GERM
00:00:09.440 – 00:00:11.360
Ciao. My name is Germ.

WORM
00:00:11.520 – 00:00:12.480
I’m Worm.

GERM
00:00:12.560 – 00:00:28.720
Welcome to episode 99 of the Germ and Worm Travel Health podcast. How to be the best pre travel patient in the world. It’s a big planet. See it in Good Health. I’m Dr. Paul Pottinger, also known as Germ. I’m a professor of Infectious diseases at the University of Washington in Seattle.

WORM
00:00:28.930 – 00:00:36.770
I’m Dr. Chris Sanford, also known as Worm, Associate Professor in the departments of Family Medicine and Global Health, also at the University of Washington.

GERM
00:00:37.090 – 00:02:05.670
Well, Chris, this is a special episode because this is me interviewing you about how our listeners can do the best job possible taking good care of themselves as pre travel patients. So today I’m going to ask you questions, Chris, about your own career. And I think we’ll all learn a lot from it. I know I will.

My questions for you include, how did you get into the field of travel medicine? Why did you choose this field? Is travel medicine really a medical field, or did you and I just make it up as an excuse to go to fun places around the world? And of course, how should our listeners prepare for their pre travel encounter when they come to see you or another qualified healthcare professional?

As a reminder to our listeners, please contact us with your travel health questions, your stories and your tips for success. Just visit our website germandworm.com or send us an email germandworm@gmail.com. Before we jump in, as always, our medical disclaimer:

This podcast is designed to inform, inspire and entertain, but you should not use it as clinical care before you travel. Please see a qualified healthcare professional for recommendations specific to you and your itinerary.

So both of us handle patients before they travel and we take care of them when they come home if they happen to come home sick. But Chris really does more of that pre travel care and I tend to do more of the post travel care.

Today we’ll hear from Chris about how he got into travel medicine and what people can do to take good care of themselves before they go. So let’s start with that. Chris, how did you get into this field of travel medicine in the first place?

WORM
00:02:06.230 – 00:06:23.400
Well, first, it’s a real field. It’s a real thing, It’s a new field, which kind of makes it exciting. It’s only been around 30, 40 years.

Wasn’t really around when I was in training and I certainly never heard of it until sometime after training.

I had the good luck to travel a lot as a kid with my parents, but then with medical school, that kind of took me out of ordinary human activities for A decade or so and I didn’t travel much, but after residency I traveled and then I went to a conference in Seattle chaired by Dr. Elaine Zhang, and it was on travel medicine and I thought it was fascinating. And then two years later I went to the same conference and it was one of the very few conferences I enjoyed from beginning to end.

And I thought this, maybe this means something. And I saw a little color flyer there and this was 1999 and it said learn tropical medicine in the tropics.

And it was for this nine week tropical medicine course called the Gorgas course in Lima, Peru.

And so with my wife and our 10 month old baby, we went to Lima, Peru for nine weeks and I just studied tropical medicine all day and all night and it was fascinating. I think I saw 60 illnesses I’d never seen before.

And I came back and now it’s 2000 and a job opened up at the University of Washington in the Travel Clinic there. And I liked that better than what I had been doing before.

I had been a general family medicine doc doing some urgent care, some ER work before, but I loved being at the university and I loved working at the Travel Clinic. A lot of what I like about working there are the stories that I hear because. And you know this, Paul, because you see these people.

Seattle, big town, big university, a lot of businesses here. But I see tourists and business people, students and tech workers and missionaries and medical volunteers, and they go everywhere.

And after more than two decades of seeing these people, it’s made my geography better. And I’ve heard story after story about people going to really interesting places and doing interesting things.

And I’ll share just three very quickly that I never would have heard these had I not been into in this very particular unique niche that I’m in in travel medicine. Saw one guy, we had a little extra time, I said, why are you going to South Africa?

Turned out he was going there, he was an engineer, he was going to a diamond mine and he was going to change, convert all of their big trucks from propane to hydrogen, which I didn’t know anything about. And he told me a little bit about it and I even understood some. So that was interesting.

And then I saw a woman, young woman, PhD student, she was going to Papua New Guinea. Why are you going? Well, I studied the phys of bees and bee wings when I filmed them with ultra high speed cameras.

So I got to listen to her tell me about the difficulties of the humidity of the jungle on her cameras. And again, it’s stuff you’d Never hear if you weren’t in that line of work.

One more very brief anecdote, just sort of the random things that I came across. Saw a very nice man, middle aged, over about a decade, and he kept going to Venezuela and Colombia and he told me he was a carpet importer.

And I remember thinking, huh, I didn’t know that Venezuela and Colombia had a real robust carpet export sort of industry. After I saw him, after about a decade, he saw me for something else unrelated.

And he said, by the way, I wasn’t telling you the truth when I said I was a carpet importer. And I said, oh, do tell. And he said, actually I was working for the DEA and I was going there because they export drugs. And he quit.

And then he got a job at Boeing, which was not security related. And he liked that a lot more. And that of course made me wonder what other stories I’d been fed over the years.

But I just love talking to the students and the business people and the researchers about what they’re doing. And then of course there’s the whole medical end of it, which I think is fascinating.

All of the things that Paul and I talk about on this show, the infectious diseases. And another thing I like about it is that it ties into so very much.

You’ll hear Paul and me on this show talk about weather and geography and politics and economics and ethics. And we have to know about all these interesting animals and their migrations and all of these drug interactions and resistance patterns.

And it’s just, it’s really complicated and it’s really interesting and it uses all my brain and I’ll never master it, but unlike a lot of other topics in family medicine, I find this whole area just really fascinating and fun.

GERM
00:06:24.040 – 00:06:36.960
And by the way, if people doubt about Chris’s passion for travel, if I’m not mistaken, you’re coming to us for this conversation from a 300 year old stone farmhouse in Puglia, Italy. You’re walking the walk and I appreciate that.

WORM
00:06:36.960 – 00:06:56.050
Yeah, probably in recent years I’ve done more travel to places like Asia, Latin America and Africa. But I keep thinking, you know, I hear Europe is pretty nice and comfortable. Maybe I’ll go there when I’m older. Well, now I’m a little older.

But you know, actually, did you know, Paul, you can drink tap water here and there’s electricity all the time and the sheets are always clean.

GERM
00:06:56.850 – 00:06:58.370
That’s just so boring.

WORM
00:06:58.530 – 00:07:02.130
So boring. It’s actually really nice.

GERM
00:07:03.410 – 00:07:14.770
Well, let me ask you this: You see patients in your office before they travel. And what are some of the misconceptions that people may bring into those visits before they leave when they come to see you?

WORM
00:07:14.770 – 00:08:53.460
You know there are a lot of them. One is that travel in general to low income countries is dangerous.

There’s this conception that France and England are safe, but most of the low income nations are dangerous. Statistically they’re a little more dangerous if you take all comers into account.

But by and large, and this is my key point in travel medicine is that danger and safety are not determined by where you go so much as they’re determined by what you do and by what you don’t do. It’s not geography, it’s behavior. You can turn see Seattle or New York City into a very dangerous place depending on what you do.

And by the same token, you can turn 95% of the world into very tourist able areas if you follow some precautions. So again, I think behavior is more important than geography, which is wonderful because it opens up most of the world.

Another misconception is to the extent there is danger and there are risks around the world, there is a pretty fixed belief even among doctors that most of the risk, if not almost all of it is infectious disease based. So it’s diseases and infectious disease is important. And certainly I talk with all my travelers about vaccines, malaria, prophylaxis and such.

But if you look at the numbers, actually most causes of bad things happening, injury and death, it’s not infections, it’s things more like car crashes, motorcycle crashes, non infectious things. So something I try to do certainly is to talk about those type of things and not just spend all the time on infectious disease.

And in fact, if you’re a pre travel person, spends 100% of the time on infectious diseases, I don’t think you’ve been fully counseled.

GERM
00:08:53.700 – 00:09:20.020
Well Chris, I really appreciate that. Of course I’m part of that ID focus as well. So I’ll talk more about my own perspective on this in the post travel context.

But I think you’re right about that. Let me step back even farther if you’re willing to answer this question.

Should everyone who’s going to travel overseas come and see you or another travel doctor or are there only certain locations or certain people who should come to to see a travel medicine specialist?

WORM
00:09:20.260 – 00:10:26.560
Great question. There’s a big divide in necessary pre travel care between high income and low income countries.

So if you’re going to the high income places, and by that I mean Western Europe, Japan, Australia, New Zealand, Canada, places like that, good income, you could, if you want to, and maybe you should if you have a medical issue. But if you’re healthy and you’re up to date on your routine domestic immunizations, all of them, it’s really not that important.

You know, if you see me, you tell me you’re going to London, I’m going to talk to you about things like flu and Covid vaccines seen in wearing a seatbelt. So if you don’t feel you need to hear that, it’s probably not that critical.

However, I would recommend it for essentially everyone going to a low income country because those countries overlap very exactly almost with where there are things like malaria, where you need to take a medication and there’s dengue fever. You want to make sure you do the right bug repellent or you need additional vaccines such as yellow fever or typhoid fever.

So in answer to your question, if you’re going to a lower or even middle income country, I would say yes. If you’re going to Euro America, it’s probably markedly less important. Would that summary gel with your take on it, Paul?

GERM
00:10:27.120 – 00:11:16.070
Well, as a traveler, yes. So I mean that’s how I have done it myself. Do as I say, not as I do. But yeah, that’s the advice that I give people as well.

I think that’s exactly right.

And as always, if there is an underlying health concern that somebody has, you know, they need to talk with a doctor if it’s going to be one of these less so called risky places, it may be their primary care doctor, it does not necessarily have to be a travel specialist, but you really should be ready for something to go sideways or have a problem related to one of your existing health conditions. Be ready for that so that you can take care of it and enjoy your time when you’re there. Okay.

So having said that, Chris, if someone is going to have one of these more adventuresome destinations in mind before they come to see you as a travel medicine specialist, what should they do to get ready for that conversation?

WORM
00:11:16.310 – 00:14:04.140
Well, most people are already very good pre travel people. Most people know the things I’m about to request.

But it does make our job a little easier if the traveler takes some precautions and some preparations. So first bring your vaccine history.

You may think that because your vaccine history is at a computer somewhere that I can get it, but I can’t unless it’s my little specific system. The computers of doctors don’t talk to each other. It’s still very archaic that way.

So if, for example, the VA has your medical record because you were a veteran I may not be able to get that. So bring some copy, electronic or paper of your vaccine record.

Because if you tell me, yeah, I had two shots two years ago, they went in this arm, then it’s hard for me to make decisions and get give advice. Also, bring a list of your medications. There are some interactions with some things that we give, for example, for malaria.

So you want to bring a full list of medications and doses and how often you take it.

Also, it’s good to write down if you’ve ever had any kind of prior reaction to either a vaccine or a medication, such as a medication to prevent malaria, and your memory may fade.

And even though if you, for example, take meflquine and had a bad reaction, you think you’ll never forget that word, maybe in 10 or 15 or 20 years you will. And so I would write it down so you can tell me, so I can avoid it so I don’t do something bad to you inadvertently. Another thing.

And you would think that I wouldn’t need to ask her this, but you’d be surprised how often folks don’t know it. Know your itinerary. Again, it makes my work harder. If I ask someone where they’re going and they say, I don’t know.

The wife, she made the thing, I’m going to Asia. When are you leaving? Well, ask my wife. Where is she? She’s at work.

Well, again, it’s hard for me to give advice if you don’t know where you’re going to. So bring me what dates you’re going to, what places, what kind of places you’re staying in in terms of time.

Ideally, you would see me at least six weeks before because that gives time for some vaccine series that gives time maybe to try a trial of a medication to see if there’s any side effects.

And my last request would be to call your insurance company, call that phone number on the back of your insurance card if you have insurance and find out what they pay for and what they don’t. Because a lot of people, reasonably enough, they say, will my insurance cover that? And some of these vaccines are expensive.

And I generally say, I don’t know.

There are so many insurance plans, it’s not realistic to expect your doctor to keep track of which insurance plan covers what vaccine and what medication. So. So it’s a reasonable question. And it’s important because you don’t want to be out of pocket for a lot of this stuff.

But the best way to do it is to call your insurance company first so you know what the fiscal hit is going to be. So you can figure that into the big decisions about which vaccines you’re going to receive and which you’re going to pass on.

GERM
00:14:04.860 – 00:14:49.340
It’s really helpful. And to be clear for all of our listeners, we wish we had those answers.

It would be so much more helpful to us as doctors to be able to say, hey, get this shot and here’s what your out of pocket cost will be. And we can often give a ballpark, but unfortunately this can be frustrating.

It’s part of our crazy quilt of healthcare coverage we have here in the United States where unfortunately it’s expensive. And it’s also unclear.

But let’s talk a little bit more depth, Chris, about people who do have chronic medical concerns, but they also want to have that more challenging trip. Is it possible to have both? And if that’s the case, what do you do when you’re talking to somebody in that condition?

WORM
00:14:49.500 – 00:16:51.300
Yeah, great question. My mantra is that most people with most medical issues can go most places, but some preparation may be necessary.

Increasingly, the international tourist industry clientele is getting older, so we have a lot of more elderly people, many with chronic medical problems going all over the world. And most of them do fine.

But it’s good to talk to your doc about it, preferably a travel doc, so that you can make sure that you’re not stepping over your level of ability. But the tourism industry is responding to people with chronic illnesses.

And for example, there are now cruises on which you can get dialysis regularly three times a week, same as at home. So what you can’t do just do is show up on a regular cruise boat and expect it to be a full hospital.

But if you look around on the Internet, there’s probably going to be a cruise tailored to your particular medical condition. And one thing I would recommend, though, is that you not really step up.

We sort of touched on this in the prior episode, but is go to a physical level of activity that’s markedly above what you do at home. So if you’re, for example, going to climb Kilimanjaro, but you smoke two packs a day and you don’t even exercise, that’s not realistic. It’s 20,000ft.

So, yeah, if you’re in good shape and jog regularly and don’t smoke, you can probably do it. But as Paul said in the last episode, travel is not a good time to markedly step up your exercise routine.

That’s a good way to get sick or to get hurt. But back to your question, Paul. Yeah. Whether you have a Cardiac history, kidney history, lung history.

There are certain rules and complications for all of this.

And actually, I enjoy seeing people who have chronic medical problems because I can give them advice, I can help them to see some really interesting places. But for example, if you need oxygen, you can’t take your own oxygen on the jet.

You need to call the airlines in advance and set it up so you can do it. But again, it can’t be impromptu. It takes some deliberate preparation.

GERM
00:16:52.210 – 00:17:03.090
With that in mind, do you ever say no? Are there examples where someone comes to you with a proposed travel plan and you say, look, medically speaking, actually, I recommend against this.

WORM
00:17:03.970 – 00:19:31.850
What I never do is tell someone or command them because I have no authority to do that. I can recommend. And yeah, I’d say 1% of the time, because I’m so Joe pro travel. I think travel is a wonderful thing.

I think it builds tolerance around the world. The world. But about 1% of the time I’ll say, you know, I think this is a bad idea for a variety of reasons, few reasons.

I saw an elderly woman not that long ago. She was early 80s, and she kept falling asleep during our encounter.

So I know I can be boring and go on and on, but I think she fell asleep four times in 15 minutes. And she was going on some fairly arduous cruise with no air conditioning, on the Amazon by herself for two weeks.

And I didn’t think it was a good idea. And I told her, and she basically said, bosh, I’m going. And I called her son, and he said, I agree with you, but mom’s pretty strong willed.

And I called her doctor, her regular doc, and I said, I don’t think it’s a good idea. And he said, I agree, but she’s pretty strong willed. Anyway, she went. She had a great time. She made fun of me later for recommending that she not go.

Another time I recommended someone not go. I saw a young man who’s an engineer for a tech firm in Seattle, and he was going to Afghanistan.

And this was before the US pullout, when it was definitely a war zone and not a tourist zone, but he was going there as a tourist. And I asked him why, and he said, well, I’m writing a novel and it’s set in Afghanistan, so I need to go there.

And I said, I don’t think you should go there. And I read him the State Department warning, category four, do not go. And he went. And then he came back and he was fine.

And he sounded a little disappointed that it wasn’t more adventurous than it was. And the last time I got this was actually the one time I got angry that I can recall is I saw a guy again.

He was an engineer for a tech firm in Seattle. He was going, I forget where he was going, in Africa, maybe East Africa.

And I asked him about his activities and one of them was quote, treating malaria. He liked to give out malaria drugs to people with malaria to save lives.

And he wasn’t a doctor, he had no medical training and he wasn’t doing diagnostic testing and he wasn’t keeping any records. And I gave him the riot act. I said, you’re doing more harm than good. It’s hard to diagnose, you’re not keeping records, you don’t have a license.

I recommend you stop doing that. He got kind of sullen and he chose never to see me again for his pre travel care.

But that was one case where I thought somebody was doing something they shouldn’t do. So 99% of the time I say good for you. How can I help you? This sounds great. Wish I was to going and send me a photo.

GERM
00:19:32.330 – 00:19:46.410
Okay, Chris, what about someone who is pregnant or planning to become pregnant during time overseas? That’s often a stressful time for people and I’m wondering how you approach this or has that ever been a source of stress for you or your patients?

WORM
00:19:47.050 – 00:22:01.690
Yes, the conventional wisdom is the second trimester is the easiest trimester during which a pregnant woman can travel. They’re over the nausea often of the first trimester and they don’t have all that extra weight of the third trimester.

And so in general, women in any trimester can travel, but it’s probably easiest in the middle trimester. However, there are some interactions between pregnancy and certain vaccines. We don’t give live vaccines to pregnant women.

And for example, yellow fever is a live vaccine. But also we don’t like to give certain antimalarials to pregnant women. They haven’t been tested, they’re not thought to be safe.

So I saw a couple, for example, who was going to East Africa. They wanted to go on safari and they were honeymooners trying to get pregnant.

Didn’t want to take birth control, but they were going to all areas with malaria, a life threatening illness. And malaria is not only life threatening, but it’s more serious than usual in pregnant women. They do worse than the average person.

So this was definitely a problem. And out of the three main ones that we give, doxycycline, mallourone and meflaquin, the only one approved for all three trimesters is Mefliquin.

But Mefliquin by far has the highest rate of side effects of those three.

And also this particular woman had a history of depression, which is a contraindication to giving Mefloquin because it makes the risk of side effects even higher. So what I ended up doing with this couple is I switched hats. I took off my doctor hat and I put on my travel agent hat.

And I said, you know, you guys want to get pregnant? Have you considered going maybe to the tropics where there’s no malaria? And I said, what about Bali? Bali is beautiful. What about Hawaii?

What about Morocco? And they hadn’t bought their jet tickets yet. And so they said, well, what about the live vaccine thing? And I said, no, that works too.

You don’t need a yellow fever shot to go to Bali or Hawaii or Morocco. And I was just kind of pulling names out of a hat. I’m not a travel agent.

And they started looking up airfares on their cell and right there in the office they decided to go to Bali. And they had a lovely time. And I think they got pregnant within a year.

So, yeah, that’s another fun thing is I’ve gotten better at alternate, equally interesting plans don’t require the travel interventions that may be contraindicated by the pregnancy.

GERM
00:22:02.410 – 00:22:24.950
Interesting. Super interesting. I’m curious about your experience at the other end of the. The lifespan.

People who are making that last trip, let’s say they are battling, I don’t know, a terminal illness, or they perceive themselves not to have long to live, but they really want to travel. Has that come up in your practice?

WORM
00:22:25.110 – 00:23:51.040
You know, it does, and I kind of like it when it does because I feel I can help these people realize a life’s ambition. I remember seeing a guy, he wasn’t that old, late 60s, but he had metastatic cancer. It was lung cancer. And actually he had given up treatment.

He was just taking narcotics, high dose narcotics for bone pain. But he came to see me and he wanted actually to go. Something I’ve never seen. And after talking to him, I wanted to go see it too.

The annual wildebeest migration in Tanzania’s Serengeti National Park. Every September, millions of wildebeest crossed the Mara River. And he wanted to see it.

And I said, fine, let me give you a little bit of warning here first. You’re going to be really far from medical care. And he was like, I don’t care. I know I could die. They can’t do anything for me here.

I want to go see it. And If I die there, it’s okay. So I basically said, yeah, let me, let me help you.

So I, you know, gave him the usual vaccines, usual medication for malaria and such. When I talked about evacuation insurance, he goes, no, you know, if it happens there, it happens there. So he went.

I saw him when he came back and he said it was a high point of his life. He said he watched from cross the river. Most of the wildebeest made it through, some drowned, some were eaten by crocodiles. Super high point.

Thank you, doctor. And I think he died about two, two and a half months later. So yeah, that again is a facet of this.

If I can help someone do that and they sort of know the risks, I am happy to do so.

GERM
00:23:51.600 – 00:24:16.940
Wow. Wow, what a story. Another question. You know, we live in this increasingly shrinking where you can travel most anywhere pretty quickly too.

And sometimes people are asked to do this for work that professionally they’re required to make a trip. I’ve had this experience where some people actually just don’t want to go to a particular location.

Has that come up in your practice and how would you handle that?

WORM
00:24:17.020 – 00:25:45.490
You know, not too often, but yes, it does. If it’s for a medical thing, I’ll write a letter in a heartbeat.

So if a woman, for example, is pregnant and her company wants her to go to a low income country or really travel at all and she doesn’t want to, I can usually find a reason to write a letter that says Mrs. Smith should not travel for these reasons. See Sanford MD.

It also comes up though, sometimes people don’t want to travel just because they have this concept that a place isn’t safe or for some other reason. So, for example, a common place, and I’m sure you’ve seen this, Paul, is that Seattle?

Since a lot of tech workers to India, often Hyderabad in the south. And Hyderabad is a big safe city. It’s millions of people, it’s clean, it’s affluent, they have super WI fi everywhere.

But I remember seeing this woman who just didn’t want to go. A tech company wanted her to go there, she just did not. She thought it was dangerous and dirty and other things that were not accurate.

And she didn’t ask me for a letter and I didn’t write her for one.

But I sort of tried to, to bring her down in terms of I tried to let her know that it was safe and there were doctors and there wasn’t rampant infectious disease. And she got a little irked. She sort of felt like I was colluding with her. Workplace to make her go there, but that’s rare. It’s come up rarely.

Like if you have a cousin and they have a destination wedding and it’s super expensive to go there and it wasn’t your idea to go there, but that’s really rare. But yeah, I do see it. So anything medical, I’ll write a letter.

But most people, obviously the great majority, really want to go to the place they’re seeing me for.

GERM
00:25:46.210 – 00:26:30.010
Yeah, I appreciate that a lot. And that’s happened in my experience too.

And you know, we are trying to be honest brokers of information, medically speaking, and also based on our own experience. So thanks for sharing your perspective with that person and I certainly hope they had a safe and healthy experience.

Sometimes we don’t know, do we, Chris? When we see people before they leave, they don’t come back.

We assume that that’s because they had a safe and healthy process and, and that we didn’t steer them the wrong way.

In a future episode, I’d be happy to talk about when that does not happen, when we actually have people come back from a trip and they’re not well, and how we can coach people on that process, preparing for those post travel visits. It’d be my pleasure to talk about that on an upcoming episode.

WORM
00:26:30.010 – 00:26:40.460
And even though, Paul, I know you enjoy seeing post travel patients, my goal is to minimize your patient load. So if you’re seeing. Seeing everybody who I’m seeing, I’m doing something wrong.

GERM
00:26:41.660 – 00:27:01.980
Yeah. So everybody understands. I never see somebody referred out of Chris’s practice because he handles his own business.

But I just mean in general in the community, whether it’s family medicine, travel qualified or otherwise. Sometimes, in spite of everybody’s best attempts, illness happens and somebody should be there to help take care of them.

Let’s talk about that on an upcoming episode.

WORM
00:27:02.220 – 00:27:02.940
Sounds good,.

GERM
00:27:18.690 – 00:27:53.050
Everyone, thank you so much for joining us here on episode 99 of Germ and Worm. As always, we welcome your questions. Please reach out to us with any concerns that you have or stories of your own.

Will include your name if you wish. But if you want to send us questions and have that be anonymous, that is totally okay.

Get us by email germandworm@gmail.com or visit us on our website, germandworm.com. If you’ve enjoyed what you’ve heard today, please subscribe, Rate us favorably on your device and spread the word with friends, family and on the socials. Those are free ways to support this podcast. I’m Germ.

WORM
00:27:53.290 – 00:27:56.980
I’m Worm. It’s a big planet. See it in good health and we’ll.

GERM
00:27:56.980 – 00:28:20.580
See you next time. This podcast is designed to inform, inspire and entertain.

However, this podcast does not establish a doctor patient relationship and so of course it should not replace your conversation with a qualified healthcare professional. Please see one before your next adventure.

The opinions in this podcast are Dr. Pottinger’s and Dr. Sanford’s alone and do not necessarily represent the opinions of the University of Washington or UW Medicine Medicine.