Proceedings of the 1st National Conference on Community Health Center – Primary Care Residency Program Linkages, "Assessing Teaching Skills and Needs" (Gordon and Mills)

Last Updated on April 16, 2022 by Lee Burnett, DO, FAAFP

In preparation for the 25th National Conference on Primary Health Care Access, to be held April 14-16, 2014 at the Hyatt Regency San Francisco, we will be publishing a series of archival works of relating to educational linkages between community health centers and primary care physician residency programs, which will be one of the topics discussed at the 25th National  Conference. The following presentation, entitled “Assessing Teaching Skills and Needs Among Community Health Center Preceptors: Results of a Recent Survey” from October 17, 1993  is by Paul Gordon, MD and Denise Mills MD, respectively of the University of Arizona and the El Rio Health Center, Tucson.

We gratefully acknowledge the sponsorship of the Wright State University Boonshoft School of Medicine Department of Family Medicine) for funding the transcription and editing of this section of the Proceedings of the First National Conference on Community Health Center-Primary Care Residency Linkages (Lake Tahoe, Nevada, September 16, 1993):

William H. Burnett, (Conference Planning Committee Coordinator):  I would like to introduce two colleagues from the University of Arizona, Dr. Denise Mills and Paul Gordon, who have done some of the most important research to date on the subject of the faculty who teach in linkage programs between primary care residency program and CHCs.  They will be introducing themselves and their work.

Paul Gordon, MD, (University of Arizona):    Good morning.  As Bill said, we’re both from Arizona and I must admit Lake  Tahoe is a beautiful place.  I feel right at home, other than the fact that when I ran this morning there was a little snow on my beard instead of sweat, but otherwise it was exactly the same.  I certainly appreciate all of you who are choosing to come to our talk about CHC linkages as opposed to going and losing your money in the other room.

As I’m sure you all know, exposing our medical students and residents to patient care settings which serve under-served peoples, has become a cornerstone of our national health manpower policy.  In a sense, the very existence of this conference, whose title is “the National Conference on Community Health Center-Primary Care Residency Linkages,” speaks to the remarkable position to which we have arrived.  More and more of our students and residents are receiving their training in CHCs.

And to me, the overlap of this linkage conference with the first day of the Western Regional STFM meeting, also speaks to the important role that we as family medicine educators have, relative to the health care needs of the under-served peoples.

There are, I suspect, at least two (if not more) groups of peoples out there, some of whom are very familiar with the linkages and others for whom it is an unfamiliar topic.  Before I introduce Dr. Denise Mills, I would like to give you some background on my linkage projects in which the University of Arizona is engaged.  I’m a ‘family doc’, who trained in a linked program, before people used that term.

After I finished my medical school training in New York  City, I was looking for a program that would give me the opportunity to work in an inner city CHC site. I went to Rochester, New York.  AT that time, the center in which I practiced was regarded as “on the other side of the tracks.” Indeed, the health center was located there.  But, it wasn’t just that I was going to a different part of town.

The rest of my residents and faculty made me feel like I was going to a different part of town, and that the work I was doing was somehow very different from what the rest of the residency was doing.  I know from our work on linkages, that such attitudes are changing.  I also believe that specific faculty development strategies (that Denise Mills will speak about) reflect how far we as faculty have come, in embracing the training of residents and students in CHCs.

I had a good experience up in Rochester.  When I obligated myself to the National Health Service Corps, I expected that I would wind up back in  East Harlem or the South Bronx, but federal policies changed, and it was decided that there was a greater need for Corps-obligated family docs in rural areas than in inner cities,.  I set out to find a rural area, never having known what one was before.

I went to Arizona, which has a lot of  them, and was lucky to find one which was close to Tucson.  I worked there for a total of seven years.  During the latter part of time there I was part-time, while I was starting at the University as a faculty person.

And them, in association with Doctor Frank Hale, I got involved with studying linkages between health centers and residency programs.  A couple of years ago, through a contract between the United States Public Health Service’s Bureau of Primary Health Care and the American Academy of Family Physicians, Frank and I worked to develop a manual on CHC – residency program linkages.

Clearly, there are different models of linkages.  You could have your students or residents go just for the period of a week or a month.  They might have a specific rotational block in one year, or another block in a subsequent year.  But the main focus of our studies, are longitudinal linkages, where family practice residents have their required ambulatory residency experiences in a CHC setting.

We also collaborated on the linkage manual with the American Medical Student Association (AMSA), which had conducted a survey in 1991 to assess the status of community-based training by primary care residency programs.  That survey was conducted of all federally funded training programs in primary care, yielding a short list of community and migrant health centers which receive both federal funding and offer residents longitudinal training.

To develop our manual, we contacted the group of CHCs identified by AMSA and surveyed them in depth about their experiences with residency training.  We asked each respondent how and when their residency linkage was established, what motivated the CHC getting involved with such a linkage, and how they got to where they are.  Those surveys helped us develop the manual.

The goal of Doctor Mills’ work, which you will hear about shortly, was to assess faculty development needs among this same select group of physicians – a short list, but we think a representative one – who worked in longitudinal linked programs.  We do not represent this list as an exhaustive one, but a reasonable compilation of the longitudinal programs known to the AMSA researchers in 1991.  Undoubtedly, there are many more programs whose residents and students are trained in community and migrant health centers.

In surveying the linked programs, we asked personnel at both the  CHC and the residency program to identify predictors of a successful linkage.  One such predictor cited by personnel from both CHC and residency programs is having faculty development programs in place.

The Health Resources and Services Administration [HRSA], in which both the Bureau of Primary Care and the Bureau of Health Professions Education is located, has promoted CHC-educational linkages actively, and the faculty development piece of it has been a HRSA priority.  An example is the “Primary Care Futures Project”, which supports a series of four two-day workshops on faculty development and networking for primary care clinicians and educators interested in or already engaged in community-based training.

Finally, the Title VII reauthroization legislation includes a statutory preference for applicants who can demonstrate the placement of graduates in practice settings where the principal focus is to serve the under-served.  This of course places great value on linkages within CHCs.  There is, thus, considerable momentum for community based training taking place in CHCs.

That makes the project on which Denise Mills is going to report timely.  Prior to her study, we knew very little about the faculty development skill levels and perceived needs of those who teach medical students and residents in community and migrant health centers.  The population surveyed, as I mentioned, is known to be teaching residents and students in linked programs.

It was hypothesized that the information from this highly select population of community faculty would be useful to our program and others in planning faculty development activities in support of linkages.

One other thing I that I will mention, is that  Denise and I are currently working on a CHC-residency linkage.  As I mentioned, I am on the University of Arizona’s family practice residency program faculty.  Denise has recently come to Tucson and is working at the El Rio Community Health Center, a Section 330 funded CHC.

We anticipate that, beginning in July 1994, we will be placing first year residents at El Rio for the ambulatory care training part of their famiy practice residency training.  For their other residency rotations, they will be working alongside the rest of our residents, so certainly for us the research on linkages is timely.  With that I will introduce Dr. Denise Mills, who will give us some exciting information related to the faculty development training needs, as perceived by those physicians who are working in education-linked CHCs.  Thanks very much.

Denise Mills, MD, (University of Arizona):  Hello, good morning.  I’m a 1992 graduate of the Valley Medical Center, Fresno County Family Practice Residency Program in California.  During my last year of residency, first year residents started their residency in a linkage between our county program and the Sequoia Community Health Center.

Even though this was just the first year for this linked program, we could see already that there would be many benefits for both residents and faculty involved in the program.  Following my graduation, I moved back to my hometown of Tucson, Arizona, and took a job with the El Rio Community Health Center.

Like most family practice residency graduates these days, I had a lot of job opportunities from which to choose.  I was interested both in teaching and in service.  One of the attractions to me of the El Rio CHC was that El Rio and the University of Arizona were in the process of developing a linked family practice residency program at the CHC.

El Rio is a well established, full service CHC. It has had a presence in Tucson for more than 20 years.  It employs over 30 providers, most of whom are primary care physicians, with some NP’s and PA’s.  All of its physicians are in primary care specialties.  It has its own laboratory and x-ray.  Its patient services include a program for the homeless and a comprehensive HIV program.  A patient advocate helps our indigent patients who don’t have insurance find needed medications.

I felt that this would be a good site to train primary care physicians.  But, like most primary care physicians, I had no formal training in teaching.  So, I took the opportunity to enter a one year faculty development fellowship, sponsored by the University of Arizona Department of Family Practice.  The research I am reporting was part of my fellowship.

There is a consensus on the need for quality teachers in CHCs, but little information on the background of persons currently teaching in CHCs and what they would regard as helpful to them.  Intuitively, we expected that CHC teachers would differ in significant ways from teachers in the University setting.

In view of that, we developed a five-page survey to asses teaching skills and perceived training needs among CHC preceptors.  We decided to look at five areas that we thought might be important and where there might be differences.  Those areas were the demographics of the teachers, their teaching experiences in  CHCs, the educational setting, the relationship of their teaching experiences to their job satisfaction, and their present skills and identified needs.

We pilot-tested our study with the University fellowship group, a number of whose physicians were CHC physicians.  In addition, we consulted with a research specialist in the family practice department with expertise in survey method and made appropriate revisions.

I contacted the medical directors of the 13 CHCs which were identified in the linkages manual.  As Paul Gordon stated, we know that there do exist some linked programs that were not included in the list.  However, useful data existed from the previous study on those 13, and each of them had established longitudinal programs.

(Longitudinal programs in family practice are those where the family practice resident has a panel of patients within the CHC which fulfills the requirement of the Residency Review Committee on Family Practice that each family practice resident have a specific group of patients for whom they are the family physician for at least the last two years of their residency.

As an example, at El Rio the two residents starting in July 1994 will have their continuity clinics there for a period of three years and will be obtaining a panel of patients for whom they will provide care throughout the three years.)

From the CHC medical directors, I obtained a list of the 80 physicians who currently were teaching family practice residents.  We got a 52 percent response rate initially.  We sent out a second mailing to those who had not responded.  To date, the survey has had a 70 percent response.  We are still receiving responses.

First, I will talk about physician demographics.  The average age of the physicians in our study was 37 years, which happens to correspond exactly with the average age of those family physicians and general practitioners nationally who are teaching, and of those who are in practice.  Sixty percent of the respondents were male and 39 percent were female.

About 75 percent were Caucasian and another 15 percent were Hispanic, with the remainder from other minority groups.  In terms of physician specialty, the majority were family physicians and the rest were represented by primary care specialties.  Over 90 percent of the physicians were board-eligible, so they were a well qualified group.

We then attempted to asses the physician’s teaching experience in CHCs.  We found that two-thirds had no previous formal training in teaching.  They had been employed at their current CHC an average of five years, although the length of the employment ranged from one to 20 years.  Their longevity in these sites – settings we associate with high turnover and stress – is a notable and positive finding.  The physicians had been teaching residents an average of five and a half years.

We asked them  how many hours they felt that they were teaching residents.  Again, we got a wide range of responses.  The average amount of time spent teaching residents in CHCs was nine and a half hours – a significant amount of time.  It is important to realize that this represents a little over a full day, and that slightly less than 20 percent of their total time is spent teaching.

When we graph out the number of physicians and the number of hours per week they reported, we end up with a bimodal curve, with about one-third of the physicians precepting one-half to one day a week, but another third teaching over 20 hours a week, almost half their time.  We have analyzed our data to see if there are any significant differences between the two groups, but have not been able to find any yet.

Each group is comprised of people form different kinds of  health centers, and of different age and experience levels.  We asked them how many medical students and how many residents that they through they might have taught in the last twelve months, and this question had a broad range of responses.

One person (who, if his response is accurate, probably teaches  in a lecture format) said he taught 100 residents.  We excluded that response and the average of the remainder was twelve residents and thirteen medical students.  Even though we do not know in what capacity they are teaching, we can assume that at least some of them are there in the CHC for a significant amount of time and thus have a significant amount of contact with our future primary care doctors.

We next wanted to look at the teaching methods that are employed in the CHC setting.  There are basically five different methods today that any physician teacher is going to use to teach residents.  They include clinical supervision in the ambulatory setting, bedside teaching, lectures, small group discussions with residents, tutorial or one-on-one teaching.

We also asked about computer-assisted teaching because we have seen – this is true at the University of Arizona – medical students these days are using computer-based learning computers as they take care of patients.  We would consider it advantageous if the students could take their computer-assisted learning experiences and continue to use such computer methods when they become primary care residents.

Although not surprising, we have found that all of the physicians were involved in clinical supervision, and the majority of them were also doing bedside teaching.  About half of them taught through lectures, small group discussions and tutorials.  But less than ten percent used computer-assisted training techniques.

Why should this figure be so low?  One reason for the relatively low use of computers, is a lack of experience among physician faculty who employ computers as a teaching method.  Another reason is that the financial constraints of CHCs can make it difficult to obtain that kind of equipment.  But I am glad this question was asked, because these data demonstrate a possible area for future attention by those encouraging teaching in CHCs.

The next subject we considered was physician job satisfaction.  It was generally felt that physicians who teach are more satisfied with their work, and that, perhaps, there is a greater retention of these physicians in CHCs.  This has not been formally assessed.  We asked participants whether they wanted to do more, less, or the same amount of teaching.  All of the physicians said they wanted to do more or the same amount of teaching; none of them wanted to do less teaching.  The majority felt that they did not have enough time to teach.

We asked the physicians whether their clinical director was supportive of their teaching and 88 percent said yes.  Since we were assessing a group that already had linkages, and Dr. Gordon already has noted that a predictor of a successful linkage  is having a supportive CHC administration, this finding was not surprising, but it was gratifying.

Next we asked how important teaching is to the physician’s overall job satisfaction.  The participants were asked to rate the role of teaching to job satisfaction on a scale from not important to very important.  The majority of physicians responded that, indeed, it was quite important to their over-all job satisfaction.

We left some space on the page to write in what the most satisfying aspect of teaching was for them. Almost everybody took the opportunity to write something down, and the responses were enthusiastic.  Respondents wrote their commitment to teaching, how it challenged them professionally, and of their appreciation for the chance for personal development.  Respondents expressed enjoyment of being involved in the education of the next generation of family practice doctors.

The final subject areas that we wished to asses were the teaching skills and perceived needs of the participants in our survey.  Using Schwenk and Whitman’s “The Physician as a Teacher”, supplemented by a review process which included CHC physicians, we developed a list of 12 important teaching skills.  The skills included formulating educational objectives, determining the needs of learners, and giving and receiving feedback.

We asked each respondent to rank their skill level for each of these 12 skills on a scale from no need to high need for skill development.  We found generally that those CHCs we surveyed have an experienced group of teachers.  Most of them reported average development in each skill.  However, in analyzing the data, we did notice concern about integrating teaching into the busy office practice – something anyone who teaches n a CHC can understand.  It points out the continuing need of emphasizing education in the CHC service versus education trade-off.

The second concern that stood out most significantly was conducting office-based research.  An article in a recent issue of JAMA entitled, “Health Care Reform:  Primary Care and the Need for Research” concluded that “… despite an enormous and sustained investment in biomedical research over the last four years, relatively few dollars have been invested in primary care research.  The limited knowledge base for many health problems hampers the development of optimal management strategies.

As we attempt to achieve universal health care, research in primary care will play in increasingly important role.”  Given that few primary care physicians nationally are engaged in office-based research, and that the time demands on CHC physicians are high, it is understandable that physicians in CHC residency linkages ten not to utilize this teaching skill.

The very last areas that we look at were the learning strategies that the physicians would use to develop new skills.  The choices given them included self-study of pamphlets, brochures, and books; small group problem-solving sessions with colleagues; peer observation of teaching, combined with feedback; feedback on the teaching performance by residents and medical students; faculty development workshops; and a teaching manual designed specifically for CHC physicians.

Again, they were asked to rank them from not useful to very useful.  Again, to a certain degree, they liked everything.  However, when we graphed the responses, all of the interactive teaching methods were those most preferred.  This was not so surprising based on what we know about adult learners.  This information should be helpful for training CHC physicians.

At the El Rio Clinic, based on what I have learned from this study, I would favor short, interactive teaching conferences that focus on one teaching skill, such as how to give residents feedback effectively, and would use interactive teaching methods to get the points across.

I have a few general conclusions, and then I would like to invite discussion:

First, the results of our survey supports the idea that physicians who teach in CHCs derive a great deal of job satisfaction from teaching and report a significant amount of time devoted to this endeavor.  They have a sense of responsibility toward their teaching, which is commendable.  The average amount of time spent working in their CHC was more than five years for these physicians.

We suspected this indicates a level of retention which is higher than that for physicians who do not teach, but we were not able to find a comparison group.  (I even asked my own  CHC if we had data on retention for physicians.  Maybe they did, but they did not want to give it to me.  It’s stressful work and there is a fairly high rate of burnout.)  There is time designated for teaching in which the physician is not expected to see patients or have other duties.  We might expect that this would increase physician enjoyment and retention at the sites.

Second, time constraints were cited as a significant factor in the physician’s ability to teach.  Time constraints often are related directly to physician productivity issues.  This study underscores the importance of allocating funds to developing teaching programs in CHCs, so that an appropriate balance of service and education can be achieved.

And finally, overall, this study shows that there is both need and desire for continued faculty development in those CHCs with teaching programs.  The physicians surveyed in our study were a well-qualified and experienced group.  However, there were areas where continued development was deemed necessary.

Specifically, practice-based research needs to receive more attention and development in  CHCs.  The development of computer-based training in CHCs may become an issue in the future, as more computer-trained medical students become primary care residents.  We need to develop interactive teaching methods for improving our clinicians’ teaching skills.  Overall, it seems that physician enjoyment and excitement about teaching in CHCs is perhaps the biggest asset for those who promote linkages between CHCs and residency programs.

That’s all I have here.  We can open it up for discussion and questions.

Darryl Leong, MD, Vice President of Primary Care Systems, Inc.):  Did you study the needs and contributions of non-physician faculty in teaching residents in CHCs?

Dr Mills:   Actually, we considered that, but for the purpose of this study, we limited the persons surveyed to physicians.  But, you are right.  Non-physician CHC personnel would also benefit from faculty development activities.

Steven Ratcliffe, MD, (University of Utah and Salt Lake City Community Health Center):  I am from a hybrid university and also work in a CHC.  I have recently surveyed 12 CHC physicians that supervise resident rotations and train residents.

A key area that they emphasized was content.  They do not have a lot of time to stay as current on medical issues as they would like to be reaching residents.  They identified the need for some kind of computer-assisted program at their sites that could help them keep abreast of medical knowledge.  I point that out to underscore the need for additional computer-assisted training of the CHC facility.

Marc Babitz, MD, (Public Health Service Regional Office, Denver):   My question is, how would this kind of feedback compare after you surveyed other kinds of teachers?  Are the educational skills and needs of CHC physicians different than what you would find in any training program?  I am not sure of the meaning of an average response to a question.  Everybody says, “Well I like this, I would like that.”  I wonder how these responses would compare to any teacher anywhere, whether there is anything different about CHC teachers versus any teacher?

Dr Mills:  Initially, when we devised the survey, we wondered that too.  We expected to find more differences than we actually did.  I suppose we could send this same survey to university-based faculty.  However, the instrument was designed as a needs assessment instrument for CHC faculty development.   It presupposes the development of programmatic responses designed to work with CHC teachers in order to develop their teaching skills.  I think we learned things that are useful for our own CHC, and hopefully for other CHCs.

The group of people we surveyed were pretty experienced.  Their linkages are for the most part well-known and established.  They have a lot of hands-on experience that may have contributed to the fadt that everyone reported at least an average level of comfort in these areas.

I need also to stress that we have not completed the data analysis.  There are other ways that we can analyze the data, such as by individual health centers, that might prove particularly useful.

Dr Gordon:  You bring up a good point, Marc.  Your boss, National Health Service Corps Director Donald Weaver, wrote an editorial for the May, 1993, issue of Family Medicine, the issue devoted specifically to CHC-residency linkages.  He mentioned the need for quality faculty development among the physicians in CHCs doing teaching as we do in the university setting.

My response to that as a university faculty member  is that we do not necessarily do a good job of teaching our own faculty how to teach.  If the frameworks of faculty development is there, it’s easier.  It’s easier to get feedback.  You can hand out a sheet and you can have someone that can analyze the results of your responses and the like.

I think an important result of Denise’s work is that faculty development in a CHC is equally imporant, if not more so, than in the university setting.  We have to be sure that as we send our residents out there, we do not expect that teaching will happen as if by magic, but that the CHC faculty knows how to teach.

I think in university settings we run across people all the time who think, that just because you are there, you know how to teach.  Clearly, not all people do.  I think our students and residents are quick to let us know about that; maybe they should even be quicker.

Tom Brown, (Pacific Hospital, Long Beach, California):  First, I would like to congratulate you on an excellent study.  It’s the kind of survey we need to see and I’m very happy you did it.  As it is a needs assessment, I would be very interested in what medical students and what residents who had received teaching in those places, felt were the strong aspects of the teaching programs while in those settings, as well as areas where they thought faculty might improve.

It would give the other side of the picture, which I think might give you a way of looking for real matches as to where there are opportunities to develop programs for teaching there.

Dr Mills:  That is a good point, and is probably fuel for another study.  Once of the nice things about starting a residency track, like we are doing, is that we can see what is going on in other places.  At our own center, we will probably discuss such things with our residents on a regular basis, in order to mold a program which is appropriate to them.

Dr Gordon:  I would also like to respond to that.  I do not know of any studies that looked at that specific question, but for what it is worth, I can speak anecdotally, having been a resident in one of those sites and a faculty member in another.  One of the things that I felt, when I was “on the other side,” was that the faculty who worked in the CHC did not get the support for teaching that the university-based faculty got.

Whether it was because of national productivity formulas or an ethic that a CHCs overriding mission was service, the CHC faculty felt much more compelled by that need to see patients.  Now, when I precept in our university family practice center, I do not see any patients.  My job is just to sit there and teach.  In the CHC in which I was a resident, the CHC faculty were not supposed to see patients.

But the patient needs were greater there.  When someone came in, they got seen by the preceptor if the resident was busy.  So, when I as a resident wanted to get some help, there was not anyone available, because the supervising physicians felt compelled to pitch in and see patients.  I think it is fair to conclude that our CHC faculty’s precepting time was not protected in the CHC the way faculty time was protected in my residency program’s university-based clinic.

Joe Ferguson, MD, (Family Practice Residency Program Director, Greeley, Colorado):    I too congratulate you on the work.  I think it is an important start in a key area.  I think that, essentially, you assessed veterans, and that is important.  If I understood your statistics, you assessed people who have an average of five years teaching residents in that setting.

I think it would be valuable to compare that with some of the folks who are now putting linkages together and who are physicians who have not yet been in a teaching role, and then look at the differences.  A way to do that with your existing data is to look at the number of years they have been teaching.  See if their answers are different from the average answers, your existing data set.

You could also extend it to a new group of  CHCs.  And I suspect, although I have no idea, that you would come out with some differences that would be useful to know.  But it is a great start and I really appreciate the information.  I am also interested in more details on the Primary Care Futures Project, its funding and objectives.

Dr Gordon:  There we a workshop yesterday afternoon and Eugenia Lewis from the Primary Care Futures Project was there.  Yes, here she is.

Eugenia Lewis, (National Association of Community Health Centers):    The Primary Care Futures Project is co-sponsored by the University of Massachusetts Area Health Education Center and the National Association of Community Health Centers.   Basically, we are sponsoring a series of five workshops around the country.  The next will be held in San Antonio on November 11 and 12, 1993.  For anyone who is interested I will be happy to give you a copy of the program.

Another workshop will be held in Atlanta in January 1994, and then there’s one for the Western Region that will be held probably in April in Fresno.  There are scholarships that are available.  Just get in contact with the workshop coordinators.

Mark Clasen, MD, Chair, Department of Family Medicine, Wright State University, Ohio):  What are the departmental or university attitudes about the CHC faculty who are expressing a desire for faculty development and research methodology?  Are you going to place them on the academic tenure track?

Dr Mills:  The relationships between the El Rio CHC faculty and the rest of the departmental faculty was a big issue when we developed the new linkage.  We have been trying to get both faculties together.  We have had at least one retreat and there is at least one more scheduled with the objective of developing a sense of collegiality.  I think the CHC faculty will have University appointments.  Maybe Paul knows exactly what the track is.

Dr Gordon:  Again, I will cite just one university’s experience.  At the University of Arizona, we certainly support the need for faculty development.  But it will come down to resources.  Who is going to pay for it?  Perhaps the Primary Care Futures Project will be a helpful start.

The second question was about whether the faculty at El Rio residency pathway are going to be on the academic tenure track.  I do not know this for certain, but my understanding is, at least at our university, only full time faculty are on the tenure track.  The CHC faculty will have academic appointments, but will not be on the tenure track.  Actually, I cannot imagine why anyone would want to be on the tenure track (laughter).  That’s a personal comment.  Thanks very much.