Tag Archive for: START HERE Myeloma
Multiple myeloma can sometimes feel overwhelming and complicated, but what can patients and care partners do to help improve their care? With this question in mind, the Patient Empowerment Network initiated the START HERE Myeloma program, which aims to bridge the myeloma patient and expert voice to build empowerment.
START HERE Myeloma Program Resources
The program series includes the following resources:
- START HERE Patient-Expert Q&A Webinar with expert Dr. Sikander Ailawadhi moderated by a myeloma patient
- START HERE Library with a robust library of digestible video content that merges the expert and patient voice
- Your START HERE 90-Day Plan personalized 90-day plan with resources from trusted advocacy partners
- START HERE Activity Guide a downloadable, printable support resource packed with information to educate, empower, and support myeloma patients and care partners in their journeys through care
- START HERE Text Alerts to receive personalized support from PEN Empowerment Leads
Patient-Expert Q&A Webinar Topics and Key Takeaways
In the PatientExpert Q&A webinar, renowned multiple myeloma expert Dr. Sikander Ailawadhi from the Mayo Clinic shares his expert knowledge to help patients and care partners fortify their knowledge and confidence, while myeloma patient and Empowerment Lead Lisa Hatfield moderates the discussion and shares some of her views as a patient. Dr. Ailawadhi and Lisa provided some in-depth discussion along with key takeaways. Some of the discussion covered:
- Diagnosis and treatment topics covered for newly diagnosed patients
- Overview of novel myeloma therapies and research updates
- Mutational markers in myeloma and clinical predictors of relapse
- Access to multiple myeloma clinical trials
- Recommended bone-building therapies for patients
- Fluctuations in light chain numbers
- The outlook for frequency of biopsies
- Treatment response with myeloma therapies
- Treatment options for myeloma patients who relapse after CAR-T therapy
- Frequency and treatment considerations with amyloidosis
- Incidence of kidney dysfunction and healthcare disparities
- Outlook for the future of multiple myeloma care
Among some key points, Lisa shared her perspective about seeing a myeloma specialist, “There is great importance in seeking out the expertise of a myeloma specialist, even if it’s just when you’re newly diagnosed, going for a consult once and then maybe upon relapse going again, if you don’t live near it, a specialist, seeking out the expertise of a specialist is really critical.”
Dr. Ailawadhi provided his expert perspective about recent developments in multiple myeloma research and treatments. “Myeloma treatment is going through a change where immunotherapy and harnessing the body’s own immune system is becoming extremely important. And when we do that, the immunotherapy is typically very targeted, so what these drugs these agents, these terms, this alphabet soup is doing is it is targeting specific markers on the myeloma cell on the plasma cell.”
Dr. Ailawadhi also shared his excitement about the future of myeloma care. “So why is this important for everybody, whether they are newly diagnosed or relapsed or long-term survivor with myeloma, because this tells you that not only are we getting newer drugs in the same classes, we are also getting brand new classes of drugs. And you can imagine that means that those brand new strategies are ways to target the plasma cell, we know cancer cells are smart, and they develop invasive mechanisms to become resistant to drugs. But every time something gets resistant if we have a brand new mechanism to go against the disease, but that’s exciting because that’s why we are seeing deeper responses, even in very heavily pre-treated patients, because we are using newer specific, relatively safe, convenient strategies to going after the plasma cell.”
Dr. Ailawadhi has also been very involved in researching and working to improve healthcare disparities, and he shared some of this knowledge during the webinar. “Kidney dysfunction can be seen in as much as 20 percent of patients at the time of diagnosis, and there are a significant number of patients who would have kidney dysfunction even as they go on with their myeloma journey. I’m interested in these healthcare disparities. I just want to point out that patients who are African Americans do tend to have a much higher incidence of kidney dysfunction and need for kidney dialysis with myeloma at the time of diagnosis or even with treatment.”
Some program participants provided valuable testimonials about the START HERE Myeloma Patient-Expert Q&A webinar.
- “I have been a myeloma patient for 8 years. This was one of the best webinars I have listened to. The speaker was excellent and the questions presented were great! Thank you for a wonderful session!”
- “This program was well thought out and I felt like Lisa was reading my mind! Super job. It makes living with a serious condition a little less scary when you see so many people have the same questions as you.”
- “Thanks for a great discussion. It felt like it wasn’t a lecture, but a conversation. Lisa is an inspiration to our support group members in South Carolina. We will be sharing this when we meet next week.”
We hope you can use these valuable multiple myeloma resources to build your knowledge and confidence toward becoming a more empowered patient or care partner.
Finding a myeloma specialist is imperative to ensure you’re receiving the best care possible. If you’re unsure where to look there are many resources at your disposable. Watch as myeloma patient advocates, Lisa and Sujata discuss their experiences with finding a myeloma specialist and share valuable resources.
Lisa what would be your experiences or maybe some of your thoughts around best practices around finding a myeloma specialist?
Oh yeah. That’s also a really good question. So I live in Boise, Idaho, and most of the people in my support group here have stayed local, which is great, but a couple of people… In fact, at the time I was diagnosed, there was a gentleman who has myeloma, he was in Seattle having a stem cell transplant, he chose to go there because they have a much higher volume of… They do a much higher volume of stem cell transplants, and he just felt comfortable having all of that, not just the doctor, we have good doctors here, they have a huge support staff in Seattle where they do stem cell transplants.
So I asked the group, our group leaders, and then the gentleman who was in Seattle, why do people go somewhere else? Why would they do that? Because it’s not quite as comfortable leaving home for a period of time, and he talked a lot about how he felt just it was a second set of eyes to look at his case and he had some other complications with his myeloma. So for me, the best thing that I did is when I was thinking about going to see a specialist, which we did pretty quickly because my spine was quickly deteriorating, we end up calling MD Anderson, but after that, so we were assigned to a specialist.
She works at MD Anderson and only sees myeloma patients. After that, I wanted to have my stem cells collected somewhere else, and I ended up calling the International Myeloma Foundation their info line, and they actually can provide a list of specialists in your area or help connect you, especially in times of… Now that COVID is starting to settle down, but during COVID, a lot more specialists were doing Zoom calls or telemedicine visits, so I think that they have a really great… For patients who are looking for a specialist, which I assume you also highly recommend because you’re… You’re in a great area for specialist, I’m not. So I would recommend seeking a second opinion from… Not a second opinion, seeking taking a consultation from a specialist, because as you mentioned, myeloma is so nuanced, it is very complex and complicated.
Yeah and again, this highlights a difference. So I live in Minnesota, and I am blessed to be living here, being diagnosed with MM is not a good thing for anyone. But then being in a place where you have all the resources and the support that you need for dealing with something like myeloma is important, and I’m also in a system which is integrated. So obviously in Minnesota, close to Rochester Mayo. My Cancer Center, Frauenshuh Cancer Center is… It’s in St. Louis Park, and we have University of Minnesota, so these three institutes are integrated and patient information can be shared if needed. So when I was diagnosed, I actually did not have to go look for a hematologist or myeloma specialist.
My diagnosis was done by a hematologist in Frauenshuh cancer center, and then she sent my reports to Mayo to the Hematology Department for a second opinion. So for me, I think I’m so fortunate and they did all of this for me, I didn’t have to do that, and then I was anyways is in the care of an MM specialist, which I think is important. And again, reiterating what he just said is like they really know the disease well enough, like I’m not saying that our regular oncologist who don’t know that, but MM is so nuanced.
If you have the opportunity, I guess you should try and be associated with an mm-specialist, a hematologist, in my case, it was laid out to me on a platter, I should say. I was very fortunate, but for the… I know a lot of people may not have the opportunity to do that, but if you have that, you should definitely try and consider that because it’s quite an important conservation, I think.
It is. I think you’re right, I know my current oncologist now, my local oncologist, he is awesome, he’s incredible, he’s a great physician, he was a great diagnostician. He’s really good. My husband, I both really like him. He also appreciates that I go somewhere else. And so that is the one thing I know I was terrified. Asking my doctors, what do you think about me seeing a myeloma specialist. I only had one little bit challenging experience when I told one of the doctors I had seen, I want to go to MD Anderson, and he said, Well, you’ll just be a number there and they don’t do much more than we would do here for that piece of my care, that’s probably true.
And even though we have really great care here and a great medical system, and I feel super fortunate with my cancer, my local cancer center there, all of the staff there is excellent. My oncologist is awesome. I still strongly believe that my course might have been different had I not seen a specialist because it is so unique and every patient is so different, and also specialist have access to some treatments that I did not have access to here locally.
So, I think that that’s super important. I’ll just mention really quick, since we’re talking about specialists, the IMF has their info line, which is… I had to write it down. The phone number is 1-800-452-CURE, which is 2873. So 1800-452-2873, and they can put people… They can direct people to a specialist, and then healthtree.org also has a list if people want to go on, maybe they’re in some dex accelerated insomnia, I guess some night they can go to Healthtree.org, and just… They can click on myeloma, there’s two tabs. Click on myeloma and I just scroll all the way down to patient resources rather than trying to navigate through that. And under patient resources, it says, Find a specialist.
So those are two resources the patients can have, I didn’t look for those, we just called MD Anderson, but I appreciate all your comments, and I think it’s great when people live near a center, I highly recommend going to the bigger center, especially if there’s a myeloma specialist my big fear was just offending my doctors here, and I think some people worry about that too, I’ve talked to other people in our support group.
I don’t know if you have any suggestions for that, Sujata, if you think that… I feel strongly now about people seeing specialists, but at the time I was nervous about offending my doctors…
Yeah, and I can relate to that because you build this relationship, you really then you’re going to see them for however long, and so you really want that relationship to be maintained as it is in a good condition, so I totally understand why you would have hesitated even to think about, Oh my gosh, am I going to offend him her by saying, I want to actually see somebody, and I’m glad that your experience was good, meaning like your doctor was supportive of you actually seeing another one. I have also heard of other patients having to navigate difficult conversations, similar to what you share is like, why do you want to see somebody, like Do you not trust us or in that kind of conversations, which I think is a little bit difficult for the patient because we’re going through a lot anyways.
And I always believe like, this is not just for the patient. The entire family goes through the whole process of diagnosis, treatments, all and everything that ensues. So it’s really difficult for the patient and who’s already going through a lot, and I would really hope that the providers, the doctors understand the state of mind, and agree, if the patient wants to see somebody else to support them in that, in that decision-making, as I say, I have been really fortunate and I had a really good experience, but I have, as you said, None of others who have not had as a pleasant of an experience, I’ve also known of patients who do not have those…
Like you were able to go somewhere else, from Idaho to MD Anderson, I know of some people in some different states who do not have that kind of support, and in fact, they have pretty challenging systems, like there is a person in my support group who lives in Alaska, and for anything, any emergencies, they have to fly down to Seattle.
So, I can only imagine what that must be like to be in that situation where you’re going through so much and then you have to figure out the logistics and the tactical things about how do you reach from point A to point B and then start with whatever procedures so thank you so much for sharing those resources. I think they’re going to be really useful for folks that are listening to this call. Those resources are really, really important. I guess we can also say PEN also has some really amazing resources that folks can leverage as they navigate through this difficult journey.
Yeah, I agree with that. And I was going to mention that, so people… When you talk about resources and accessing the resources that that is a big problem, we see that here, because we’re in a more considered more rural area, and so we draw from multiple rural states, our support group does, but also there’s the financial difficulty. So, I’ll just throw that out there too.
Those are two really good resources that I mentioned before, but if people want to reach out to me at PEN or send an email, that would be fine too. I can help direct them to decent resources or some place they could at least start looking for resources because it is really important for people to get that consult from a specialist, I think so… Yeah, I appreciate that.
Myeloma patient advocates Lisa and Sujata share their experiences with bone marrow biopsies – what to expect and how to prepare.
And then there was one more thing that you spoke… When we started with the conversation, BMB. Let’s talk about BMB the dreaded swear word.
It is next to dex. I think it’s the second. Maybe it’s equal with Dexamethasone, people talk about dex being the worst thing about myeloma, the BMB, the bone marrow biopsy. Yeah. Did you have one? Right when you were diagnosed?
Yes, and it wasn’t a pleasant experience. I was obviously, as I mentioned, I had a surgery an emergency surgery, it was pretty… It lasted for six hours and I was wrapped up in all sorts of things, and then I had to have the BMB while I was on an ICU bed, so… Totally not in the best place to start, and it was the first time I was going to have it. So it wasn’t a pleasant experience. It was super painful, they could not sedate me for obvious reasons, because whatever was going on, but post that I had the next BMB, I’ve had a couple… I’m not sure that’s a good thing or a bad thing, the next one, I had it in Mayo and I learned that I could actually be partially sedated and so I wouldn’t feel anything, which was like, Oh my gosh, I thought that was the best discovery mankind had ever made. And ever since then, I’ve always requested for being seated through that process, because otherwise it can be really, really painful, so I don’t know if you want to talk about what the procedure is. I am going to assume some of the folks here have been through this, unfortunately.
Yeah, because the bone marrow biopsy is the only way to actually see the myeloma cells, the cancerous plasma cells, it is necessary, it’s also necessary to get it done so they can diagnose the genetic abnormalities, the cytogenetics. But yes, I actually had a little bit different experience. So again, every patient is so different, I prefer not to be sedated because I don’t like sedation, I don’t like the way I feel, I don’t feel good when I have it, so I did have it done and I was… Where I went the first time they didn’t offer sedation, it was, this is 20 minutes, and it wasn’t comfortable.
I will admit that I didn’t like the worst part for me was when they numb the area with lidocaine, they gave you the little shots before they do that, so I’ve had six of them total now, but I’ve had the most recent one. The sixth one I had, they did sedate me and I think it’s conscious sedation, so it’s like you said light sedation, I don’t remember any of it, but I didn’t like it because I had two days of recovery from the anesthesia, so… Yeah, so I think the…
Going back to somebody who’s maybe anticipating it for two nights straight, I couldn’t sleep, I was so nervous about the bone marrow biopsy, I just thought This is going to be so painful. I had excruciating pain in my spine anyway, ’cause it was collapsing as I was going through, I had radiation first, so the bone marrow biopsy didn’t seem to affect me quite as much the first time, but this last time, it seemed to be a little more uncomfortable, especially afterwards, but from my understanding from the bone marrow biopsy, they go in either with the needle, basically the thick needle or where you go to the Mayo Clinic in Scottsdale uses as a drill, and I guess that’s supposed to be faster, and a lot of people think it’s more comfortable, go into the bone marrow and try to take some of that bone marrow out… The soft part of the bone out, they actually take two different samples, but I think the most, uncomfortable part if you’re not sedated, I think is that vacuum-type feeling, and then there’s like a pop… And that was super uncomfortable. I thought that was probably the worst part of not sure if it’s pain or discomfort or what, but I do remember that looking back though, now, every time I’ve had one, I always say that wasn’t so bad.
I remember it, but it wasn’t… I don’t remember it being too bad, so what they do is they will collect enough… They usually have a lab person available as they’re to make sure that they have enough of a sample and the right… The right cells and enough of it, so they usually will only go in once I had one where they had to go back in a second time to try to aspirate some more… The bone marrow, they’ll look at that takes a few days to go through the lab and look at that and see what your genetic abnormalities are with the myeloma cells themselves, and what the volume of cancer cells is in your bone marrow.
But yeah, I just remember, either way, if you’re sedated, you don’t feel it at all while it’s happening, if you’re not sedated, you can feel, especially when they’re numbing it up, the lidocaine shots and that stings, it’s a sting three or four times and takes a little time for it to set in, and then that suction that pop, that’s what was the most uncomfortable, and I think that really the most pain that I felt was the bruise-like pain, the couple of days afterwards, they’re not walking, but just sitting on it is bandaged up really…
Well, you can’t take a shower for a day, but when I would go to sit on it, it just got bruised, but… Yeah, the bone marrow biopsy, nobody looks forward to those… It’s nice to know that there is something in the works, even mass spec testing, which isn’t quite as sensitive… It’s nice to know that there’s something that works, to maybe look at other ways to test for the myeloma. Yeah, not fun. It’s a necessary thing though that when people are diagnosed with multiple myeloma.
That’s absolutely the true statement. I don’t like it at all. I am also anxious before I have my… I’ve had four now, so… And every year I’ll have to have one, so I know that that’s a necessity, as you said, I do feel anxious, but I keep telling myself this is needed to assess overall disease involvement and hopefully the results are better than last year, so I kind of… That’s how I sort of create some positive energy around that experience because it’s not a pleasant experience, and as you said, it does hurt for a couple of days after I actually have… Sometimes it goes on for a week that I have, or discomfort, but again, each to his own people might have different experiences, but I think the more we talk about it, the more we hear other people’s experiences, we might just feel like, Hey, mine was not all that bad, I look at her, him, what they’ve gone through and things like that, or even just thinking like… It’s different, it’s nuance.
Everybody goes through different experiences like you prefer not being seated, I prefer being sedated, so it depends on each one’s experiences, but the bottom line is there are options available, everybody understands, it’s a difficult procedure, everybody understands it’s not pleasant, nobody wants to put the pain through that if they had a choice.
Right now, we don’t have one, so I think just thinking about in a positive way and embracing it, I guess might just help, it helps me, so I’m hoping that it helps others as well, just changing the perspective a little bit.
Yes, so who does your bone marrow biopsies? I’ve been to… Sometimes a nurse practitioner does them and sometimes an RN does mine, and I know some of our local doctors do them, oncologists do them, what type of professional does your bone marrow biopsies?
With Mayo, I’ve had it twice there, they have specialists, they have a whole team that does obviously Mayo, they do like MM treatments, like they have 500 patients doing biopsies every year. That’s what I heard. I had mine there too, so it’s a well-oiled machine, they just have departments for every little thing, so that’s different, but even when I do it with my local cancer center, they have a specialized team, so it’s not the nurses, there’s a specialized team. There’s a different procedure.
Again, it’s different to how Mayo does it. When I do it at my cancer center, they actually do a scan before I have a BMB, and to make sure that they’re going in the right place. Which I thought like Wow, that’s great. Just as a second level of precision, but yes, that’s different to Mayo, but it’s always like a specialist doing it for me.
Yeah, and then how often do you have to have those on a regular basis, like annually or just as things change with treatment?
Annually. So, only just… Obviously, for my diagnosis I had that and then six months later, and I had a stem cell transplant and I did a BMB prior as well then, a couple of months after I did that again. So that was the only time and it happened more regularly, but since then it’s been like yearly.
Yeah Okay. Yeah, the bone marrow biopsy is interesting because I know a lot of… There’s different ways that they test that and now they have a more sensitive test, so everybody has different..That’s the other part of alphabet soup. Some people have something called flow cytometry or NGF or NGS. So anyway, yeah, it’s kind of interesting that everybody will have different ways of going through that or different experiences, so anybody who has questions, you’re welcome to reach out to me at PEN or any of the other resources that are out there.
After an initial myeloma diagnosis, you’re plagued with various acronyms referring to treatment, different mutations, and much more. Hear from myeloma patient advocates, Lisa and Sujata, as they break down how they’ve navigated and continue to navigate through what they deem the “alphabet soup” of myeloma treatment.
Hi, my name is Lisa Hatfield, and I’m a myeloma patient. I was diagnosed back in 2018. I am an Empowerment Lead at Patient Empowerment Network, and one of the things that we are frequently asked is, What are all of these letters and acronyms when you’re diagnosed with myeloma? So just a nutshell, this is why myeloma is so complicated and confusing based on my story. So, I was diagnosed, like I said back in 2018, I have kappa light chain only myeloma. When I was a newly diagnosed myeloma patient, which is MDMM versus RRMM, which is relapsed/refractory multiple myeloma patient, I have kappa light chain only myeloma.
I have…and I’m just going to spew out all of my letters and numbers, I have translocation 11, 14, I have monosomy 13, I don’t have an M spike, which means all of my antibodies are normal, my IgM IGA, IGG are normal. After a surgery and radiation, I went through six months of KRD, followed by another three years of just the R, which is Revlimid, every month I have…in addition to my myeloma labs, I have a CBC, a CMP. Every year I have something called a BMB, bone marrow biopsy. I have a PET CT and MRI every year, and then I do something with my bone marrow biopsy to check for something called MRD status by NGS, which is currently, I’m MRD positive at 10 to the minus 6. So, all of those letters, it’s just a big alphabet soup for people to try to understand myeloma, it gets really, really confusing.
One of the things as a myeloma patient that I recommend to people is the IMF, The International Myeloma Foundation, just to add a few more letters to it, you can look at their website at myeloma.org. They break down each of these phrases and words and letters and acronyms and whatnot.
So newly diagnosed patients and patients who have had myeloma for a while can understand all of these letters and all of these numbers and what these genetic mutations mean and what the tests mean. So, I guess, Sujata, I know you’ve been through this too. We’re just having conversation. How did you…when you were first diagnosed, I’m curious too, and for other patients, how did you get through all of the letters and things being thrown out at you.
Yeah, Lisa, this is funny. So, my name is Sujata Dutta, I’m a board member at the Patient Empowerment Network, and I’m also an MM patient. I was diagnosed with multiple myeloma in December of 2019. And Lisa, you summed it up really well. This alphabet soup is actually a real thing. The first time when I got to know about it, I actually, obviously, like many, many folks that I have known that are on this journey, it comes up as a surprise, it just is… For me, it was interception, I can actually say that word and spell it, I think, but at the time when I was diagnosed, I had no clue what the doctor was talking about, I had this massive inflammation of my lymph nodes and I had to have emergency surgery ’cause the lymph nodes had caused damage to my big intestine, and then we did some research, we as in the doctors, and after a week post-that surgery, I was diagnosed with multiple myeloma. Again, I can say that today, but when they told me about multiple myeloma, I’m like, I have no clue what you’re talking about. They had literally had to dumb it down and say this is a kind of a blood cancer…
I’m like, oh cancer all right then. So, the alphabet soup is actually a real thing, I do have M-spike Lisa, unlike you. My kappa light chains are fine, but it’s been a long journey and not there yet, so still…my goal is to achieve MRD or remission. I’m not there yet, I still have involvement through my proteins, not so much in the bones, so let’s break that down a little bit, Lisa.
Let’s talk about that alphabet soup and how do you navigate that through as a new patient, I would say not even a new patient, like an existing patient like me, sometimes I’m like baffled, like, “Oh, my gosh, what is this report saying to me?” So, thanks for sharing that resource about IMF but what else…as you started, just think about those early days, weeks when you were diagnosed and all of these terms were thrown at you, how did that feel, and how did you overcome some of it, if not all?
That’s a good question. So, I went in to see my, my local oncologist here, after I’d gone through radiation surgery down at MD Anderson because I was going to have my chemo here, and in his office, there was a poster up for a local myeloma support group, which I was not excited about, I thought, Well, maybe I’ll go, but I don’t want to…I already feel down enough that I’ve already overwhelmed enough with my diagnosis, but we just…I called the lady, her name is Sheri, called her up, we talked about myeloma, she had myeloma for seven years, and I was super inspired by that, so we showed up, I had a walker I and walk with a walker because of all the damage to my spine and showed up limping along with my walker, and everyone there was talking about, “Oh, you’re newly diagnosed, what is your M-spike?” That was something new that I hadn’t heard, and I hadn’t had that discussion with my doctor, I didn’t realize at that time, it was because I did not have an M-spike.
So I think, like you said, it’s overwhelming enough to just receive that diagnosis and in my mind, I remember thinking back, Okay, if I talk to a new patient, if I can get through this and make it a few years out, what are the things that were the most confusing to me, and I think understanding the type of myeloma, if I were to…
If patients were to ask me, understanding the type of myeloma patient has, the genetic mutations and understanding what their M-spike is or is not, if they are just…if they’re a light chain, only if they have light chain only disease. Those would be the things I think, because it is so confusing to patients in them, I think as they go along, maybe they can ask their team, “Well, what does that mean? Or what do those letters mean?” Yeah, it’s okay to ask those questions.
Absolutely. Ask as many questions as you can, you’re encouraged as a patient to ask questions or at least I was. I think what is also important to note is like with MM, it’s an individual, it’s a very individualized sort of a disease, so although we put it under the bucket of multiple myeloma, everybody experiences it differently, they even have reactions to medication very different, like just yesterday I was talking to somebody in my support group and they had a really different experience with one of the drugs that I take regularly, daratumumab (Darzalex) every four weeks. She just had the first dose and it was such a bad reaction, she ended up in ER.
So not scaring anybody, I’m just saying everybody has different reactions, somebody might take to some medication really well versus others may not…and just between the two of us, we have different types, you don’t have that, and so there are these nuances, which I think it’s just important to acknowledge, there’s nothing to be scared of…it’s just acknowledging the difference of how multiple myeloma works versus some other cancers maybe…I think it’s important. And you brought up a good point about trying to understand the labs, we don’t have to be experts.
I don’t think I want to be an expert. I have folks that are experts that will take care of me, but just so that I understand the basics of it, and then I’m able to ask questions for my own self, like educating myself.