moreover, before this consent is given, the doctors should explain everything to us. We need to confirm that we have understood their recommendations. This used to not be the case. Doctors were held in high esteem. So let us consider why this has changed. In my opinion, these changes are due to two main reasons. Firstly, we have become more aware - we have access to the internet, to lots of information. Sometimes we go to the doctor only to have him confirm our own diagnoses, which we have already read online. In theory, we could treat ourselves, we just lack the ability to issue a prescription or referral.

Arkadiusz Nowak
Consequently, the role of the doctor is a little different. Secondly, there are more and more doctors. It is no longer the case that becoming a doctor is difficult. Now practically anyone with a bit of patience and intelligence can become one. Especially now that new medical faculties are opening up at universities, even technical ones, which is sometimes debatable. Access to the doctor is also different, and this has reduced his authority. We did a survey on trust in the medical profession. Nurses are quite high, while the highest is pharmacist. Paramedics are not included, which is interesting.

Arkadiusz Nowak
We have limited contact with the pharmacist, but a visit to the pharmacy usually ends with the dispensing of a medicine or advice. Therefore, trust in the pharmacist is different. But I would be cautious in interpreting these public trust figures. The medical professions are at the service of human beings and deserve respect. This does not mean that they cannot irritate us with their expectations or demands on the system. Anyone can become a doctor, nurse or paramedic, but not everyone wants to. These are professions that require special aptitude and continuous preparation to provide assistance, and are burdened with additional responsibilities.

Arkadiusz Nowak
It is not only doctors or nurses, but all medical professionals who have these additional responsibilities to help in various situations.

Monika Rachtan
Yes, in a private situation too.

Arkadiusz Nowak
Of course. For this reason, these professions deserve deep respect from us, even though their demands sometimes irritate us.

Monika Rachtan
Some patients complain that they are treated badly by doctors. But we, as patients, are also to blame. For example, the lack of cancellation of appointments, which has recently been much publicised, is not only disrespectful to doctors, but also to other patients. Doesn't this mean that if we don't respect the doctor or other patients, we can't expect the doctor to approach us with much empathy?

Arkadiusz Nowak
No, the doctor should always approach with empathy and respect, even if he or she is met with a lack of this respect from the other side. But there is another aspect: we often talk about patients' rights and this is a good thing. These rights are even codified in the law. Recently, a lot of time has been spent promoting these rights, which is important. Every patient should know their rights and be assertive in exercising them. But the patient also has responsibilities that are not regulated by law. Not cancelling an appointment is one of them. It is our ethical and moral duty. In patient education, we should pay attention not only to rights but also to duties.

Arkadiusz Nowak
If a patient does not cancel an appointment, another person cannot benefit from it. And if we are talking about thousands of non-cancelled appointments, the same number of people could benefit. The patient may not feel the consequences of not cancelling an appointment, but it is their moral obligation. So we should also educate patients about their duties, not just their rights. One of these duties is to respect medical professionals. It cannot be that a patient comes and shouts at the doctor or is demanding. Of course, the patient may be stressed, but that does not justify disrespect.

Arkadiusz Nowak
Indeed, a patient who goes to see a doctor is meeting a person who is deciding important aspects of his or her future and social role. Therefore, we need to realise that there are limits to behaviour. We should also not be ashamed to talk about the fact that a doctor sees up to 30-50 patients in a day. If 20 of them do not take care of their hygiene, the doctor may be annoyed and tired. We should not only talk about patients' rights, but also about their responsibilities in their relationship with a medical professional.

Monika Rachtan
I had a visitor, a lady doctor, who spoke about her work at the counselling centre. She meets patients at different stages of treatment. Although she is happy that they come back to her, she also has to explain that not every illness fits into her remit. Patients who trusted her because she had cured them of a serious illness come with different problems, such as varicose veins, which are no longer in her area.

Monika Rachtan
Something will happen.

Arkadiusz Nowak
The doctor is also a human being and so is the patient. Both may be tired and irritated. Everyone acts within their area of competence and capacity. Therefore, the patient should be aware that if he or she goes to a specialist, he or she will not receive treatment for all possible illnesses. That is simply not how it works.

Monika Rachtan
I would like to touch on a slightly different subject. You often talk about people suffering from diseases like alcoholism. I read opinions on the Internet that if someone smoked, he should pay for his cancer treatment himself, if he drank, he should treat himself. If he didn't vaccinate and got sick, he should also pay for it himself. What do you think?

Arkadiusz Nowak
I am strongly opposed to this simplistic approach, which is very unfair in this case. Following this line of thinking, each of us would have to pay a lot for treatment, because lifestyle is the main determinant of the diseases of civilisation. Of course, there are diseases that society deems more 'worthy' of treatment, such as alcoholism or drug addiction. Sexually transmitted diseases or HIV/AIDS, on the other hand, do not arouse such compassion and desire for care. But it is in the case of HIV/AIDS that patients in Poland have the least reason to complain. Addiction often occurs after repeated use of psychoactive drugs, leading to psychological or physical dependence.

Arkadiusz Nowak
We are able to accept the abuse of alcohol with some pity, but there is no such understanding for other psychoactive drugs, namely drugs. In both cases, we are talking about a serious mental illness. They are relapsing diseases and, unfortunately, often incurable. Treatment has to be long-term; we will not solve the problem in a few weeks. Someone who completes therapy may be at best a cured alcoholic or drug addict, but not a cured one. There is no guarantee that they will not relapse after a certain period of time.

Arkadiusz Nowak
And every disease has a cause. Often these causes are due to human behaviour. But that's the way it is; not all of us are polite, not all of us adhere to a healthy lifestyle or undergo regular preventive examinations. We do not all avoid risky behaviour, including in sexual intercourse. And various diseases affect us. The health care system must include a place for every patient, regardless of whether they are guilty of their illness or not. In the end, we are mostly to blame for our illnesses.

Monika Rachtan
I think if we are assessing difficult patients, like smokers or alcohol and drug abusers....

Arkadiusz Nowak
And obese people too.

Monika Rachtan
It is often our inability to look critically at ourselves.

Arkadiusz Nowak
Exactly. I always tell my medical and other medical students that a doctor, as well as being competent and empathetic, must be free from prejudice. Because we are all prejudiced against someone, often because of that person's lifestyle or the illness they suffer from. We only change our attitude when we ourselves or someone close to us joins this group. Then we start to wonder how this is possible. And suddenly we find that a great many young people are suffering from this type of illness, and their parents are surprised.

Monika Rachtan
It shows on their faces.

Arkadiusz Nowak
Yes, it is not written on the face, but linked to specific human behaviours. That's why, spitefully, I sometimes tell the parents of these young people that they should do a retrospective of their parenting process.

Monika Rachtan
You are the president of the Institute for Patients' Rights and Health Education. What does this institute do?

Arkadiusz Nowak
The reason for setting up the Institute was to promote patient rights. When we set up the Institute together with Igor Grzesiak and a few others, our aim was to introduce a piece of legislation to regulate patient rights. It took a long time, but finally Minister Ewa Kopacz, when she was Minister of Health, decided that it was worth doing. And indeed, these patient rights were codified, the Patient Rights and Patient Ombudsman Act was created. The office of the Patient Ombudsman was then created. As a non-governmental organisation, we noticed that a lot of patients approached us because previously there was no ombudsman office, only the Office for Patients' Rights in the Ministry of Health. We helped them interpret various issues related to the violation of their rights.

Arkadiusz Nowak
At a certain stage, I felt it would be important to create opportunities to integrate the patient organisation community. At that time, many such organisations already existed. Some were well-known, others were only locally active in small towns or communities. It became our task to create a platform to exchange ideas, experiences and educate these organisations. This has produced many competent leaders who are now educated partners in discussions about the health care system. And I am really pleased that there are more and more of these leaders, they represent different organisations and are able to fight for their rights and interests.

Arkadiusz Nowak
Our action at the Institute is therefore based on three main directions: firstly, the continuous promotion of the idea of patients' rights; secondly, the integration of patients' organisations and associations; and thirdly, health education, which is still insufficient in Poland.

Monika Rachtan
Education. I will still ask, but now I would like to ask about these patients' rights. Are they still often violated in Poland?

Arkadiusz Nowak
They are being violated, as evidenced, for example, by the annual reports of the Patients' Ombudsman and his activity in starting cases. He either finds out about them ex officio or patients report potential violations of their rights. Which does not change the fact that things are getting better. There will never be a situation where patients' rights are not violated. But compared to earlier years, I think there is a big change in awareness. Patients know their rights, they may not all be able to claim them, but this is the next stage. Also there is a growing awareness among doctors and nurses.

Arkadiusz Nowak
Treatment providers are increasingly investing in hiring a patient rights officer to spread the word to staff and monitor for violations. We have many different rights, and every case is a potential area of violation.

Arkadiusz Nowak
The most common complaints concern violations of the patient's right to health services based on the latest medical knowledge and access to medical records. Sometimes there are also issues of violation of the right to dignity and intimacy. This is difficult to define, as it all depends on the subjective feeling of the patient.

Arkadiusz Nowak
If a patient feels that his or her dignity or intimacy has been violated, he or she has the right to review his or her assessment with the Patient Ombudsman and to seek redress. This is one of those rights that is very capacious. It applies to many situations, not just the extreme ones, such as leaving a patient undressed in a room without a screen. The issue of respect for intimacy is easier to define, whereas respect for dignity is a much broader catalogue of situations.

Monika Rachtan
Are there situations where patients do not exercise their rights, fearing that the doctor will treat them worse if they do?

Arkadiusz Nowak
I think these situations are quite common. Patients often don't claim their rights because they are even afraid to bring it to the doctor's attention or to ask additional questions. They are afraid that this might be the moment that will cause the doctor to misjudge them. Of course, the doctor also has other patients, so sometimes patients are left uninformed, which violates their right to full information. Whether it is the doctor or the nurse, they should ask if the patient still has questions and if they have understood everything that has been presented to them. If the patient does not ask and then resents it, the problem lies mainly with the patient.

Arkadiusz Nowak
This is often the case. Doctors or nurses sometimes even find it kind of insulting to ask a patient if they have understood everything. But that is not the point here. We need to make sure that the language we speak to the patient is understood by them. Doctors and nurses often use professional language and terminology that is obvious to them, but may not be clear to the patient. This is where mutual communication is needed. Patients should not be afraid to ask questions.

Monika Rachtan
I recently accompanied an elderly person on a commercial visit to a specialist in a large city. This patient was from a small town. The doctor greeted, introduced himself and asked at the end if the patient understood everything. He also provided a phone number and email address in case he had additional questions. The patient was surprised, as this is not the case in his locality. There, everything is done quickly, no one asks, no one explains.

Arkadiusz Nowak
Yes, but every patient has different expectations. For example, my father, who is 87 years old and already requires round-the-clock care, went to a doctor's appointment for a simple ultrasound. I asked him later if he was satisfied and how the examination looked. He replied that the doctor was nice and kept explaining to him what she was doing. However, he did not expect this and was not able to absorb it all.

Arkadiusz Nowak
But the doctor behaved really correctly. Another thing that often surprises us, and there are hundreds of such examples. One patient said to me: 'Listen, what a great culture. Imagine, I'm in hospital and there was one doctor who, before he entered the room, knocked and asked: 'Excuse me, can I come in?'"

Monika Rachtan
This should be normal.

Arkadiusz Nowak
Exactly, but this is rare in Polish hospitals. Doctors just walk in. This patient said that it created a lot of respect for this young doctor among all the co-patients. Everyone commented on how amazing it was. This should be standard, as should having the doctor introduce himself and say who he is and what his speciality is. It costs very little and reduces the distance between patient and doctor. Fortunately, this is happening more and more. I talk to medical and nursing students and for them this is something that is absolutely obvious.

Arkadiusz Nowak
On the contrary, I have to show clips from various films that show inappropriate behaviour by doctors to generate discussion. But they say that for them it is foreign, because they live in a different culture. For them, saying 'good morning' and introducing themselves is a matter of course, even if you have to do it 70 times a day.

Monika Rachtan
I would like to ask about patient education.

Arkadiusz Nowak
This is the Achilles' heel of our health care system.

Monika Rachtan
Well. What can each of us do to be a better educated patient? Is browsing Facebook and commenting on posts a good way to go, or is it better to look at the website of an institute?

Arkadiusz Nowak
Firstly, there needs to be a willingness to be aware of one's own health issues and the risks around us. Secondly, one needs to develop an awareness of preventive behaviour, both in terms of a healthy lifestyle and the use of preventive examinations. As Poles, we are far behind here, not only in terms of caring for a healthy lifestyle, but also in terms of carrying out preventive examinations. I believe that the problem lies in the lack of systemic solutions. There is not enough investment in prevention, because there are always more important needs, such as the purchase of modern drug technology.

Arkadiusz Nowak
The effects of such prevention can vary. There may not even be any, so it is often considered a waste of resources. Meanwhile, patients with rare diseases could be treated with the same money. This is a systemic error that has been going on for years. At the education level, too, there is no subject like 'Health Knowledge' or 'Health Education', although this has been talked about by many health ministers.

Arkadiusz Nowak
If we started to introduce health education in a systematic way, we could see tangible health results. But because this is something distant, no one wants to invest in something that will produce results in 10 years' time, or may not even produce results.

Monika Rachtan
Other countries have such items in operation.

Arkadiusz Nowak
They function, it is called differently. In Poland it is explained differently, most often that health issues can be addressed in other subjects too. But if these activities are uncoordinated and not done systematically, they do not work. In addition, worldview issues also affect health education.

Monika Rachtan
I will conclude with a question and ask for a one-minute answer. It is about three key points that every patient and listener should remember in order to better navigate the health care system.

Arkadiusz Nowak
The first thing: it is useful to understand how the health system works and what our place is in it. There are tools that can reduce queues, but the patient often doesn't know about them. The second thing: we must not be afraid to talk to the doctor or nurse and ask, enquire. It is our right and even our duty. The third point: while mindful of our rights, we must also be mindful of our responsibilities, such as cancelling appointments. If registration is possible online, so will cancellation.

Arkadiusz Nowak
Only the problem of the elderly and those without internet access remains. In these cases, it will still be necessary to call.

Monika Rachtan
Mr Arkadiusz, thank you very much for the interview. I wish our listeners good health and thank the Institute for its patronage of the programme. I hope we are educating patients together.

Arkadiusz Nowak
Thank you very much.

Monika Rachtan
Thank you.