Awaiting the Supreme Court’s Abortion Pill Opinion

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All eyes are on the Supreme Court this week, as the temporary stay in the Texas mifepristone case expires. Andy speaks with Fatima Goss Graves from the National Women’s Law Center about the confusing rulings and what she expects the justices to do. Former FDA Commissioner Josh Sharfstein also joins to explain the dangerous precedent this case could set for FDA-approved drugs and drug development.

Keep up with Andy on Post and Twitter @ASlavitt.

Follow Fatima Goss Graves and Joshua Sharfstein on Twitter ​​@FGossGraves and @drJoshS.

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Andy Slavitt, Fatima Goss-Graves, Josh Sharfstein

Andy Slavitt  00:18

This is IN THE BUBBLE with Andy Slavitt. Welcome to the show, please send me an email at I got one the other day, I won’t reveal the name of the person who sent it because I don’t have her permission. But she wanted to press upon me the point that I think it’s worth reiterating that when it comes to choice, when it comes to the question of women’s reproductive rights, it’s not so much a matter of just of a woman’s health issue. As I sometimes talk about it on the show, it’s also a matter of a fundamental women’s rights issue, and treating women as less than capable of having agency over their decisions. I think that’s important. What’s also important is that the people who are attempting to take that agency away, aren’t quitting. They’re not stopping at Dobbs. They’re trying to cut off any and all means that are safe and approved and effective that women use to make what is gotta be a very difficult decision. But it is the individuals decision. That is not what, you know, Republican, conservative politicians are preaching these days. And the latest, of course, is the lawsuit against the use of Mifepristone. And that is a case that is about to be heard by the Supreme Court. There are some confusing rulings, we’ll get into those rulings. Those rulings have been stayed there for about a year from the Supreme Court, a very, very, very powerful, volatile issue. And I’m so grateful to have Fatima Goss Graves. Back on the show. She’s the president of the National Women’s Law Center, and Josh Sharfstein who was formerly at the FDA, now with the Johns Hopkins. But this whole matter of a judge saying that the FDA cannot approve a drug as being safe and effective is the route that they’re going down here. And so I wanted to get an FDA perspective here. It’s a great show. It’s a great interview. It’s a great podcast. And so I’m not even going to tell you about the hats and T shirts and coffee mugs available that say in the bubble, because it will be crass in the middle of such an important topic. So forget I mentioned it. Instead, let’s bring on Fatima and Josh.

Andy Slavitt  02:39

Fatima, it’s so good to see you again.

Fatima Goss-Graves  02:42

And so happy to be here.

Andy Slavitt  02:44

And Josh, is this your first visit to the bubble?

Josh Sharfstein  02:47

This is my first visit but not my first podcast with you because you came on public health phone call,

Andy Slavitt  02:53

that’s for sure. And with any luck, it won’t be your last visit to the bubble. But you’re you know, you’re up against a pretty stiff competition in Fatima if this were a competition, because she’s wonderful. But I’m so glad to have you both. So maybe I can start with you Fatima? Can you just give us a overview on how you interpret what is happening and what the landscape is like on this issue?

Fatima Goss-Graves  03:18

Well, the current landscape is effectively mass confusion. That is what we are finding that providers are worried and confused. People who are seeking abortion care confused. And so the first thing that I always feel compelled to say is that as of the time of this recording, Mifepristone is available and medication abortion more broadly, is available in this country. And then the second thing I feel compelled to say because I think there is huge confusion. I feel compelled to say even with Josh on the call is that Mifepristone is safe and effective. And in over 20 years of practicing law when I read judge Kacsmaryk, the district court judge in in Texas, when I read his decision, the thing that was so astounding was that he just so flagrantly and blatantly disregarded medical terminology, the hundreds of studies that are out there and sort of put his own worldview in its place, which is definitely not the role of a judge.

Andy Slavitt  04:33

And if you’re a woman, you feel like what that there are that people are having a war over your body?

Fatima Goss-Graves  04:39

And you’re not a part of the conversation, right? That’s what’s so outrageous, both in the Kacsmaryk decision, but in general, in a lot of the public discourse. Absence is what this will mean for individuals and their ability to get the care they want and need to control their bodies. and to control their lives and futures, and to manage their care the way that they want.

Andy Slavitt  05:05

Mifepristone, if I’m not mistaken, was approved by the FDA in the year 2000. We have plenty of time and plenty of evidence. Fatima, can you just remind us what Judge Kacsmaryk logic was what he was saying in his ruling? And then I want to ask Josh, who was very senior person at the FDA this morning to meet with the FDA than almost anybody I know, to reflect on how a judge can reach those sorts of conclusions. But remind us what he’s saying?

Fatima Goss-Graves  05:36

Well, first, he said that the people the plaintiffs before him had standing to bring the case. And you have to understand who these people were who brought this case, this was a group that was formed after the dobs decision, but purposefully located in Amarillo, Texas, in part because that location guarantees you’re going to get judge cast Merrick because he’s the only judge for that area. Right? What he said is this group of people who purport to represent providers that they have standing to bring this case because they potentially could be affected if Mifepristone has side effects.

Andy Slavitt  06:20

If Mifepristone has side effects.

Fatima Goss-Graves  06:23

So like, if you’re a doctor, your complaint might be that you are forced to treat the side effects from Mifepristone. So he said, because these doctors say they have that worry that they could bring this case challenging Mr. Preston’s effectiveness, not the people who have used it or plan to use it in the future. So that was one thing. And then he said that the FDA got it wrong 20 years ago, and didn’t undergo a rigorous process. They made mistakes along the way.

Andy Slavitt  07:00

So let’s bring in Josh here, tell us what you know about the FDA process, the safety and the efficacy of grip of presto, and maybe get to what your thoughts are on a judge using this sort of logic?

Josh Sharfstein  07:14

Sure, well, the FDA, as you said, approved this medication back in the year 2000. And at the time, there was a large database that was available to FDA to review to look at the safety record. And they also consulted with Advisory Committee, which they typically do with recommended approval, there’s major support for approval from professional organizations. And they went ahead and approved it and put in place a number of safety restrictions that overtime they’ve studied and found a number of them not to be necessary, are able to be loosened somewhat. And this is a medication used by hundreds of 1000s of people every year with a very strong safety record from that. And it maintains the full support of the American College of Obstetrics and Gynecology and other professional association. So you know, as medications go, this is not particularly controversial. I mean, we’re used to controversies, the FDA, where you have the leading professional associations weighing in one way or another on, on, you know, major complicated clinical questions. That’s just not the case for this medicine, that this medicine has been really pillar of reproductive health care for more than two decades.

Andy Slavitt  08:33

Yeah, so we’re23 years, hundreds of 1000s of women every year prescribed this medication. What can you tell us about the side effect profile and the amount of side effects compared to the many, many, many drugs that the FDA has approved and that are on the market?

Josh Sharfstein  08:50

Well, you know, every medicine has side effects. Every medicine also, you know, is imperfect in different ways. I think one of the biggest issues for Mifepristone is that it doesn’t, you know, fully work, sometimes there needs to be a surgical procedure, in order to finish the abortion, and that is, in a certain percentage of cases, most of FDA safety restrictions are based on making sure that people who are prescribing it know how to help people in that situation, which isn’t, which is uncommon, but not completely rare that something like that would happen.

Andy Slavitt  09:24

Well, isn’t birth control that perfect as well?

Josh Sharfstein  09:27

Right, everything’s not perfect. And in fact, you know, Mifepristone is a lot safer than pregnancy to the pregnant person, you know, that pregnancy is a very risky condition, and under some circumstances, particularly, so, you know, the context of this is that there’s really not a lot of controversy on this being an appropriate medicine to use.

Andy Slavitt  09:50

Says you but you’re only a medical scientist. You don’t have a law degree. So what gives you the qualifications, Josh, to make that determination?

Josh Sharfstein  09:59

I mean, the people FDA who work on these determinations are, you know, scientists who and doctors and other health professionals who this is what they do for a living. And they’re really devoted to it. You know, I mean, working in an agency as you did in the federal government, Andy, you know that, like, you’ll bump into someone in the hall and start talking to them about their careers, and you realize they know so much about what they’re doing, they have forgotten more than you’ll ever know about a very particular issue. And that’s what the people at FDA who work on this issue do.

Andy Slavitt  10:34

Right. I mean, back before the FDA, we would have hucksters who would come to our towns and tell us about promising side benefits. And we hired a bunch of scientists to review the situation. I’m gonna come back to you and talk a little bit later about some of the applications here. But I want to go back to you Fatima for a second, because I’ve got a theory here work with me on this. That maybe the judge was after something else, besides just being worried about the safety and side effects of a medication and the impact on the physicians? I know, I’m going on a limb here. But is that possible?

Fatima Goss-Graves  11:11

You know, that might have seemed like a radical idea. But I actually think he’s pretty clear in his opinion. And he’s clear that around his views of personhood in the language that he used, where he said he rejects the term fetus, for example, and instead was sort of making the case of the harm, basically, to the fetus. And giantly discounting the harm to the individuals who seek abortion cares, you know, citing a blog, of testimonies of women who say they regret their abortion, and so he has a bigger agenda here. The other thing I just want to name is that we’re talking more than 20 years of a medication that has been approved. And that means lots of people are using it providers understand what they are supposed to do with it. And he stayed his decision that would have up ended access to this medication for only seven days. Right. So he created an emergency where there was none. And that’s an emergency for the courts. And we’re all sort of waiting for the final decisions. But it’s also an emergency for people who have to scenario plan around what they will do if his ruling is allowed to go into effect.

Andy Slavitt  12:41

So the Justice Department has said that it disagrees with the Fifth Circuit, and it has asked the US Supreme Court to weigh in now. Maybe just for completeness, you can just give us briefly what the Fifth Circuit has said, because while it did stay the ruling, it had some very troubling elements. But I really would like to then ask you what you think we can expect from this Supreme Court, which is the same Supreme Court that put down the Dobbs decision.

Fatima Goss-Graves  13:09

So you know, the Fifth Circuit decision, and it’s, I think I’ve seen some almost misreporting about that decision, because people have made it sound like the Fifth Circuit has found some sort of grand compromise or something. But it actually had the same flaw that the district court decision did and that it replace sort of court science and judgment for our the FDA determination. And that is a dangerous idea, no matter what level or how they do it. And so, you know, it would have left Mifepristone. Its original approval, but it would have discarded the 2016 and 2021 changes. So it would have changed the week of availability would have changed the ability to access it by mail, he, you know, went through various changes. The other thing it did was it kind of revived this sort of, you know, almost like zombie law called the ComStat act that was designed to restrict the mailing of obscene material and your feet, right. Yeah, right. It is likely unconstitutional now. Although, here’s the thing, when the Supreme Court opens the door to sort of willy nilly up in in precedent, it leads litigants to believe that everything is on the table and that they should do things like revive 150 year old laws that they thought was likely unconstitutional.

Andy Slavitt  14:50

So the Supreme Court has put a temporary hold on this ruling that was just announced last Friday. What do you expect them to do next?

Fatima Goss-Graves  14:56

So, you know, I try not to make giant predictions, I can tell you what I think the Supreme Court should do. The Supreme Court should remand with instructions to the district court in all of the ways that he got it giantly wrong. Just beginning with standing, these people should not be in court in the first place. And this should all go away. That’s what should happen. I’m not sure that’s what’s going to happen.

Andy Slavitt  15:21

There’s a range of possibilities. Let’s take a break. And then, I want to ask you about what precedent this would set for all of us in this country who rely on drugs, to keep us alive and manage our chronic conditions, we’ll be right back.

Andy Slavitt  15:57

Josh, when you think about this sort of very new world that the FDA would find itself in, should this really go into effect, this idea that a judge apparently, based upon a belief that, at the minimum, any side effect profile of any drug, which is you fall established includes every drug that’s ever been approved, and that people take and rely on to manage their chronic conditions to manage their cancer, to manage life threatening diseases? What does that precedent do to all of our ability to rely on the medicines that we need?

Josh Sharfstein  16:38

I’ll tell you my opinion. But I’ll also tell you the opinion of a lot of patient groups, and the opinion of a lot of pharmaceutical companies and their trade organizations. The FDA plays a really important role in creating a fair and predictable playing field for drug development. And when people can count on the FDA, and the FDA delivers, then investors will put tons of money into finding new cures and developing new products. But when there’s a total wild card that someone could come out of nowhere wake up in the morning and decide that they’re going to invalidate a 20 year old approval, then people start to wonder what could be next. And so it’s dangerous. And that is my view. But it is also the view of some leading patient organizations, the Cystic Fibrosis Foundation, groups of patients with multiple sclerosis or ALS. I think 30 groups issued a statement. And it was, you know, not a weakly worded statement. I think I can pull it up. The implications of this ruling go far beyond Mifepristone. If the judge’s ruling is allowed to stand, patients may no longer have the security of knowing that determinations about drugs. So safety ultimately lie with the experts. And in a brief to the Fifth Circuit, a number of companies and I think the trade organization bio said that they were worried about decision wreaking havoc on drug development and approval, generally causing widespread harm to patients, providers and the entire pharmaceutical industry. It’s a really serious thing. I mean, we take FDA for granted. And we take all the different ways that this, you know, agency makes determinations for our safety for granted. But then when you pull back the curtain, and you see that it’s really an agency that exists because we trust it, you know, and it works because we trust it. And it’s vulnerable to a judge just showing up and saying, Actually, I just think differently. It really shakes the foundation of what we take for granted and what really supports our health in this country. And that’s why here’s what I’ve seen what I think is an unprecedented response from the entire world that, you know, cares about pharmaceutical drug development and safety too.

Andy Slavitt  19:08

Safe to say that the scientific community is pretty unanimous in this?

Josh Sharfstein  19:12

I mean, I’ve never seen this kind of response. It is. It is a very strong response.

Andy Slavitt  19:17

Okay, that’s helpful, better said. So but I want to ask both of you this question. To me, it feels like this could extend even far beyond the FDA. For example, if I’m a physician, if I’m an emergency room physician, I think I have standing relative to the use of firearms, because they’re my emergency room. I have to deal with children who are getting shot in schools with firearms. And if it standing like this, if a ruling like this is allowed to go into effect, what’s to stop a liberal justice from saying we’re gonna have to ban all firearms. I recognize that that’s a wild hair kind of concept, but isn’t that what we sort of throw ourselves open to? How about two of you respond to that?

Fatima Goss-Graves  20:05

Well, it is one of the reasons why you typically have to have an actual injury to bring a case that that is not a new idea in our lives. So it’s a well-worn one so that you don’t have this sort of upheaval. And people who don’t have a meaningful interests, challenging statutes, laws, decisions that are important. And if law is now this flexible thing that ebbs and flows, depending on the jurist here before, I have to say, I’m not sure that progressive lawyering has actually caught up with this notion. I think many folks, you know, maybe even like myself are sort of holding on to the promise of stability and rule of law. But if we are in this wild west, I think you will see a back and forth.

Andy Slavitt  20:56

If I were conservative justice at the Supreme Court, it might help me to think about that as an implication, Josh, what were you gonna say about this?

Josh Sharfstein  21:04

I was gonna say, look, even in the realm of medications and vaccines, you there’s a lot of reason for concern about what a precedent like this could set. You know, there are people who really don’t like vaccines. And people who think vaccines are unsafe, It’s not like a leap of faith to think they might try to get a judge to take them off the market, or, you know, huge different vaccines off the market, or there are people who really don’t like medications for depression or other psychiatric conditions. And they have a whole case there. And, you know, people are allowed to say things people can think things. The question is, how do we judge those things and who gets to decide, and Congress that it should be the FDA using evidence and not, you know, a random judge who wakes up and decides that they’re gonna, you know, pick a side.

Andy Slavitt  21:55

Feels like a clear cut case of science versus politics. And I want to come back to Fatima. This point about the fact that there are real people in the meantime, that are paying the price,  Mifepristone is part of a two drug regimen, typically, with other drug called misoprostol. Help us understand the stakes here, for women, if Kacsmaryk’s ruling were allowed to stand, or even the appellate court ruling were allowed to stand greatly, greatly curtailing access, what would that reality be for women?

Fatima Goss-Graves  22:31

I mean, I think the first reality is going to be a lot of confusion. I think if this ruling goes into effect, there’s a real worry people will think that they can’t access this care anywhere. And that they will think that whether it is true or not. So that’s the first challenge. The second challenge, I think will be more of an FDA challenge of what to do, because the FDA will have conflicting rulings, potentially, unless the Supreme Court is very clear around it. And so that’s that is another challenge for the FDA. But if we are in a worse scenario where myth personas up the market, you know, there is still other medications, medication available, and you name I suppose style, but other medication available, I will just say it will be a travesty in my view, because it’ll mean that people can’t get the care that they actually want or that their doctor is recommending.

Andy Slavitt  23:34

And those other medications, those other medications are still curity, they will remain available. If this were allowed to stay.

Fatima Goss-Graves  23:40

I guess that’s the other point that there is nothing to think they won’t use the same series of wild arguments to try to go after each medication one by one, they are of telegraph to us the plans, especially around the column stack. And so our job is to ensure people can get the care that they need and are not penalized for it. And we have been preparing for times like this and worse and so we will be doing all we can at the National Women’s Law Center to ensure that that is a reality. And every leader in my view, every elected person, in my view, has the responsibility to do all they can to make sure people can get the care they need.

Andy Slavitt  24:31

Okay, let’s take one more final break. And I want to come back and start to focus in on the impact of this on women. And the impact on basically the political landscape ahead as this continues to emerge as the singular most important issue in our election cycle so far. We’ll be right back So, we talked about how politics is weighing into health and science. So let’s go there. Okay, I want to talk about politics for a second. You know, we had a very meaningful election in Wisconsin, which we did an episode about on Friday. That’s a case where by 11 point margin, a justice was elected the Wisconsin Supreme Court, almost entirely on the issue of women’s reproductive rights. But I’ll go further, there is a recent poll from the Public Religion Research Institute. And the results of the poll, which is very extensive research, by the way, they it’s very extensive questions about abortion 72% of Americans oppose. And I’ll quote exactly from what they oppose. They oppose laws that make it illegal to use or receive through the mail, FDA approved drugs for medical abortion couldn’t be more clear. 72% of Americans oppose this. That is a very, very, very large percentage. So from a political standpoint, as you look at Wisconsin, you look at what Ron DeSantis has signed into law. In Florida, let’s abortion ban after six weeks, as you look at judges appointed by Trump making these very political rulings, how is this affecting the politics here?

Fatima Goss-Graves  26:37

So every time abortion has been squarely on the ballot, people have voted in favor of it, whether that has been directly for ballot initiatives, or in the case like the Wisconsin election, judicial election, people understood that what was at stake in that judicial election was whether or not the state of Wisconsin weighed as a draconian abortion ban in place. So the voting public isn’t confused. And it’s not even necessarily across party. It’s not even, you know, blue states versus red states versus purple states. That’s not how this is lining up. The vast majority of people in this country are in supportive abortion access. And that is more true when you’re talking about medication abortion. And still we are seeing these efforts by a minority of people to pass laws that do the opposite. So you know, they are not doing things that are in at least their short term political interests. They seem to be using the power they had to enact personal worldviews. And I think people wish that wasn’t the case. But this is a part of a broader effort, and it is going to require us to show up again and again to defeat it.

Andy Slavitt  28:06

Josh, you live in and around Washington, and you’ve been in it around, certainly policy, but also by reflection politics, both at the state level. And in Washington. I’ll give you some other numbers here. Letters circulated around the US Senate, asking senators to sign an amicus brief and the Republican side either in favor of supporting judge Kacsmaryk ruling and on the Democratic side. It amicus brief, condemning the Texas ruling. Okay. 50 Democrats, 50 Democratic senators, signed that amicus brief condemning the ruling. Only 11 Republican senators, palette to professional politicians, pro-life every one of them. We’re willing to sign that ruling. What does that tell you?

Josh Sharfstein  28:56

You know, this is some speculation. But obviously, Democrats are willing to sign their name to the position more than their counterparts. You know, I think that it’s obvious that this is a, you know, hot political issue, like very hot political issue, and it’s gonna have all kinds of implications for elections. And, you know, the way that I think about this, in part is that there’s just a lot of risk of, you know, not just on the issue itself, which is enormously consequential, but collateral damage that the issue can cause. And what we’re seeing here is collateral damage to the FDA in the world of the FDA, that, you know, will have its own set of ripples, you know, there are all these different ripples, political and otherwise that are coming from just the issue of abortion and all the fights that are happening and they’re huge public Cultural ripples from that. And now you have just an entire other dimension to the consequences. And, you know, it’s hard when you’re like, having to fight on a political issue that matters so much to be thinking about the ancillary issues. But, you know, this is one that it’s important to think about, and it cuts in different ways. But I think it we all benefit, when there’s a trusted science based regulator that can make good decisions for all kinds of products. And, you know, seeing that as an important value, whether you’re a Democrat or Republican is really important. And I say that gingerly. Because, look, there are times when there have been Democrats who have pushed against the FDA and even the scientific staff at the FDA on particular issues. And, you know, being at the agency, sometimes you feel the pressure of politics on different things. And it’s hard to see past those issues to an underlying value of having respected science based regulation. But I think it’s really important. And you can see when it gets attacked, so directly, like in this case, how important the consequences are. So I hope that no matter where people are in the political spectrum, on abortion, they can see like, we don’t want to keep investors from investing in medications and treatments, and that we want to be able to trust the medications that we take. And that should be, you know, kept out of this, even as we’re fighting an important fight.

Andy Slavitt  31:36

Yeah. But look, it’s, it’s an appropriate point for you to make. There are many of us in this country right now who are dependent on medications, to manage our chronic conditions. And we are well aware of the side effects. We’ve been living with them for years. But we need them, we need them to live a normal life. And I can think about anything from people with depression to people with epilepsy, to wake up one day, and find that those medications have disappeared, then you’ll know what it feels like a little bit of what it must feel like right now, to be caught in this whirlwind, that women are caught in around for Princetonian, and this is bad enough, but you’re right to point out that this is a precedent we don’t want to set you know what it tells me, Fatima that number is telling me that politicians are good at one thing, if they’re good at one thing, it’s reading polls, it’s reading polls, and only 11 senators willing to stand up for their belief, their quote, unquote, pro-life belief, but unwilling to sign on to that statement, tells me that politicians understand that Republicans have unleashed hell upon themselves. They political hell upon themselves as they’ve unleashed it on women. And I invite you to give us your parting thoughts. I know, you’ve got to get somewhere. And I really appreciate you being here.

Fatima Goss-Graves  32:58

Well, my, my only final thought is if that is the case, if they believe that the havoc that this decision will have on this country is serious and cannot stand, then there will be plenty of opportunities for them to show up and pass legislation in the aftermath. And so that will be the true test.

Andy Slavitt  33:20

I can’t thank you enough, Fatima for being here yet again. And as long as this issue remains at the forefront, I’m so grateful to have you able to educate people and explain people to come through it. And Josh, I think you showed up quite nicely, even with Fatima as your competition. So what do you think Fatima, we should have Josh back sometime again?

Fatima Goss-Graves  33:42

Definitely. It’s been so good to be with you, Josh.

Josh Sharfstein  33:45

Likewise, I’ve learned a tremendous amount. Thank you.

Andy Slavitt  34:01

Thank you for listening to that. Now, I will tell you that if you go to And you go to the shop part you will find brand new brand new in the bubble T shirts, hats and coffee mugs. They’re spectacular. They go with everything. They go with everything. And they’ll really be a great way for you to finish out your week. And you can meet interesting people, if you kind of wear them in public or drink your coffee in public and be like, oh, I listen to that show. Or oh, I’ve never heard of that show. Tell me about it. That’d be kind of cool. Look, […] the show on Friday. We’re going to talk about the fact that in seven states in this country, we are on the verge of people being asked to cut their water use by 25%. Imagine having cut your water use by 25% it doesn’t really seem possible. But maybe it is. Why is that the Colorado River running out of water? Monday show is going to be about how we cured new diseases using science. It’s sitting around on our shelves. fascinating conversation on Monday. Okay, that’s all I have. We’ll talk to you on Friday. Thanks for tuning in

CREDITS  35:19

Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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