Creating Health: Transforming Models of Care: A Clinical Conversation with Mimi Guarneri,MD,FACC,ABOIM,and Robert Rountree,MD

Mimi Guarneri, MD, FACC, ABOIM, is board-certified in cardiovascular disease, internal medicine, nuclear cardiology, and integrative holistic medicine, is a founder and president of The Academy of Integrative Health and Medicine (AIHM), serves on the founding board of the American Board of Integrative Medicine (ABOIM), which is the integrative medicine board certification exam offered by the American Board of Physician Specialties^® (ABPS), and is a clinical associate professor at the University of California, San Diego (UCSD). Recognizing the need for a more comprehensive and holistic approach to cardiovascular disease, Dr. Guarneri founded the Scripps Center for Integrative Medicine and served as medical director for 15 years. In 2011, she received the Bravewell Leadership Award. In 2012, she received the Linus Pauling Functional Medicine Lifetime Achievement Award from the Institute for Functional Medicine and the Grace A. Goldsmith award from the American College of Nutrition. She helped create and continues to direct several national integrative medicine-based conferences in San Diego that draw thousands of health care providers from across the United States and globally. Dr. Guarneri is cofounder and medical director of Guarneri Integrative Health, Inc. at Pacific Pearl La Jolla in La Jolla, California, since 2014, where she leads a team of experts in conventional, integrative, and natural medicine.

Robert Rountree: Tell us a little bit about your background. I know that your undergrad degree is in literature, so that is a far cry from medicine!

Mimi Guarneri: I grew up in Brooklyn, which has now become the hip place to live. Who would have thought it at the time? And you are right—I majored in English literature at NYU, and I loved it. But I also knew I was destined to be a physician.

I will never forget my college counselor, one of a few women scientists on the Manhattan project. “You will never get into medical school because you are majoring in English literature.” And of course, I thought, “This is the best thing she can do for me, because she completely motivated me to prove her wrong.”

When you major in English literature, you have to write articles, you have to read all types of books. It is not like biology, where you learn about the cell and then you get tested on what the mitochondria do. I thought English literature was a lot harder than science.

When you go to medical school, they expect one thing. They expect you to take in an enormous amount of information and memorize it. And unfortunately, they do not even expect you to think about it or to question it. That was my medical school, anyway. I remember being with PhD students in some of the science classes, and with everything the professor said, the PhD students would say, “Why?” And the medical students would just be saying, “Okay, I will memorize that. I am not going to ask why. It is just too much.”

Dr. Rountree: Before going to college, did you have an inkling about medicine as a career?

Dr. Guarneri: I did. When I was 17 years old, I told the local volunteer ambulance service that I was 18 so I could volunteer to work on the ambulance; I already knew that I wanted to go into medicine. I thought maybe I would want to do research, but I was not quite sure. But I always knew I would go into medicine. For a period of time I thought I would be an anthropologist. I loved anthropology, archaeology, and literature. And I kept saying, “No, no, I am not going to do that.” I knew on an intuitive level medicine was what I was meant to do. I experienced a lot of loss in my life very early, which I think also added to it. My mom died of sudden death when I was eight years old. That was, I do not have to tell you, a very traumatic event. And my dad died of a pulmonary embolism when I was 17.

I had great role models; one was my family doctor. You know the days of the family doctors? I had a Marcus Welby in my life. He would come with an old broken-down car and my grandmother would cook for him three days in advance if she knew he was coming. It just shapes you early on when you have these experiences, and you think, “Well, I want to serve. I want to help. I want to do something to help people that are in the kind of situations that I have been in.” I think it shapes who we become when we are young and have such tragic events in our life.

Dr. Rountree: Was there anyone in particular who gave you inspiration or guidance back then?

Dr. Guarneri: I had an uncle who I wrote about in my book, The Heart Speaks, when I talk about the family doctor's office. My uncle was a family practitioner who ran his office basically out of his house. We could go from the house to his office, and I can remember going in there playing with mercurochrome bottles and little alcohol swabs. He was helping people, and people loved him because of it.

So I grew up with the old-fashioned doctor's office as part of my experience. My aunt would throw in a load of laundry and then go check in a few patients and then go and cook dinner.

I always felt destined to go into medicine on some deep level, and then I had these life experiences that just made me say, “Okay, I want to be able to serve. I want to be able to help. I want to be able to do something when people are in distress.” I had great role models—my uncle Vic and my family physician who sparked my desire to serve others.

Dr. Rountree: From there, you ended up at the pinnacle of specialty medicine as an interventional cardiologist. Was that a natural evolution for you?

Dr. Guarneri: Yes, and a kind of crazy choice, because there are very few female cardiologists. That is the first thing. A female interventional cardiologist was almost unheard of.

I always liked the quick fix, and there was no quicker fix than opening an occluded artery in someone who was having a heart attack. There was also no greater reward in terms of feeling like you made a difference. That probably comes from my background of having so many losses.

And you can do that with interventional cardiology. You do not usually see people unless they are in some sort of distress or extremis. You have this opportunity to do something that can make a difference at that point in time, including save a life.

It was not really until I was doing 700-plus procedures a year when I met Dean Ornish, and I will never forget how I met Dean. I was in the cath lab; when I opened the door, he was there smiling. I thought, “Who is this guy?” He said, “I am Dean Ornish,” and “I would like you to do a research study.”

I thought for sure he was going to want me to do intracoronary radiation, which we were studying at that time. We were studying stents and I wrote many stent articles. All of a sudden, he starts talking to me about yoga and meditation and diet. And I thought, “This is crazy.” It was so far from my paradigm. Of course I never learned about any of this in medical school.

My mentor, Paul Teirstein, said, “No, no, this is important work.” He said, “Let us do the research study, and you will be the principal investigator.” And I thought, “Oh, my God, I am going to be principal investigator on a study that involves vegetarian diet and yoga?” Things I knew zero about. In one week, I had to get myself up to speed on lifestyle change.

So I travelled up to Northern California, where Dean was hosting a lifestyle change retreat. Imagine an interventional cardiologist going to be a retreat participant in lifestyle change. My body felt like it was in shock, giving up coffee and eating a 10% fat vegetarian diet. I frequently thought “I am just going to order room service.” But I made a commitment. I thought, “I cannot do the research if I do not know how to teach the participants lifestyle change.”

Then I watched over the course of a week how retreat participants began to blossom. Literally, their chest pain was getting better. People were cutting their insulin in half. It was really my first true wakeup call to lifestyle change. And I thought, “Oh, my God, could it be that I missed a big piece of this going to medical school?”

I decided to be a participant in the research. So everything the patients did, I did. So I did yoga over an hour a day. I learned to meditate. I ate a 10% fat vegetarian diet. I did it all. And it started to change the way I thought. And I thought, “We are so good at intervention, and we are awful at creating health. Awful at prevention.” I would put in stents and then go up to the intensive care unit where patients were being fed roast beef and mayo sandwiches. And I thought, “What the heck is this disconnect?” There was such a disconnect between creating health and treating disease. It was never really something that was taught to me in medical school. So it was a wakeup call.

I was at Scripps at the time, performing all of these procedures, and then I started doing research with Dean. When the research was coming to a head we had a 91% reduction in chest pain with lifestyle change. That is why I laugh now when people talk about studies such as the A Very Early Rehabilitation Trial (AVERT). “Oh, you do not have to stent everybody with chronic stable angina?” Of course not. But we need to take care of people in a different kind of way than just the ill to the pill, every drug for every ailment way of thinking.

And so at the end of the research, I looked at Rauni King, the nurse for the Ornish program, and said, “We cannot let this program go. We have to do something,” and we decided to create the Scripps Center for Integrative Medicine. So that is what we did—we built the Scripps Center, where I served as medical director for many years.

At that time, we worked with a true visionary named Penny George. Penny's husband Bill was the CEO of Medtronic. Penny was very interested in holistic medicine, because she had her own experience with breast cancer. We had a meeting at her home, and talked about, “What can we do?” We decided to map who in the country, whether a hospital or an academic center, is doing anything that even sounds similar to Holistic Integrative Medicine so we could learn from each other.

We created the Bravewell Collaborative, which I was the chair of for many years. It was really a way to bring together a group of struggling integrative centers and we asked, “How can we help each other? We cannot compete. We need to help each other.” Bravewell Philanthropy allowed us to meet and come together to share our experiences.

We realized we could not change health care if we did not change the way clinicians are educated. We had to change the way providers think. So we convinced the Bravewell donors to at least pay for fellowships for clinicians to go to Andy Weil's Fellowship in Integrative Medicine. Andy's program was the only program at the time. We said, “We have to educate people that can start to lead this movement.” Many graduates of this fellowship are now national leaders in Integrative Medicine.

As terrific as this is, I think we should be further along, and I really think we are not further along because we have been too siloed.

Dr. Rountree: Are you saying that integrative medicine is too siloed?

Dr. Guarneri: I think so, because just like we have cardiology and dermatology and all those silos, we have the academic consortium, functional medicine, and holistic medicine. The silos need to work together to move Integrative Medicine forward.

But, even within our own community, I think there has been a lot of competition, distrust, and misunderstanding. I was on a call this morning with two integrative centers and one of the country's biggest funders for integrative medicine, and even to this day we were talking about how can we increase the acceptance by health care providers? How can we address the misinformation and bad actors in the field? Even after 25 years, this is where we still are.

Dr. Rountree: As if there are no bad actors in mainstream medicine.

Dr. Guarneri: That is the part that really bothers me. When everybody talks about evidence-based, they forget that most of it is level C evidence. I was one of the researchers for the chelation study, the Trial to Assess Chelation Therapy study. Even when we demonstrated that the diabetics benefitted from chelation and vitamin supplementation, the conventional cardiologists had a hard time accepting this. Chelation was out of the paradigm of ill to the pill. It is shocking to me that, to this day, with a country that is obese, diabetic, with heart disease, and fatty liver, for every patient who walks through the door, we are not talking about creating health. I do not get it. I really do not. All of these diseases are modifiable and can be prevented.

Dr. Rountree: Right. Unfortunately, the mainstream needle does not seem to be dramatically moving in the direction of preventive medicine or getting underneath the real problems that our population is dealing with. The irony is that thousands of practitioners have gone through Andrew Weil's program or the functional medicine training—practitioners who have now been trained in a dramatically different way of thinking about health care.

Dr. Guarneri: Many Integrative Health and Medicine clinicians are struggling in their practice because we are teaching a different model of care that does not work when you have to see 30 people per day. We need a model of care that is totally different. We can argue about what that is, but when you are teaching lifestyle—I learned this from the Ornish research early on—you teach in a group. You bring people together. You teach nutrition to 30 people all at once, as opposed to one person at a time.

The result, those doctors who are able to, end up having an elite practice—my practice is one of those elite practices—where affluent people can afford care. To me, this is not right, and it certainly is not aligned with my philosophy. I trained in city hospitals. I trained at Kings County and Bellevue Hospital in New York. A majority of my training was not from elite hospital systems.

If we pay clinicians for keeping people healthy and for keeping them out of the hospital, we would have a different health care system. But we pay the most money to the orthopedic surgeon, the neurosurgeon. Pediatricians are paid the least. So we have a whole value system and a whole value structure that is not working.

Dr. Rountree: Do you think the problem is primarily the reimbursement model that the insurance companies use? Are they the big drivers in all this?

Dr. Guarneri: I think they are the big drivers. We code things just so insurance companies pay for it. Our whole training is focused on the “ill to the pill.” We “name it, blame it, tame it” and of course bill for each diagnosis.

So what is the best way to teach people? The one-on-one appointment limits what you can do. When I conducted the Ornish research, as the MD, I was in the background. I was there if they needed me. Every patient in that program was meeting with the nutritionist once a week, learning in groups to cook, exercise, do yoga, and meditate. It was all group learning.

I really think that if we are going to create health, we need to start with our communities, and we need to teach people in groups. Health care systems are not health care systems. They are disease care systems. We are asking them to do something they do not even have a model for, and it does not work.

Dr. Rountree: Yes. I am sure you have read How Doctors Think by Dr. Jerome Groopman. It was a very popular and successful book published back in 2007 that I thought would change a lot more attitudes than it did. He talked a lot about how most medical mistakes are made because docs are running through their day and have too many decisions to make and not enough time to think carefully about what they are doing. He essentially said that to practice good medicine, especially when addressing complicated problems, you have to spend time with people. You have to know their story, their narrative, all the things that you are talking about. It is difficult to accomplish that in a typical 10-minute visit.

Dr. Guarneri: Yes. And you also have to be able to connect with them, because when patients have that connection to you, they are more likely to listen to your advice. Sometimes they are even more likely to do it because they want to please you. They want to come in and say, “Hey, I lost 10 pounds” for you.

He talks about creating sacred space within the office. And I am a firm believer in placebo and nocebo. So if you do not have that relationship where you create a sacred space and you can make suggestions and really understand someone, you are not going to have a successful outcome, and research supports this. The people who have a good relationship with their physicians end up having lower A1Cs (blood glucose test) and better cholesterol levels.

I think this is why concierge medicine actually has better outcomes. The research is starting to show that concierge medicine patients have better outcomes. Could it be because they have few patients and more time to think and get to know their clients? And they know their patient's family, and they know their patient's stress level, and so on. I am not saying everyone should have a concierge clinician, but I am an advocate for the power of relationship and connection.

Also, I think people relate to each other. This is why programs even as simple as Weight Watchers are successful, because people come together, they cheer each other on, they have accountability. It works. And look at the Daniel Plan (www.danielplan.com) that Mark Hyman was involved in. Their outcomes were better than any conventional health care system in terms of creating health. That is what I mean. The model we have does not work for health. It works for acute care. If you are having a heart attack or a stroke, then a trauma center is a great place to be. But it does not work for health creation.

Dr. Rountree: Yes, absolutely. So here is an interesting contrast. I was listening to this podcast with Tom Dayspring, who is an internationally famous lipidologist. He talks for hours about how a specific abnormal lipid pattern increases the risk of heart disease and how you need to prescribe exactly the right statin at the precise dose, and if the statin is not working then you should proceed to a proprotein convertase subtilisin/kexin type 9 gene (PCSK9) inhibitor. But there is no mention at all of the context—how does heart disease occur in a specific human being, right? How does it fit into the big picture of the human condition? I am sure you have another take on cardiovascular disease besides saying it is all about the lipids.

Dr. Guarneri: It is all about looking at what really is causing cardiovascular disease. We always talk in functional medicine about root cause. I love what Dr. Dale Bredesen says, “If you have 30 holes in your roof and it is raining, and you decide, ‘Well, I am going to fix the hole on the upper right’, you are still sitting there with 29 reasons for the water to be coming down on you.”

To me, just giving a statin or Repatha, a PCSK9 inhibitor, is like fixing one hole. We are doing that in cardiology because that is all we have. It is the tool we have in our toolbox. It was not until the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT) study when cardiologists recognized that inflammation was a cause of cardiovascular disease. “Whoa, maybe this C-reactive protein test (CRP) and inflammation has something to do with it, because people with the same low-density lipoprotein cholesterol (LDL) levels, if the CRP is high, are those who are doing worse.”

PROVE-IT was a wakeup call that maybe it is not all about cholesterol. Not to mention that 7 million people die a year of air pollution, which is the number-one risk factor for stroke. There are things that are not even being considered or looked at, because they are too complicated. But to write a prescription for a statin, that is an easy thing to do.

Dr. Rountree: And yet, it seems like the majority of mainstream docs—especially cardiologists—are practicing that kind of medicine. You are saying it is because they cannot look outside of their own tunnel vision.

Dr. Guarneri: You also have to look at their life and their day. You can imagine if you have 25 patients on your schedule, and you have got to get through your day, not to mention an emergency or a couple of phone calls, what is the easiest thing to do? I found this when I was at Scripps. It was so much easier for me to write for a statin and know I am going to knock the heck out of that LDL than to sit and teach people how to eat. There is no time to sit and educate someone about underlying causes of inflammation or even just to discuss how most disease begins in the gut. How do we even begin to do that in a 15-minute appointment?

This is not sustainable on any level. And again, it goes back to everything from the health of the planet to the quality of the foods we are eating, to the air that we are breathing. These challenges cannot be fixed with a statin.

Dr. Rountree: I would like to talk about that excellent review article you and Drs. Mark Houston, Deanna Minich, Stephen Sinatra, and Joel Kahn wrote back in 2018 on nutrition and coronary heart disease for the Journal of the American College of Nutrition. I wonder what kind of feedback you got from your colleagues about that article. One of the outstanding things about the review was that it was so well referenced. After reading it, I immediately thought, “This is impeccable. How can you dispute this kind of evidence about the benefits of nutrition?”

Dr. Guarneri: Most conventional clinicians do not read this literature. And if they are not taught it in medical school, they do not accept it. I remember the article we wrote on niacin. Remember when all the negative niacin press came out? And for those of us in cardiology who at the time were dealing with the atherogenic lipid profile of low high-density lipoprotein-2 cholesterol, high triglycerides, and small particles, niacin was the holy grail. And there are enough studies to support using it.

And then there is some bad research such as putting niacin in a bar of margarine or mixing it with a drug to block flushing. After a few poorly designed negative studies many cardiologists concluded niacin is of no benefit. My colleagues just stopped the niacin. They did not question the research. That is the scary part.

Dr. Rountree: The same thing is going on with omega-3 fatty acids from deep sea fish oil right now. One day fish oil is the darling, and the next day everyone dismisses it.

Dr. Guarneri: Well, I thought it was going to be the darling for longer because there are pharmaceutical-grade products, such as Vascepa^®. Pharmaceutical companies are making money on it, so I thought for sure it was going to be more acceptable. Most of the research is flawed. How can you determine the benefit of omega 3 without measuring omega 3 levels? Most conventional medical research does not look at nutrient levels to determine what an individual actually needs. It is like taking giving everyone in the room the same dose of vitamin D without measuring levels and determining who really needs it.

Dr. Rountree: Exactly, “let us see what happens.” These studies are never individualized. It is the opposite of personalized medicine.

Dr. Guarneri: That is my point. That is not where we come from. Personalized medicine is part of the new model. When you start talking about functional medicine, you start talking about getting to root cause. For all my cardiac patients, I at least have a three-day stool sample, an intracellular nutrient evaluation, an adrenal stress index, and some genetics. I do not know how we practiced so many years, to be honest with you, without these tools in our toolbox.

Dr. Rountree: Yes. When you are doing functional medicine, it becomes so much a part of you that you think it is normal. You think it is normal to look for these things, and then you realize, there are actually doctors who do not check omega-3 fatty acid levels. They think it is too esoteric.

Dr. Guarneri: We think it is normal. Exactly. And they criticize us for it. I heard you talking earlier about vitamin D and what is the right level of vitamin D? The Institute of Medicine states 30 is enough. And we can show literature that this is not necessarily true.

So I think we have to just keep training clinicians, whether it is through functional medicine or through the Academy of Integrative Health and Medicine. We need clinicians to open their eyes and look beyond what they learned in medical school.

Dr. Rountree: Here is a million-dollar question for you. Is the incidence of atrial fibrillation on the rise? And if so, why? I get the impression that more and more of my patients are getting it, even people who do not have coronary artery disease. Trying to understand this phenomenon seems to be an example of how we need to think outside of the box.

Dr. Guarneri: Well, it is a great question. There is a lot of atrial fibrillation (a-fib). So what do I see? Of course, the more obesity we have, the more sleep apnea we have, the more inflammation we have, the more a-fib we have. So the higher the obesity rate, sleep apnea rate, the more a-fib.

When we teach the medical students about atrial fibrillation we start with the basics. Are the thyroid levels normal? Let us make sure the potassium is okay. Let us make sure the magnesium is okay. But we do not look at any other intracellular nutrients. And most clinicians do not even look at intracellular magnesium levels. Or if somebody has a serum potassium of 3.5, it is considered normal. Well, it is not normal for a-fib.

And I cannot tell you how many second and third opinions I have done for atrial fibrillation secondary to sleep apnea. Anything that changes vagal tone could be a cause of atrial fibrillation. So that includes gastrointestinal conditions, including food sensitivities. So I think it is on the rise for many reasons, but certainly obesity being a big one. And sleep apnea being a big one.

Then we also tend to treat everyone the same, but they are not the same. The skinny woman with a-fib, low blood pressure, and no apnea is different from the obese patient with coronary disease. Yet, both can have atrial fibrillation and most cardiologists tend to treat them the same. The woman frequently finds her way to my office because of medication side effects. All I have to do is give that individual electrolytes, and I can almost guarantee her a-fib is going to improve. Magnesium, potassium, and keep their blood pressure up to about 110. It is like a magic bullet.

So there are different forms of a-fib, but I think the rise you are seeing is related to lifestyle.

How many people come in and they are completely dehydrated, and that is why they are going into a-fib? Or they are eating too much sugar, and that is why they are going into a-fib? Or they have food sensitivities that trigger their a-fib. Again, nobody is looking at these things, because they are not part of the standard protocol.

Dr. Rountree: Absolutely! Do you find that some of your colleagues are starting to reach out to you and ask for “out of the box” ideas?

Dr. Guarneri: They do. When I was at Scripps, they would always send the patients who did not want to be on statin therapy. “Okay, you do not want to be on a statin, you go see Dr. Guarneri. She will do something different. We do not know what it is, but she will do something different.” But medicine is a funny place, because now the issue always becomes, “Well, if we send you someone, they never want to leave you. They do not want to come back.” One, they get too healthy. But two, they realize, “Oh, my God, I want a doctor that is a little bit different than what I was getting.” It is kind of sad, because people do not know all the treatment options. Many people get their information from television commercials or magazines. They are getting their information from health food stores, which are not necessarily bad places, but that is, again, why we need to keep pushing to educate clinicians. And the younger we can get to the education of clinicians, the better off it is going to be.

Dr. Rountree: Another podcast I was listening to was an interview with Dr. James O'Keefe. He is a preventive cardiologist at Saint Luke's Mid America Heart Institute, which is a huge group of cardiologists in Kansas City, Missouri. He begins the interview by saying, “I started my career as an interventional cardiologist, and then I had this epiphany that maybe there is a person attached to those blood vessels.” As a result of that insight he shifted his entire career toward a focus in lifestyle medicine. On hearing this I immediately thought, “That is Mimi Guarneri's story!” I wonder if there is a support group for reformed interventional cardiologists.

Dr. Guarneri: Well, when I was on a call this morning, there was a cardiologist from a major organization talking about how to get integrative medicine into the community. Let us teach nutrition, help people transform their stress response and stay physically active. In short, let us teach lifestyle medicine. If that is not the bread and butter of cardiology, I do not know what is. I really do not. So we have a lot of education to do. But then, again, as clinicians retire, hopefully the system will change.

Dr. Rountree: What do you see as the future for your work? I know you have a big clinic in La Jolla, California, right now.

Dr. Guarneri: Yes, I have a big clinic, but it is a clinic that does a lot of education. With Southern California University, we have a physician assistant program for integrative medicine. I have many medical students as well. I am always trying to build bridges. How do we learn from each other and how do we work together? How do we do interprofessional education? How do we bring Integrative Medicine concepts to clinicians who are working in clinics so that they can think a little differently?

That is what I have been spending my time doing. I keep pushing the Academy of Integrative Medicine to create a big umbrella. We all do not have to be doing the same thing. If the Institute for Functional Medicine (IFM) has a great immune module, which you have been such a great leader for, we do not need to repeat that.

Let us bring together all the best teaching of our global organizations and work together to move the field forward. I do believe that the more that we work together, the more we can build bridges, the more we can start to transform the system. We have to keep pushing to do that.

Dr. Rountree: Yes, I strongly agree. It seems like new integrative medicine professional organizations are forming all the time, and the result is they are splitting instead of lumping. It seems like we need to do more lumping.

Dr. Guarneri: I think we need to do more lumping. There is so much to do. We do not have to repeat the same things over and over again. So if something is working somewhere, and we have something good over here, great. Let us go and learn IV infusion therapy from the naturopathic doctors. Let us learn hyperbarics or environmental medicine from somewhere else, and let us make it available and bring it all together. But again, we are siloed. I am sorry to say, we are still very siloed.

Dr. Rountree: If people want to follow you, keep track of your writings, and so on, is your website the best way to do that?

Dr. Guarneri: I would come to our website, Pacific Pearl La Jolla and poke around there. I have some fun interviews that I have done with some of my mentors, such as Gladys McGarey and others. There is some fun educational information and lots of recipes. So that would be a good place for people to start.

I just completed the PBS series called Live Better Now. I just picked a few concepts that I wanted to bring to the average person, such as nutrition, food sensitivities, hormone balance, and social connection. This PBS special aired all around the country for the past two years. It is coming close to its end, and then I am going to be doing something with the Food Revolution Network for next fall. That will be very exciting.

Dr. Rountree: It has been a great pleasure to spend this time with you. My heartfelt thanks for everything that you are doing. I know that you have influenced so many people around the world, and trust that you will continue to do so for a long time to come.

Dr. Guarneri: Thank you for all you do, and I really appreciate your time and inviting me.▪