Odunsi, Pisters, Platanias, and Ulrich: How immigrating to the U.S. shaped their perspectives on oncology

Leonidas Platanias: Thank you, Narjust, thank you for moderating this, and thank you to the Cancer History Project for this panel. I was born in Athens, Greece. I grew up in Athens.

The way the system is in Greece, you have to compete. It was very competitive to get into medical school…but when you went there, it was all free. It was good training.

What happened with me—there was a new medical school, the University of Patras, in those days, that had just been created by professors, Greeks who were in the U.S. They had returned back. The intent here was to create a university there with American standards. It was inspiring for us as students, we were hearing a lot about it. They were using multiple choice questions for exams—that was not in the other schools. It was very interesting.

Somehow, I got connected. I got inspired about the idea of coming here to do my clinical training. Interestingly, I had tried, also, to go to Australia. I had applied. I had tried to go to England. They would not take me then. But I was lucky.

There was a research position at NIH, because one of my professors who had been on sabbatical there decided to come back, and accidentally, I met him, and he was nice enough to connect me to get this position.

Anyway, to make a long story short, that’s how I got to the U.S. I went first to NIH. After that, I passed my exams and I went to New York to do my residency. Then I moved to Chicago in 1989. At the University of Chicago at that time, where Kunle is now—as a fellow.

Since then, I stayed in Chicago. At some point, I became director of the cancer center. That’s my story.

Platanias: It took some steps. It was not so straightforward.

Peter WT Pisters: Certainly. It’s great to be with all of you. Well, I was born in a small town in Southwest Ontario. When I was 10 years old, our family moved to the United States for four years.

In those four years, I acquired two things that were very important later in life. The first was a love of baseball. The second one was a green card. We went back to Canada, I went to high school and I went to college, and eventually went to medical school there, but because I had a green card, the immigration opportunities were open to me.

When I graduated from medical school, my wife, who was a classmate, and I, were one of 106 in our class. We were the only two that went to the United States.

We went to the U.S. because it was my belief that I could get better training there. We landed in New York city. I did my residency there. My wife was at Cornell, and that created a great environment for the two of us to thrive at the early stages of our careers.

I was then recruited out of Sloan Kettering to MD Anderson, came to MD Anderson, was a surgeon in academic surgery for a long time. Got more involved in administration. Eventually, was a vice president at MD Anderson.

Then I left MD Anderson for a while and went back to Canada, as a health system CEO in Toronto, leading the group of hospitals that represents the main teaching hospitals for the University of Toronto at University Health Network.

That was tremendous experience for me, my first job as a CEO. When the opportunity opened up here at MD Anderson, they said, “Are you interested?” I said, “Absolutely I am.” I loved the institution. I loved the culture. I was fundamentally interested in cancer and everything that we could give back to cancer patients and their families. That’s what brought me back into this role.

Cornelia Ulrich: Well, mine was really more a sequence of random events rather than a dedicated plan.

I grew up in Germany. I was a first gen student, first one of my family to go to university. While I was at the university studying biology, I applied for a Fulbright scholarship without really knowing much about the U.S., but then that summer, I explored the U.S. universities and traveled around, and was really impressed.

I was very lucky to receive the Fulbright scholarship that brought me to Oregon State University in 1991. There, I really learned a very different way of learning and student engagement. For the very first time, I encountered any female professors in my field of study, and professors with the family, while I really had been discouraged in Germany to even imagine being a biologist with a family.

This was really motivating, and just made me rethink what I might be able to do. After my master’s degree, I decided to apply for a PhD program, because I really found the way of learning and student engagement in the U.S. so much more interactive and motivating.

I did my PhD at the University of Washington and the Fred Hutchinson Cancer Research Center. I became faculty at the Fred Hutch, advanced to full professor and leadership there. Then I did what Peter did. I went back to Germany, to my home country, in 2009.

I co-led Germany’s first comprehensive cancer center, the National Center for Tumor Diseases in Heidelberg. I did that for five years, bringing back myself as a role model, I think, in that environment. Then, I was offered the opportunity at Huntsman Cancer Institute, which is really a cancer center here in Utah with tremendous growth, and an exceptional, really fun leadership team. I couldn’t say no to that. I came back in 2014 and became cancer center director in 2018.

Kunle Odunsi: Yes. Thank you. My journey started, obviously, from Nigeria. I was born in Nigeria, went to medical school in Nigeria.

While in medical school, a number of events drew me to cancer, and cancer research. One was really just some of the professors. These were Nigerian, U.S.-trained professors who were in the medical school. They were just the smartest. We looked up to them. They really inspired us as young medical students at the time.

After medical school, I transitioned to the United Kingdom where I trained in obstetrics and gynecology. Then I came across, also, some very talented gynecologic oncology surgeons, and and researchers.

At that time, CA 125 had just been discovered for ovarian cancer. There was a lot of buzz about having a biomarker for ovarian cancer. A lot of research going on. It drew my attention that this was something that I wanted to do. After Cambridge, that was where I had my clinical training, I was able to apply for a research fellowship to the Royal College of Obstetricians and Gynecologists, to be able to go to Oxford. There, I went into the lab and did research, leading to a PhD.

After that, what next? By this time I had completed the training in England. I was a member of the Royal College of OBGYN. What I wanted to do was gynecologic oncology. At that time, there were only—I think only about three training spots in the entire country. It was so difficult to get into this specialty.

I had to transition to the United States. Of course, that meant starting my residency all over again. It was a four year residency at Yale School of Medicine, went on to Roswell Park for my fellowship in gynecologic oncology.

Then I stayed on faculty at Roswell Park for 20 years before being recruited to University of Chicago about a year ago, where I was recruited to be cancer center director. U Chicago, as you know, [has an] exceptional environment. I’m just having fun with our leadership team, and all of the things, excitement that is going on.

Platanias: I wouldn’t say it was hard, although I grew up in Greece, and Greek food is great. At the same time, I was used to unhealthy food and sandwiches. There were a lot of McDonald’s and places like that in Athens, so it didn’t make a difference to me. It was not hard.

Pisters: Well, I think for me, the adjustment—my parents were Dutch immigrants. So, at home, I was used to a northern European cuisine.

The Dutch are not necessarily known for their cuisine, but we had unique foods in our home environment. Then when we went to the States, I was exposed to a completely different way of eating.

Of course, when we got to Texas, we learned to love margaritas and Tex-Mex.

Ulrich: Germans are famous for some things, including bread and chocolate.

I missed the bread, especially at the beginning, but for the chocolate, I just bring it back with me—suitcases full—whenever I come back to the U.S. I still do that.

Odunsi: In Nigeria, the Nigerian cuisine, it’s rice and plantain and all of those types of food.

My adjustment actually took place when we moved to England. I already adjusted to sandwiches and all of those—actually fish and fries—fish and chips is what it’s called in England.

The adjustment was not too difficult when I made the transition eventually to the United States.

Ulrich: Well, I could go on for a long time, but there are also many opportunities. I have to say, maybe I’ll talk first a little bit about Germany, because when I went back to Germany to become cancer center director there, there were only 6% female professors in medicine.

My leadership role was very unusual, and I feel so much with some of our underrepresented minorities now who are the only people of color in the room, because that was what I experienced there. It’s simply not something that people are used to, and associating that role with it.

For example, I’ve been asked to load the slides of a male colleague at a conference, right? That’s pretty typical of what could have happened there. But I have to say at Huntsman Cancer Institute, it’s actually been a great benefit for me to succeed another woman director who really provides exceptional mentorship, and that’s Mary Beckerle.

We have a very diverse leadership team and there’s a lot that I learned throughout my entire journey in different cultures and being the only one. There are, I think, for women, definitely different communication patterns and identical styles that exist between a woman and man will be interpreted differently.

I think that’s something we all are dealing with as we’re trying to overcome our inherent biases that we have. There’s a lot I could talk about also about teams and mentorship of young women, but I feel overall it was an advantage for me to be a woman to come to Germany, because I was somebody who had to be on the table, but I also was pulled in a lot of different directions.

I think that’s the same, a little bit now. We have only, I think, about 6% female cancer center directors in the U.S, and so there’s more work to be done. I really appreciate all my colleagues from all different backgrounds, and I think diversity really matters to find the best solutions.

Odunsi: That’s a good question. The first thing that I will say has helped me as I reflect on my journey, it’s just the ability to work with different types of people.

Remember, I’ve lived now on three continents, in Africa, Europe, well, in the UK—it’s really not part of the European Union anymore, as well as in the United States.

The ability to be able to interact, work, collaborate with people from all kinds of backgrounds, that’s number one. Number two is tenacity. How do you persist even when you encounter disappointment and failures? How do you keep going? How do you pick yourself up? How do you learn from your experiences?

So, the very long path that I have taken has prepared me well to be able to deal with both success and failures. Then, number three, it’s just the breadth. I think the breadth and depth of experience, of people skills, that comes with the long training.

As you know, especially when you just talked about internship, when you have those long nights of calls and you just keep going and yet, you are dealing with all kinds of people. I think that journey actually prepares you for leadership.

And also to understand how to relate to both people who are your superiors, people who are junior to you. It’s really a total package, I think.

Ulrich: I just want to second what Kunle said about bringing different perspectives to the table, and I think about different leadership models, funding models, health policy across Europe and the U.S.

I think I learned a lot about the impact that leaders can have on the culture and success of their own institution. I feel we have probably a little more of a balanced perspective as international leaders, that we can think outside the box.

Persistence and taking opportunities when they present themselves. I’m a very curious person, and there’s nothing I couldn’t imagine doing, almost, except for maybe skydiving.

I’m a person who really is very curious about many different aspects of cancer. I care a lot about my faculty, my students, and what they’re doing. I think that overall curiosity paired with perspective and persistence or tenacity is very important.

Pisters: That’s such a great question. I think, for me, probably the first thing possibly most important is the value of empathy.

The ability to see the experience through the eyes of the patient and the family, understand the emotions that they are experiencing, and adjust what you do using empathy as your guide.

That was so powerful for me as a surgical resident seeing all kinds of patients in all kinds of difficult situations, sometimes self-inflicted, sometimes as a result of trauma, sometimes as a result of cancer. That’s the first thing.

I think the second thing that I found so helpful was to understand the value of teams, or to consider teaming as a verb, and to study how teams function and what makes teams effective; because ultimately, what we do as leaders is coordinate team function and analyze team dynamics.

So, understanding teaming as a verb and understanding the principles and pickup of a strong and effective team.

The third thing I think that was helpful for me is understanding the value of emotional intelligence, and how critical it is to our success as leaders.

As a surgical resident, your emotions get pushed and your buttons get pushed in a whole variety of ways, and if you can learn to recognize those emotions in yourself, and very importantly, to self-regulate those emotions, then you become a better person, not just at work, but at home also. I think these three things have really helped me to become a better leader over time.

Platanias: Well, one thing that is important to remember is when you leave your country, especially if your country is far and you immigrate here, your whole world changes and things are more difficult.

You are always worried if something happens to my family in Europe or whatever, you deal with something much more difficult. You change completely.

You do that because you want to do it, but this is something that defines you too. You understand more the difficulties that your patients have, too. You can relate more when you see other people and other problems.

When I did my residency in New York, it was at the peak of the AIDS epidemic. It was at that time—One of the hospitals I was rotating [at] was a county hospital, and talking about overwhelmed hospitals, it was like a war zone with patients intubated on regular floors. It was really crazy how intense it was.

This intensity combined with just having arrived here from somewhere else, makes you tougher and helps you to prepare with issues of leadership. One thing, the way I operate at least, is to never give up. If you have a goal and you think that this goal is worth it to keep insisting, at some point, it will happen. I think that’s the most important lesson I learned.

Pisters: Well, it’s a very interesting question. Many people, particularly Americans, believe that nirvana is the Canadian healthcare system.

As I experienced it, I found that was not true. When you look at countries and you rank order them like with the Commonwealth [Fund] does, you can see Canada ranks out at number 10, or number 11.

Canadians are hardwired to compare themselves to Americans. Of course, America is at number 12 or number 13, and so Canadians are pretty complacent about the system that they have. The strength of the system is universal access that’s based on residency. Of course, the fundamental flaw in our system in America, is that insurance and therefore access is linked to employment.

That creates tremendous challenges in large groups of individuals who do not have access to the front door of American medicine, because they don’t have employment or their employer doesn’t offer insurance.

Seeing that really in two roles as a CEO, I think was very, very powerful for me, because I could see both the strengths associated with universal access, as well as a lot of the limitations associated with that as it relates to the ability to perform research and the ability to see centers of excellence, such as MD Anderson.

You don’t see institutions of excellence or elite institutions in an environment that really is designed to elevate the medium, but not to support our pathway to excellence.

Odunsi: That’s a good question. I have seen healthcare in an under-resourced environment that is Nigeria while I was in medical school.

Some of those issues persist in a country like Nigeria where the healthcare system is highly fragmented. It’s not very well coordinated. It’s truly a low-resource setting. I’ve seen that.

In the United Kingdom, the healthcare system is more the welfare system—universal access. I’ve seen some of the limitations. It has its strengths, but it also has weaknesses. Prolonged patient wait times for surgery, for procedures and so forth.

But as Peter pointed out, I think the United States health system really has the opportunity to be the best in the world because of so many factors. This is an environment where we care about research, innovation, but unfortunately, we still struggle with access.

In fact, if you look at the numbers, of the 600,000 cancer patients that die each year in the United States, about one in five of them could be prevented if they had access to high quality care.

We have a lot of work to do in balancing highly-sophisticated medical care with access for the regular person who maybe does not have insurance or is underinsured.

Ulrich: First of all, let me tell you, I got a degree in health services research and I had the pleasure of teaching in a class on international healthcare systems to medical students, and there were three systems, the British, the U.S., and the German that we talked about, and the Canadian, but let’s forget that.

But we compared it to cars. The British were always like—it’s like a bus, right? It gets you approximately where you want to go, it’s kind of reliable and you somehow get there and it’s cheap; right?

The American healthcare system was like a truck with a lot of holes, gaps, problems that would drive or not drive, and you were either lucky or not.

The German healthcare system, I still would say, despite all the problems, that we all think because it’s too expensive, is Mercedes coverage. We have, not only after birth, you get to stay in the hospital as long as you like, you also have a midwife come to your house.

You have health spa visits that get covered when you have burnout, or when you’re tired and that’s for mothers…you sense a lot of passion here, right? I just want to say, this has actually been a big challenge. For me, it pains me to see so many wonderful things in the U.S., but then how many patients do not have the access they need, cannot receive the care they need, have not the ability to get the treatments in many cases as well.

The big difference between Germany and the U.S. is health insurance is universal. It’s not just public, it’s also private, but pretty much everything is covered, and everybody knows that. It’s a minimum coverage. Our billing is about 4% of the cost.

All that money can go into healthcare, and it avoids this huge administrative and billing overhead. That’s where I would love for this country to go, for the benefit of all.

But I also love the research and care integration. I think that’s amazing in the U.S. I think team science is much more developed, and the ability for people to speak up and bring ideas to the table without much hierarchy is really a huge strength for the United States. And so, these are my two faces of the US healthcare system.

Ulrich: There’s a strong history of places, beautiful places you can go to, and it’s paid for for several weeks.

And it’s not just rehab after an illness, but it’s a strong belief in the well-being of people.

Platanias: Well, I did not really practice in Greece. I finished medical school and I came here, but I have to say, although there was universal coverage in Greece those days, the system was not working well.

It was not what we just heard from Neli. It was very dysfunctional those days. Now, it has improved a lot. It’s much better, but when I left in the eighties, it was not that good. Now, coming here, and I think what Otis asked, if we found the disparities surprising.

I have been in both. I have worked as an intern and resident in a county hospital, and then I have been in great hospitals. And yes, the disparities were stunning, especially the days when I was in New York in the peak of the AIDS epidemic. I was really shocked how hard it was for these people being there with limited, well, not limited resources, but with an overwhelmed health system from many people being sick.

There is no question we have major disparities. Peter addressed that, and everybody else pointed to that. We still have the most advanced medicine in the world. That’s why we are all here, because you can do things here, you can do research and you have the opportunity to do all that. Like Kunle, I think we can do even better.

It’s a complicated question, but the disparities clearly are not something that makes sense. Everybody should have some basic health coverage. That’s a basic human right, pretty much, to be treated. That’s what I think.

Platanias: Absolutely.

Odunsi: That’s a good question. I came to study residency directly, just like Leon and others. Once you get into this system, the first thing is you need to prove yourself.

I think people look at you with suspicion, but once you prove yourself and you are accepted, I think you’re fine. That was my experience during residency. But to the point about people looking at you, to kind of reflect that you are less-qualified or less competent, actually, I experienced that when I was applying for fellowship.

I think there were two or three people in my residency class that were applying for fellowships. I was an IMG. I’m also Black.

When I applied for a fellowship from Yale—I think I got only three invitations for fellowship, whereas my counterparts got like 20 invitations for fellowship.

So, what’s the explanation for that? First of all, my name maybe, is not familiar, my medical school is outside of the United States, all of those strikes.

Yes, it does exist, but as we’ve all pointed out, I think tenacity, persistence, don’t give up, drive through whatever barriers and obstacles that stand in the way. I did not let that detract me from the big picture, from the goal of what I wanted to accomplish, and I was fortunate to get my fellowship done at Roswell Park Comprehensive Cancer Center.

Platanias: I don’t think I have experienced xenophobia in the medical field. I think that’s why we are here, because the country welcomes other people.

I think we had the chance that we normally—I told you, I tried to go to England, there was no way I could find a position there, but here you can do it.

Personally, I have not experienced directly xenophobia in the medical field, but I have, at the beginning many, many years ago, there have been incidents outside my profession that I have felt some xenophobia long time ago, but I ignored it. I just never paid attention.

I think, although Kunle has a different experience, in general, this country is welcoming of IMGs, and there is a long tradition and history of people coming and training here. I think we should separate xenophobia as an incident with medical training.

I don’t think it’s much in the U.S. medicine, but that’s my view.

Pisters: Well, when I made the transition from medical school and I landed at Bellevue Hospital in New York, it was a big change for me.

But New York and this country in general are a melting pot. Just like Leon says, I found people to be, generally speaking, very welcoming.

The medical staff at NYU and at Bellevue Hospital was really an international medical staff. I really felt like I fit in, and it was individuals and teams made up of people from different places in the United States and from other countries that were working to care for the patients. I really embraced that, and learned a lot from the experience of being in a multicultural environment in the early years of my training.

Ulrich: I personally have not encountered any xenophobia, but let me talk to you a little bit about something else. I mean, Germany comes with a history that involves the Holocaust. And in Germany, I had not met any Jewish friends or colleagues.

This is always in the back of people’s minds still, and I have now so many wonderful friends with a Jewish background. Why I’m bringing this up is I think it’s just because we as leaders also have responsibility to think about that as we have conflicts in the world where people are experiencing immense pain, and we need to bring these people together and still make sure they see each other as humans and not as representative of a culture.

When I came with my Fulbright, they told me if you’re a nice person, they’re going to remember you as Neli.

If you’re a bad person, they’ll remember you as German. I think we are representatives of our culture, and we can bring that in and can also help bring others together to make sure that people see each other as people.

Pisters: Great question. I think in our environment, there is too much focus on academic productivity, and not enough focus on the holistic contributions of people to their institutions.

I think that when we bring an approach that is really focused on, how do we build a world series team? How do we recognize the contributions of many people? And that you can play a variety of different roles and you’re just as valuable a contributor to the team.

Ulrich: What really doesn’t matter is your own ego, and you need to let your own ego go, and be part of the team.

I think the one thing, also, that you had asked, is “What mistakes did you make during your career?” And that ties in with what Peter just said.

Sometimes I really prioritized work a lot more, and later I learned that the lunch is more important. The relationship, rather than the paper that goes out.

Odunsi: One thing that I think really doesn’t matter is just this ability to be able to give up and think beyond yourself, to be able to give up some of the things that are really your own—if I can use that word, but to focus more on the team is what I’m finding.

The other thing that I will add—I think we haven’t talked about family. Family really matters. I know you’re asking about what doesn’t matter, but I will go on to say family matters as you go along in the career trajectory, also to make sure that we pay attention to our families. And we recognize that in people that we work with, even as leaders, to make sure that we encourage a work-life balance.

Platanias: What really doesn’t matter is that you are a foreigner.

When I came to this country, it never crossed my mind that I would be director at Northwestern at some point. You just realize that everything is possible. You can do everything you want, if you are determined. Being a foreigner, being an immigrant doesn’t matter. You can get through it and be successful. That’s what I realized, at least.

Platanias: What was the question? “If you have any message…”

Ulrich: I met with my Ukrainian faculty and my former postdoc is Ukrainian. The key message is just, we feel with you and we really feel your pain. I think having that international background and being a little bit closer with the home country…we can never really understand what you’re going through right now, but we’re there for you.

Platanias: I will second that. Having an international background brings us closer to them, and I think we can sense a little more their pain and suffering, and clearly, they are in our thoughts and they have our support and anything we can do as cancer center directors to make it easier for them. That’s exactly what we would like to do.

Odunsi: I will echo those comments.

I will echo those comments as well, that we empathize, we feel their pain and we stand by ready to help in whatever way we can.

Pisters: I think what I would add to what others have said is that this is clearly a humanitarian crisis of unprecedented proportions.

We’re also seeing a response in the Ukraine from Zelensky, from NATO, from the international community, from the business community, that none of us could have ever predicted.

The strength and resolve of the Ukrainian people is something that we will be talking about for generations. What they’re doing to protect their country, their sovereignty, is something that we all admire as Americans. The whole world is behind them at this moment in time, and we will never forget what we are learning right now.

Ulrich: Yes, definitely, compared to the German system.

Germany is really struggling with its colorectal cancer screening, and that’s very sad. That’s very sad because it would be so easy to do a better job there, and just encourage everybody to come in.

There’s also a question about treatment and overtreatment, and what are patients’ wishes—and is more treatment always better? And I think there’s a more healthy relationship with that dialogue in Germany, perhaps than here.

Pisters: Speaking of cancer screening, for sure, Ontario had an exemplary system that exceeds anything that I’ve seen in the United States.

In a publicly funded, publicly administered healthcare system, the province, the ministry of health, has your information—and they would routinely notify you when you were due for a mammogram, or a sigmoidoscopy, or occult blood testing.

It was done in a systematic data-driven way using a centralized database. There’s probably a model for other provinces and certainly for other jurisdictions in how to use data, and use a centralized system, that’s easier to do, obviously, when there’s single payer, and facilitates screening of 16 million people in an organized data-driven way.

Odunsi: In Nigeria, the treatment for cancer is very fragmented. The healthcare coverage system is really not very strong, and patients have to pay out of pocket for the most part.

If you’re wealthy, you go out of the country, you go to the UK or United States, or other countries for your treatment. Essentially, if you’re not wealthy, if you cannot afford it, it’s almost a death sentence right away.

But what I have to say, is that I think the system in the United Kingdom, similar to the system in Ontario, also has this national call and recall system, whereby you get reminded that it’s time for your screening.

This is a national centralized method whereby, wherever you live, even if you move from one region to the other, you still get a letter in the mail saying, “you missed your Pap smear,” or “you missed your mammogram” or “your colonoscopy.”

That kind of system is likely to enhance earlier detection of cancers. I see that type of model, along with the one that Peter described, as potentially a model that we should try and shoot for in the United States.

Platanias: I don’t have much to add. I think the U.S. prevention system is probably, depending on where you are, more advanced than other areas. But there is one issue unrelated to that, that I wanted to bring up before we close. I can do it now, or…

Platanias: One thing that I had in mind when this panel came up was to discuss training grants.

Training grants right now do not allow people from other countries to participate unless they become U.S. citizens or get the green card. I think there should be an appeal to NIH to change that.

I don’t think it makes sense to exclude international people from training grants. In fact sometimes, they have problem filling spots and so on, and I just wanted to bring it up. I don’t know how others feel here, but I think this is something long overdue.

Ulrich: I agree 100%. I think we have so many brilliant minds coming here of people from all over the world. I wasn’t able to get a K award, but that forced me to write my first R01—but the pay lines were 25%, not 9%. And so I got an R01.

But it really limits the ability of young international trainees or faculty by not being able to have access to training grants. And it limits the U.S.’s potential through that as well.

Pisters: I think what we’re bumping up against is strategic immigration policy.

What we are needing as a country is a strategic approach to immigration, and understanding that gifted and talented people should be kept in our country to help us foster innovation and discovery for the rest of humanity.

Right now, we operate some of the finest universities in the world. When individuals finish degree granting programs, they’re sent back to their own countries, instead of doing what Steve Jobs said years ago, “Anybody finishing a PhD or Master’s program in the United States in graduate training should have a green card stapled to their diploma.”

Odunsi: I love the idea as well. I agree. I think we should always be looking for talent.

That is what has driven this country. This is a country of immigrants, we just happen to be the immigrants, the ones that came here. I think just driving for talent, looking for talent, and the training grant is an opportunity to identify talents that we can retain in our system. That is how we’re going to keep driving innovation.