Episode Transcript
[00:00:01] Speaker A: You're listening to the Doc Lounge Podcast. This is a place for candid conversations with the healthcare industry's top physicians, executives and thought leaders.
This podcast is made possible by Pacific Companies, your trusted advisor in physician recruitment.
[00:00:20] Speaker B: Hi everyone and welcome back to the Doc Lounge Podcast. I'm Stacey Doyle, your host and today I'm really excited to introduce you to our guest, Dr. Michael R. Skoma. Dr. Skoma is a board certified infectious disease specialist whose background spans some of the most respected institutions in medicine. He completed his residency at NYU Long island and a fellowship in infectious disease and clinical immunology at Yale New Haven Hospital, where he also trained in transplant infectious disease and conducted research in chronic viral infections.
He now serves as an attending consultant at NYU Langone Health and Lenox Hill Hospital while also running boutique practices in Long island and Manhattan's Upper east side. What's unique about Dr. Skoma is the way he blends world class expertise with highly visible personalized care, extending his reach through both in person and telemedicine visits to patients across the US And Europe.
He's been named a Castle Conley top Doctor multiple years in a row. And today we get the chance to hear directly from him about his journey, his work, and the ever evolving field of infectious disease.
So welcome to the podcast, Dr. Scoma.
[00:01:31] Speaker C: Stacy, thank you for having me. It's a pleasure to be here.
[00:01:34] Speaker B: We are excited to have you. And I first wanted to just kick it off. Tell us a little bit about how you got into the specialty of infectious disease.
[00:01:46] Speaker C: So thank you for the question. That's an important one. I had actually started with my father. I had started with my father, who was an infectious disease doctor actually. So I was exposed, and my mother had been a nurse, so I was exposed to really nothing but medicine at a pretty early age.
Used to see dad come home late at night, you know, would hear some of his sign outs with respect to the patients that he was seeing.
And then ultimately that was the path that I went on upon graduating college and, you know, hearing about, you know, his, his patients and seeing what he was speaking of, and then ended up, you know, pursuing medical school and then a residency in internal medicine. You know, when you're training, you have to start with kind of the basics. And that was at nyu.
And when I distinctly remember, even though it was a number of years ago, I used to always gravitate towards whatever rotation I was doing, whether it was intensive care unit or night float or any of these things that are pretty brutal regimens, especially back in the day when it was not so regulated in terms of capped hours and things like that. I used to always gravitate towards the septic patients, the infected patients, the immunocompromised patients, meaning their immune systems have been been attacked either by, or have been compromised by virtue of having a transplant or being on chemotherapy or having HIV or hepatitis C. And it was just kind of like a natural gravitation towards these patients coupled with. This was the same hospital where my father had, you know, served as a private practice much, much like myself, never, you know, never employed by an.
And it basically kind of went from there. And when it was time to decide on where to take continuing medical education, it was a natural fit with respect to going the infectious disease immunology route, for which I ended up proceeding to a pretty distinguished fellowship at Yale New Haven, which was an amazing experience.
It was obviously the main hospital itself that was in downtown New Haven, coupled with the va, which, you know, is a unique experience for anyone because it's kind of really, you know, you know, every person who's done medicine or trained in medicine knows the adage, you know, see one, do one, teach one. And that's really how it was with respect to, at the va. And it was an invaluable experience because I saw things there that, you know, many instances I would never yet see again in my career just with respect to a major, major top tier institution like that. So it was an invaluable learning aspect as pertains to the craft of infectious disease. The things that you don't learn in fellowship and what you do learn when you come out are the other aspects of just the day to day, the business aspects, the financial aspects, and all that come with in particular being a private practice doctor. And that is really equally just as important.
[00:05:12] Speaker B: So tell me, why did you decide? It sounds like obviously your father was a great inspiration to go the private practice route. So tell us a little bit about how you went about developing your own practice.
[00:05:27] Speaker C: So initially I had joined up with my father and was working under him with him, and we did that for a number of years.
He had become ill with a terminal condition.
And at the same time I realized that I did need to branch out and expand both the brand, the patient type, the patient populace, and it was essentially the ingenuity to basically begin a, you know, find, found a PC, which is Michael Squoma Medical PC, and basically expand that scope of practice to an additional hospital, expand the referral patterns within the hospital, but then more so to really expand the outpatient aspect because that is really truly where you have the most freedom and the most autonomy to treat that. It's not within the confines or the auspices of a system type practice, and particularly not to get ahead of things, but with respect to what I do deal with in the outpatient setting, there's really no other way to do it other than being a really having true total autonomy to be able to treat these incredibly complicated, complex sick individuals that I treat.
[00:06:56] Speaker B: Well, it sounds like you have a perfect blend and I know your practice is doing really well. So tell us. I know that you have a model of both in person and telemedicine and you're here in Europe, so how did you think to even kind of do both of those things?
[00:07:14] Speaker C: So the main things that are most crucial for a doctor is you have to be a problem solver.
And if I'm dealing with these, they shouldn't be esoteric, but unfortunately as pertains to the rest of the medical populace, they are. When you speak of these things such as chronic fatigue syndrome, chronic neurological Lyme disease and associated tick borne infections, fibromyalgia, autoimmune diseases, immunological deficiencies, long Covid, which has exploded in the last few years for sure, and all its downstream related issues like mast cell activation and POTS and autonomic dysfunction, you're going to be dealing with, you're going to be dealing with a field where there are not a lot of not many providers.
The majority of the information that patients are going to get is going to be largely self driven off of research, going online, the, you know, self help groups, Facebook groups, Reddit groups, et cetera. And you know, that coupled with the reach that's necess, the reach that's required for these patients, that many are across the country, many are in other countries, it's very easy and seamless to basically take a telemedicine approach. Added to which even with some local patients that are here in the New York metro area. So some of these patients are extremely ill, they're homebound, they're bed bound, they have such a degree of neurological inflammation that they cannot even really do much of a screen time. I mean, to some of my people, doing a simple telemedicine like this would be impossible. And you have to just do it by phone or do it by a surrogate or text. The idea is basically people need care, they need the best of care and the most personalized care and you need to accommodate the patient however possible.
And if you take that approach, good things will happen and things will progress. And things will move forward even in many of these virtually kind of impossible cases that I do that I do take on. I don't believe anybody is unable to be treated or untreatable. That's not my mantra. That never has been and that never will be.
[00:09:42] Speaker B: Well, that sounds like a very inspiring ethos. And obviously I know you've provided a lot of care and improved the outcomes for so many people. So want to thank you for that for sure. And wanted to you mentioned a few of these more chronic illnesses. So I wanted to dig in there a little bit and give education to our listeners around these.
One of the first one that comes to mind is, you know, Lyme disease and these tick borne infections are really been in the news lately with celebrities and we're hearing a lot about it. Tell us about this and what we should know.
[00:10:19] Speaker C: Lyme disease and related infection and related tick borne infections like Bartonella and Babesia.
Unless you're diagnosing somebody in an acute stage of illness and it's more straightforward, they can be very difficult to diagnose.
Well, people have referred to these things as the invisible diseases that they oftentimes strike. Young, vibrant, you know, well, well achieved, high achieving, otherwise healthy patients.
And on external appearance they may look okay, you may check cursory blood work, it may look okay, you may scan them with an MRI of the brain and spinal cord and that looks okay. And meanwhile they're devastatingly ill. And so that's the thing that's most important to know with respect to, for example, Lyme and related tick borne infections is to always have to kind of have a consideration of that in your differential when you are evaluating somebody for these nondescript symptoms of perhaps fatigue, a wired but tired feeling, intractable headaches, brain fog, the lights bothering you, heart issues such as palpitations and feeling horrible when you go from a seated to a standing position, gut distress, nausea, failure to gain weight, numbness, tingling, muscle pains, joint pains, all of these things that you will see in the media and being described by, you know, certainly in respect to more high profile patients such as, you know, Bella Hadid, though she's not a patient of mine, of course she is in the news with respect to her long standing struggle and an apparent recent worsening and her seeking out, you know, extensive treatments and things of that nature.
So it's very important to have a good handle on these things, but at the same time to realize that there are other similarly invisible insidious disease processes that can mimic things like Lyme disease or Bartonella or Babesia, these other tick borne infections that you have to consider especially in this, I don't even want to say post Covid age because we are still in a Covid age. This still a lot of hospitalizations, it's still making people pretty sick.
There's been an explosion obviously of these post Covid long Covid type patients and the way that they present.
It's literally interchangeable with respect to how these chronic tick borne related patients can present or patients that have mast cell activation disorders or people who have viral reactivations like Epstein Barr and these other herpes viruses. These, they all present very similarly. So you really have to look at things with a very kind of broad differential and kind of a discerning clinical eye. Cause at the end of the day that's what really drives a lot of my decisions. It's not gonna be a finding on a blood test, it's not gonna be a finding on an mri. And that's why I take a long time with my, particularly my consultations and follow ups and I maintain very reasonable availability to be able to reach my patients. Because what's, you know, what's, I mean you may, you know, Stacie, you may. And just seeing this with your own healthcare system where doctors.
What's the biggest gripe? I can't reach my doctor. I had a simple question. I started on this medication.
I don't know whether I'm really having a side effect or not or is this kid. That can be expected.
I'm so sick already, I don't want to get worse. I need to reach my doctor and I can't. So what is that patient going to do if they can't reach their doctor? They're just going to stop what they're taking and you're not making progress. And the idea is to have these patients moving forward no matter how difficult, no matter how sick.
That's the goal obviously with respect to a proactive medical approach.
Any patient for that matter.
[00:14:34] Speaker B: And you mentioned this post Covid error in care. Tell us, I mean you're on the forefront of this. What are you seeing in terms of some of how these symptoms show up? And I know you were talking earlier about different like pots and things like that. It can, can kind of, you know, I guess almost like start with, you know, kind of have those conditions be something that springboards from this. So tell us a little bit more about what you found.
[00:15:01] Speaker C: So yes. So this is one of the largest arms of my outpatient practice are all that pertains to long Covid and it's kind of really predecessor which is chronic fatigue syndrome, which is really a misnomer. These patients are not fatigued. They've got a devastating illness that's going on, which is why we really kind of refer to it as myalgic encephalomyelitis. Now, probably more than half of patients who have long Covid they meet these specific kind of criterion for myalgic encephalomyelitis, ME it's essentially, if, I mean, it's extremely complicated, it is does not nearly have the research that it requires, it does not have the FDA approved trials that it requires. But essentially it is a kind of a complex neurological microvascular type disease which leads to what we call autonomic dysfunction. You know, when we look at the autonomic nervous system to kind of, you know, boil it down for the viewers in more of a, you know, kind of just more of a basic fashion, you know, what is the autonomic nervous system? Well, that, that governs your, your heart rate, your breathing, your respirations, your brain function, the amount of blood that gets to your brain or gets to your extremities, your digestion, your nerve function, if that is altered.
You literally have somebody who, depending on the severity of their disease, whether they're mild and they're just, you know, mildly affected to the more moderate, to the severe and very severe, where we are talking about people who are bedbound and horizontal, 247 dark rooms, noise canceling headphones, the lights blanked out. I mean, they are in such a state of neurovascular and autonomic disarray, it would literally blow one's mind how sick someone can be. And we're talking about young, otherwise healthy patients. These are not like my hospital patients who are understandably, you know, older, they've got heart failure, they're on dialysis, they're coming in with sepsis and things of that nature.
I would take any of those consoles and twice on Sunday. With respect to the complexity, yes, they're deathly ill, but we have a more obviously defined approach and understanding as to what's going on with those hospital based patients as opposed to these outpatients where we don't have again, the trials and the understanding of things that we really, that's really necessary. And it's just a large, it's one of the largest, I think, mass disabling events that we've really seen. And I saw, saw this when I was on the front lines in 2020 in the hospital seeing people coming in. Yes, they were coming in, in respiratory failure. You know, they were, they couldn't breathe, they were going on respirators. You got your X rays and it just looked like completely whited out lungs. But the thing that got me more, that irked me more way back, you know, five, five, six years ago now was that they were having strokes. Their clotting markers and their inflammatory markers were in the hundreds of thousands. I mean, absolute, absolutely off the charts. And that's when it kind of, you know, clearly just in real time appeared to me we are dealing with something that we've not seen before.
So it would not surprise me, unfortunately, and devastatingly to millions of people, that this is the sequelae that we're seeing in many instances of not severe COVID infections, but in many instances varying degrees of severity of patients. And I tend to generally deal with the sicker, with the sicker patients if they're, by the time they're coming to see me, they've been to the big name institutions, they've been to other providers, they've been to, in some instances other countries.
And they need somebody who's going to be, as you know, take the time, the personalized approach, the proactive but safe approach and kind of a very, kind of reasonable back and forth approach because that is what's necessary with respect to treating these patients and moving forward.
So I find it fascinating, I find these patients so interesting. But there is kind of the mantra in medicine and I will kind of joke with them about this.
And this is even back from what my father had said to me. He said, michael, you never really want to be an interesting patient because know with it comes usually something quite, quite terrible and difficult to figure out.
[00:19:52] Speaker B: Tell me, how are you?
What is your approach to giving relief to some of these patients that you just talked about or patients that have chronic, you know, conditions.
[00:20:03] Speaker C: So for example, with any type of chronic condition, I look at it in terms of three tiers, right? So the first is we've got to accurately diagnose or as best as possible diagnose what we think of the issues, what are the red herrings and what we think is really going on.
Once you have that, you can enact a treatment plan.
Now with respect to that, obviously first and foremost you have to have someone feeling better.
But I don't think of it as just treatment of symptoms. I think of it as treatment of the underlying mechanisms that are causing those symptoms. So if somebody has mast cell activation, that's driving a lot of their things. You've got to target that and treat that. If you have somebody with what's, you know, what's called pots, Postural orthostatic Tachycardic Syndrome. It's in the news, New York Times had featured it, that the diagnoses, the number of incidences has tenfold, increased in the last two, three years since the inception of COVID That you have to basically target those underlying mechanisms that are driving symptoms to bring relief to the patient, whatever their symptoms may be, whether it's severe neurological compromise or chronic pain related issues.
Cognitive issues, which is kind of colloquially turned brain fog, but I don't like to use that term because I feel it kind of cheapens the, the diagnosis. It's a devastating, devastating issue to be depersonalized and derealized and feel like you're not even in your own body. It gets them more actually than even the physical limitations. It's the neurologic, the neuropsychiatric manifestations are bigger. And then lastly, and what is the goal in not just this but any aspect of medicine? You really like to get at the root cause and treat the inciting cause because that's the only way that you're going to get true relief, cure, et cetera, et cetera. And obviously we try to do that whenever possible.
It is a little bit more straightforward in some things than others with respect to tick borne related issues or mast cell related issues. You know, we know what the driver is, so we can hit that driver. Now it's obviously becomes more complicated the longer someone is so sick for the severity of their illness and things of that nature. It gets a little more abstract when you're looking at things like long Covid or again me cfs which has been around, at least coined for decades. It's a little more difficult to get at the root cause now. I am one of the more proactive people probably in the country with respect to my approach towards long Covid. In particular that I am using monoclonals.
I'm just giving examples, not specific advice or everything is obviously patient specific use of antivirals, things that are gonna target what we think by best clinical experience.
I'm in touch with all of the top researchers in the country.
It's a mutual collaboration. I wanna know what they are working on in terms of markers like lab data, data points, things of that nature. But more importantly, they want to speak to me as the person whose finger is in the office, in the trenches, on the clinical pulse.
What's working on people, what's not working on people, what am I finding and so again, it's a mutual collaboration that drives my approach and it's a generally successful one in many incredibly sick individuals.
So it's extremely gratifying because it's a bit of a difficult time in medicine right now, especially when we're talking about system based medicine and metrics and things of that nature that you kind of lose sense of really what it is to be a doctor. I mean, I know this may sound cliched, but it really is true.
I really, I gained, I've gotten that sense back tenfold with expansion of the outpatient practice, that it really is truly what I think medicine should be, which is a doctor patient relationship or doctor patient family relationship. And that, you know, I have a lot of very young patients, they're in their early 20s, and you know, fortunately a lot of them, they do have very supportive family members. And I am as involved with the family members as I am with them because it's all a mutual kind of effort to kind of get them moving forward.
[00:24:45] Speaker B: Forward.
Well, thank you for that inspiration because that is a theme that we, you know, cover here on the doc lounge is just, you know, the state of where medicine is today and for providers and how, you know, with so many things that they're facing today, it can almost take, you know, that original purpose and joy out of, you know, their profession and practicing. So would love. I think you just gave a really big hint about what has helped. That kind of, you know, flip, flip and turn the page for you is really having this private outpatient practice. Is that what you would recommend? Or what is some advice you would give to physicians that may be struggling right now?
[00:25:28] Speaker C: So that's an excellent question, but it's very nuanced because the question, it's kind of like, pick your poison.
Do you want to be employed by a system, for example, which that's by and large the bulk of medicine, I mean, particularly in my area in Manhattan, New York in general.
And you're gonna be subjected to regulations and metrics and things of that nature with respect to system based medicine. But if you're sick, you can take a sick day. If you have a personal issue, they will respect that and give you time.
You will have plenty of time for a vacation.
It's certainly a better quality of life. Now, when you go to my end of the spectrum, which I can't say I would advise for everyone, it's a tremendous amount of work. That's the thing.
And I like to think I manage a work life balance as best as possible, that I have A family. I have a beautiful wife, two beautiful children who are, you know, who are in elementary school. But there's the inevitable sacrifice that comes with that.
But I saw that from an early age with my father. However, that said, that was a long time ago. It's a lot different now. You have to basically work harder as well as smarter, which is kind of the opposite end of what everybody says. It's, you know, just work, work, you know, less hard, but work smarter, not harder. But that's unfortunately, if somebody were looking to do, for example, what I'm doing, that would be my advice to them. You know, do not have any errors about.
Again, not to repeat it. But working, working smarter, not harder, because it's probably not going to happen.
It takes a while to be able to cultivate things to where they need to be in terms of serving an outpatient clientele, which is generally speaking, very complicated, very sick, spans the country as well as spans the globe to other countries.
So it's a tremendous amount of work. So tremendous amount of work.
And I'd like to say that though I try, like I had mentioned, I try to manage a work life balance, I generally speaking kind of more balance the work. And my wife is what, who really kind of obviously is the backbone of things and balances the life aspects as best as possible in addition to career and everything else. So it's a partnership. It's partnership.
[00:28:16] Speaker B: I love that, love that advice. And is there any other. Obviously it sounds like having a strong partner helps with the work life balance. Any other tips? Obviously working smarter is important that you would give to fellow clinicians.
[00:28:32] Speaker C: Well, I mean, the aspect of working smarter, I mean with respect to insurances being out of network, you're not subjected to, you know, the insurance rates and reimbursements which have, it's not a secret, obviously. And the denials that have. It's no secret that have just gone down and down and down in the last, specifically the last three or four years, I think probably whether it's just the culture of things, of economics, of the healthcare system in general. Is it the fallout from the COVID pandemic where there was just, I mean, just billions and billions spent on care and payouts and things of that nature.
So yeah, it's important to keep that in mind with respect to, if you can carve kind of your own niche with respect to self pay patients, a potential concierge model, it's going to benefit you in the short run and the long run, giving you the autonomy to treat as you'd like as well as, you know, having a reasonable degree of reimbursement for what is extremely, extremely important work that I think goes unrecognized in much of society to doctors and healthcare providers in general, whether it's physician assistants, nurse practitioners, nurses, physical therapists, psychologists, the whole, the spectrum of health care.
[00:30:04] Speaker B: Well, well said. And I think, yeah, definitely unrecognized. And, and I'm glad that you're bringing it to light. It sounds like you're really up with, you know, staying in touch with the researchers, which is so huge. So I'd love to hear your thoughts. What do you think, you know, in the next five to 10 years, where is the future, you know, of infectious disease medicine going?
[00:30:28] Speaker C: I think one thing is, I think it is inevitable that we're going to see some degree of an emergence of AI in terms of AI as well as things such as gene therapy that are going to change kind of our approaches towards how we view things as it goes, as it pertains to general infectious disease.
You know, things have not really changed for a very long period of time.
We have our culture methods, we have our data methods. You know, maybe every few years a few different antibiotics will come about. I would say that there's a tremendous role of advancement and there needs to be. I mean this is, this is a catastrophe in terms of, not to beleaguer the point, but what I had spoken about with respect to chronic tick borne related issues, long Covid me cfs, there needs to be. There clearly are on switches. I've had patients literally tell me the day when they got sick. So if there's an on switch, there has to be an off switch. But we don't have many of those yet. And I think that the drivers of that with respect to research are going to hedge around more possible AI based models, genetic based models. There was something that came about, I had seen it online. There's a neurological syndrome called Huntington's disease.
It's genetic. So it is genetic. And we don't have any basis to think that things like Long Covid or me CFS can be genetic. But again, we don't know that for sure because we don't have enough research.
And I had seen it, it was trending that they did some genetic sequencing of insertion of a remnant of a virus in a number of patients that were suffering from Huntington's disease, which is, you know, to the audience it's a, it's a long term, slow, painful neurological demise. And by inserting this, this, putting these people through this this genetic intervention, they improved their disease state in like 75% of the patients in a roughly short time.
That's remarkable. If we're able to do that with other disease processes even outside of what I treat, things like Alzheimer's, things like Parkinson's, things like multiple sclerosis, things like als, you know, these things that are generally striking down many otherwise fairly young, fairly vibrant people.
It just adds the urgency to it. I understand. I have a lot of people in the hospital that are 102 years old and they're in the hospital all the time. I understand that. And that's the natural course of aging. And there's only so much that can obviously be done with respect to that. Of course you take it as proactive as possible, but it is what it is with kind of respect to the situation when the urgency that I'm met with when I have a 21 year old who cannot complete college because they are homebound and bed bound 24 7, cannot even do a zoom call, cannot even tolerate medications because they react so badly, it bothers me.
I think about it at night, it seriously affects me.
And that's why again, what we speak about with respect to. While I am more of a clinician tapping into the people that are doing the top research in which I am going to be publishing a case series with the people from the Sinai core clinic who as far as mainstream medicine, they are at the forefront of long Covid and me, CFS related research. We're going to be publishing a case series together of my experience in terms of a cohort of number of patients of mine that I've used more cutting edge approaches like monoclonals and long term antivirals, things that are not done by a lot of other providers.
So it's important to really have a collaboration between the two because this is a significant, very urgent situation for sure. And I think we need to apply that to all of these disease processes.
[00:34:48] Speaker B: Dr. Scomo, when will that be published? If any physicians listening or patient and wants to access that, do you know?
[00:34:56] Speaker C: I'm basically putting it together with two of the doctors, the main doctors that head up the Core lab, it's Dr. Petrino and Dr. Pro Al. We're basically going to be working on it and I specifically don't have a timeframe in terms of which it should come out, but it should be a reasonable turnaround. Turnaround time. I'll be the lead author, I would expect probably in a few months from now.
[00:35:23] Speaker B: Amazing. Well, that's something everyone can be excited to Access once it's available. So we'll keep everybody in the loop that's in our network.
I want to thank. Thank you so much for joining us today and sharing all of your insights into, you know, infectious disease and patient care.
Let any listener or any physician that may want, you know, even either to engage you and have. Have you help them with their care or if they have just general questions from other physicians. What's the best way to get ahold of you?
[00:35:54] Speaker C: Yes, I mean, I'm. I'm always reachable. I'm happy to. You know, I will sometimes even field some consult requests myself if I get a. If I get a message. And I just feel that the person just really has a lot of questions that, for example, my office staff or my office manager just, you know, are just, you know, that I would be the best equipped person to answer them. I'm always happy to speak to people to gain a sense, if not to obviously take them on as patients, to steer them in the right direction to. To give them any type of insights. I'm available through obviously, my website online.
I do have two practices, one in Long Island.
You know, the phone number is. Is. Is available online. It's 516-746-2212.
My city number is 212-756-9999. But they're of course, on my website as well as I do post on X a lot. And I have a lot of people reach out to me in that way, particularly from the diseases that I kind of spoke about. There's a tremendous amount of advocacy on there from that perspective. I have a lot of people reach out to me that way. I'm really not very hard to get a hold of or to find because I basically work seven days a week. So I'm pretty readily, you know, available to. To.
[00:37:18] Speaker B: To.
[00:37:18] Speaker C: To speak with people should they have any questions, concerns, what. Or seek counsel or consultation.
[00:37:26] Speaker B: Fabulous. Well, it's been an absolute pleasure having you on the Doc Lounge podcast. We'll definitely link your website so everyone can access that and have a way to. To reach you and learn more. And to our listeners, thank you for tuning in and be sure to subscribe for future episodes. Thank you so much.
[00:37:43] Speaker C: Thank you for having me.
[00:37:45] Speaker A: Thank you to all of our listeners. If you would like to be notified when new episodes air, make sure sure to hit that subscribe button. And a big thank you to Pacific Companies. Without you guys, this podcast would not be possible.
If you would like to be a guest, Please go to www.pacificcompanies.com thank.
[00:38:10] Speaker B: You.
