Chair File: Leadership Dialogue — Driving Community Health Improvement with David Perlstein, M.D., of SBH Health System

00;00;00;25 - 00;00;34;02
Tom Haederle
You may not think that a rural health care system in New Hampshire and a major independent hospital in the Bronx, New York, share many of the same concerns, but they do. For care providers of every size and location, it's critically important to identify and adapt to the needs of the communities around them, since no two are exactly alike. In this month's Leadership Dialogue Series podcast, that shared concern for meeting the needs of patients and families where they are  - for being responsive - has given Dr. Joanne Conroy, CEO and president of Dartmouth Health in rural New Hampshire and AHA's 2024

00;00;34;02 - 00;00;51;22
Tom Haederle
Board Chair; and Dr. David Perlstein, President and CEO of SBH Health System in the Bronx, a lot to talk about.

00;00;51;24 - 00;01;18;22
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. SBH Health, formerly known as St. Barnabas Hospital, opened in New York in 1866 as America's first chronic care facility. Over the years, St. Barnabas Hospital has demonstrated a great ability to evolve to meet shifting demographics and address social determinants of health, as we hear in today's discussion.

00;01;18;24 - 00;01;42;27
Joanne M. Conroy, M.D.
Good afternoon and thank you everyone for joining us today for another Leadership Dialog discussion. I'm Joanne Conroy, CEO and President at Dartmouth Health and I'm currently the chair of the American Hospital Association Board of Trustees. I'm looking forward to our conversation today as we focus on how our fields can influence and drive improvements in the overall health and well-being of our communities.

00;01;42;29 - 00;02;10;12
Joanne M. Conroy, M.D.
As hospital and health systems leaders, we certainly need to strive towards delivering high quality health care. But we all appreciate the fact that a lot of what we do has to do with the health of the communities outside the walls of our facilities, and we need to be just as passionate about improving the health and health status of the people in the regions we serve as the rural health care system, serving New Hampshire and Vermont.

00;02;10;15 - 00;02;44;28
Joanne M. Conroy, M.D.
We have a unique opportunity at Dartmouth Health to focus not only on care within our walls, but also our communities. And we have a group that focus on rural health equity that has identified some frightening statistics that if you live 15 miles away, you often live 15 years less on average than other communities. It is critically important that we identify how we can shift the environment that our patients live and work in in order to have the best lives possible.

00;02;45;00 - 00;03;09;12
Joanne M. Conroy, M.D.
You know, it's interesting. I've got a fabulous colleague that's joining us today, Dr. David Perlstein. And David and my communities are similar and different. We all have issues associated with poverty. We have issues that are associated with housing and the lack or the availability of housing as well as transportation. But it's very different in the Bronx than it is in rural New Hampshire, Vermont.

00;03;09;14 - 00;03;31;11
Joanne M. Conroy, M.D.
But a lot of things that we can learn from each other. Now, I want to spend some time talking about David Perlstein who shares our convictions that hospitals and health systems have to provide value to their communities. And you only need to look up SBH Health to really appreciate what they have done over the last... David, it's been almost eight years,

00;03;31;11 - 00;04;00;12
Joanne M. Conroy, M.D.
you joined in 2016... where they've really made an impact on that community. David is the president and chief executive Officer of SBH Health System, which is formerly known as St. Barnabas Hospital, located in the Bronx. This system includes a teaching hospital and ambulatory care center, a behavioral health facility, among many other health services that are provided for a very multi-cultural community.

00;04;00;15 - 00;04;39;05
Joanne M. Conroy, M.D.
He's a pediatrician by training and joins St. Barnabas initially as a director of pediatrics before serving as the CMO and then stepping into the CEO role in 2016. He continues to be clinically active and has spent the majority of his career promoting better health and better health care in the Bronx. He has a special interest in this social determinents loss of health and has written and lectured nationally and is also past chair of the AHA's Committee for Clinical Leadership, which is an advisory body that helps guide the association's policy positions on clinical matters.

00;04;39;05 - 00;04;43;19
Joanne M. Conroy, M.D.
So David, welcome and thank you for joining me.

00;04;43;21 - 00;04;54;28
David Perlstein, M.D.
Thank you. Great to be here. Great to be here. And it's great to meet you also, finally. I've heard a lot about you and my sister and her family actually live in Concord, so yay.

00;04;55;00 - 00;04;59;11
Joanne M. Conroy, M.D.
Maybe she gets some of her care from our ambulatory care facility.

00;04;59;11 - 00;05;02;00
David Perlstein, M.D.
And it would be hard to believe that she doesn't.

00;05;02;03 - 00;05;19;22
Joanne M. Conroy, M.D.
So our viewers love to know a little bit about our guests before we jump into all the great work you're doing. So can you tell us a little bit about your path and what is actually influenced the work that you're championing now at SBH Health?

00;05;19;24 - 00;05;51;24
David Perlstein, M.D.
Yeah, So I was a reluctant doctor and I come from a family of doctors. So I'm one of those guys that believed that no way where my genes or my or the influences on my family were going to instruct what I became in the future. And believe it or not, I mean, generations, my grandmother, my grandfather, my great uncle, and they were all in different types of care, but they all were very involved in the system.

00;05;51;28 - 00;06;12;01
David Perlstein, M.D.
Some of them were academic, some were not. My grandfather, who is a is a pediatrician also, was a co-founder of the American Academy of Cerebral Palsy. And so he recognized very early on that kids with CP had normal intelligence in many ways, and they were being treated as if they were not normal. You can't escape that. My father was a neo-natalogist.

00;06;12;03 - 00;06;37;08
David Perlstein, M.D.
My grandmother, I mentioned, grew up in also in Chicago and graduated from Rush in the 20s and was the first female president of the Dermatologic Society in Chicago. So these are folks that were doing pretty amazing things, though. I was getting ready to go to law school and I had an epiphany. That's really, I think, the best way to say is I realized I couldn't escape the drive.

00;06;37;08 - 00;07;02;22
David Perlstein, M.D.
I couldn't escape the need to do good now. So I took a different route than all of my relatives. I actually was already married and had a child when I started medical school. That informs you in a different way, right? You're basically approach the whole medicine thing and patients very differently than you do when you're when you're in your low twenties and suddenly decide, you know, I finished college and I'm going to become a doctor.

00;07;02;25 - 00;07;27;05
David Perlstein, M.D.
And I will tell you, it had a huge impact on what I wanted to do with my life. Once I got out and I chose pediatric kicks because I didn't have patients for adults at the time. And I realized that, you know, when you're taking care of kids, you always have to maintain a certain level of openness. You just have to and you have to be very aware of whatever bias you have.

00;07;27;05 - 00;07;47;15
David Perlstein, M.D.
But also, I'm somewhat of a child anyway, so it made sense. And I came back to New York because we left my wife and I left New York. We went to Cincinnati where my parents were, and that's where my dad practiced at the University and Children's Hospital. And then we came back here and I attended Cornell, the residency at Cornell before it was New York Presbyterian.

00;07;47;18 - 00;08;06;12
David Perlstein, M.D.
And then I thought I would do some specialty care. I was positive I was going to be a cardiologist and was accepted to this joint program that they just started between New York Presby Columbia and New York Presby Cornell. And then they asked me to stay on and be the chief. And so I spent an extra year being a chief.

00;08;06;12 - 00;08;30;29
David Perlstein, M.D.
And then three months into that, I realized, I can't keep doing this. You know, my kids are going to be in their thirties by the time I finished my training. And I took a deep breath and decided primary care. And I joined a boutique, Upper East Side practice taking care of very rich people. At that time, this was in the in the late nineties we had just introduced child health plus. And we didn't take any insurance except for two.

00;08;31;00 - 00;08;50;17
David Perlstein, M.D.
One was to be able to care for the Cornell faculty and the other was to be able to care for Cornell staff. So I took Blue Cross and I decided to also open up my practice to CHIP. And I remember the first time I had a CHIP patient come in. It was a Mexican woman, young Mexican woman with two kids in her stroller.

00;08;50;17 - 00;09;21;14
David Perlstein, M.D.
And and I saw her took care of it. And my partner said, can I talk to you after this, after the patient left? And she literally said to me, you really shouldn't bring those people here. And then I was gone in a month. That ended that relationship. And I was lucky to fall into an opportunity at St. Barnabas because St. Barnabas had had just founded their own Medicaid managed care plan, because Medicaid managed care had been coming to New York and they needed it.

00;09;21;16 - 00;09;46;25
David Perlstein, M.D.
I was hired actually, as the as the director of Ambulatory pediatrics. I served as a vice chair. We were given the funds to actually build the department and ultimately, you know, brought in a residency. I mean, it was really a lot of fun, a lot of work. But we were doing it for a really to be able to have pediatrics available, both on an outpatient inpatient side in the hospital, in a community that actually is filled with women and children.

00;09;46;28 - 00;10;04;27
David Perlstein, M.D.
And then I had a big mouth. I kept seeing things that didn't work and I kept suggesting things. And then I became a member of the medical board and then I became a medical director. I ran quality. You know, I followed that weird path of you do something, and they say, Well, try this. I became a chief medical officer.

00;10;04;27 - 00;10;38;13
David Perlstein, M.D.
And then in 2016, as you mentioned, I became CEO. But I've always approached everything I've done with the lens of taking care of children and communities. And because of that, it just has given me a different credibility, I would say. And we are a physician-run organization. It's not a it's not a new thing. But I think that the the idea behind how we got to the point where we were even open to doing some of the things that we were doing has to come from the fact that if you're taking care of children, public health has to be part of the discussion.

00;10;38;16 - 00;11;03;13
Joanne M. Conroy, M.D.
We know you've had an incredibly purpose-driven career and incredibly fortunate for the people who receive their care at St. Barnabas and now SBH Health System. There are some organizations that are really just grounded in purpose, and yours is one of them. I can name a few others in the country that are just that is their North Star.

00;11;03;15 - 00;11;29;14
Joanne M. Conroy, M.D.
It does change how you make decisions and how you use your resources. Now, you did some things at SBH Health. Educate me. I don't know if you did it before or after the rest of the world, but a lot of things. Your kitchen...don't you have grass or like some farm thing on the roof of one of your facilities?

00;11;29;17 - 00;11;56;14
Joanne M. Conroy, M.D.
You've invested in fitness facilities. Yeah. That, you know, everybody was all in on these and that late, you know, 2006 to 07 or 08 and I think it was to attract people. But I have a feeling that you got into it for a different reason. So talk a little bit about how did you shift from delivering care, which I'm sure St. Barnabas was all about.

00;11;56;14 - 00;12;03;03
Joanne M. Conroy, M.D.
How do you deliver that care to actually how do you care for the community outside the walls? Because that is a shift.

00;12;03;05 - 00;12;29;29
David Perlstein, M.D.
Yeah. So before I go, any deeper, you have to understand the history of St. Barnabas, right? The history of the hospital, the history of SBH health system. It's an independent community hospital. No affiliation with any religious organization. It was founded by an Episcopalian in 1866 as the Home for the Incurables. It was close to the current campus, but it was not on the current campus, and it was the first chronic care facility in the country.

00;12;30;04 - 00;12;50;19
David Perlstein, M.D.
It was the second in the world. The first one, opened in England a year earlier. And it was really for, you know, wealthy patients who were in the in the city to recover from TB. I mean,  that really is, I think what the majority of the work was about. Listen, we're in the Bronx and the Bronx changes over time.

00;12;50;21 - 00;13;25;15
David Perlstein, M.D.
So at some point in the late 1800s, a hospital was actually built on the site that we are currently at right now, continued with the name The Home for The Incredibles and the whole place was funded by all of those wonderful names that, you know, the Vanderbilts and the Astors and the Spalding's and and they were actually funding a lot of the care at that point so that people didn't have to pay in order to get the care they needed.

00;13;25;17 - 00;13;52;19
David Perlstein, M.D.
But at some point, you know, the community starts changing, the needs start changing. There's a split between kind of chronic care and and acute care that's occurring. The hospital is getting old. Throughout the teens and the twenties, there was a continued move towards delivering two types of care and ultimately a new building was built in the thirties, I believe, and the name was ultimately changed to St Barnabas Hospital in 1940s.

00;13;52;22 - 00;14;23;13
David Perlstein, M.D.
And then they also rolled that they basically built a nursing home at the same time. So they split the services between acute and chronic. But again, it's being done because the community needs change/ It was an old Italian and Irish and Jewish neighborhood originally and then that changed over the years. You know, certainly the seventies saw a huge change, but even before that the neighborhood was already changing and we had to redefine who we were going to care for and how we were going to care for them.

00;14;23;15 - 00;15;10;06
David Perlstein, M.D.
And we've done that pretty well over the years, though it's amazingly challenging in a place like like the Bronx, because there were a lot of just demographic changes that occur because of immigration patterns. So even at the time that I've been at Barnabas since 1999, you know, we've gone from primarily a Puerto Rican like and African-American community that we care for to a transition to kind of a Dominican and then we saw a transition to a Mexican, we saw a transition to the Albanian and Yemeni, and now we're seeing West African population and a very large, much larger South and Central American population that are now moving into the Bronx.

00;15;10;08 - 00;15;29;16
David Perlstein, M.D.
You now have to be aware of all the cultural norms. You have to train your staff on how to do it. You have to talk to people. You have to be in the community saying, what do you need? What do you want? And so it's amazing that we're still standing. I will tell you, I mean, you you have to know is that I just, you know, said all these things about Barnabas.

00;15;29;18 - 00;15;54;05
David Perlstein, M.D.
But we are 95% government payer and 88%, I would argue, is funded by the Medicaid system because we have mostly dual eligibles, because we're a poor report community. And that's how we even allowed ourselves to be open enough to move down the road because no matter what we do, no matter what decisions we make financially, we're not going to make a profit.

00;15;54;07 - 00;16;14;14
David Perlstein, M.D.
Our costs are pretty much set by our union partners and our revenue is set by the government. And I don't control for that. I had a board for many years when I first was chief medical officer and moving into a CEO. I had a board member kept saying, Well, you know, you're going to lose X number of dollars.

00;16;14;14 - 00;16;19;13
David Perlstein, M.D.
You have to cut out of the budget. And you had to do the model for them and said, Well, it doesn't work.

00;16;19;18 - 00;16;20;06
Joanne M. Conroy, M.D.
Yeah.

00;16;20;09 - 00;16;38;28
David Perlstein, M.D.
You know, what am I going to cut? We're going to cut psychiatry out when I stop seeing behavioral patients, even though the community, trust me, needs behavior. Am I going to cut addiction medicine out because it really doesn't cover the cost of care? No. You know, I'm a health care provider. I don't make widgets. You know, I don't make cars.

00;16;39;00 - 00;17;05;24
David Perlstein, M.D.
I exist at the at the health and pleasure of the community. So if you come into it thinking this is an opportunity to do something different in order to move the community in the right direction, to give them the tools and the ability to live more productive lives, to be happier like everybody else, it really makes it possible to move into the things that you were talking about in terms of the opportunities to build a wellness center.

00;17;05;28 - 00;17;28;06
David Perlstein, M.D.
And so that was what primed our ability to even do this. The other thing that primed our ability was the waiver. The first New York State waiver. They got the district delivery system reform, incentive payment program, Medicaid adjustment. And it really changed the way we were supposed to deliver care. Moving New York from a volume based system to a value based system.

00;17;28;09 - 00;17;57;16
David Perlstein, M.D.
That was a program that was that started in 2015. And then expired in 2020. And of course, what happened in 2020, COVID. So everything kind of just stopped. But we were fortunate because during those early years, as we were trying to move towards value, we stared at our empty lot across the street from the hospital that had been held for I can't tell you how long with the idea the board would build a new hospital

00;17;57;16 - 00;18;20;01
David Perlstein, M.D.
one day. It became clear that that is not what we needed to do. And in fact, in 2014, we did change our name to SBA Health System because, you know, the majority of our care was no longer being delivered in a hospital setting. It was really being delivered outside the walls. But I'll tell you about the moving from, you know, volume to value.

00;18;20;01 - 00;18;54;00
David Perlstein, M.D.
It enabled us to look around at what the social determinants, what the needs of the community were. Housing became a huge issue, we knew that. Food insecurity, a huge issue, and we found a really good partner. We found a developer who was mission-driven, who agreed with us to build 314 units of affordable housing on our land, and we donated the land in exchange for this because, you know, they could have built, I guess, co-ops and condos and tried to make as much money as they could.

00;18;54;00 - 00;19;19;00
David Perlstein, M.D.
We just wouldn't have given them the land, then. But in exchange for building out these 314 units, we also demanded that at least 50% of the units were held for the community. And we also worked with a group to make sure that 95 units were actually held for previously homeless individuals. We were moving people off the street and into stable housing that had support. In exchange for all that

00;19;19;00 - 00;19;43;03
David Perlstein, M.D.
we we actually got them to build a shelter for us, a 50,000 square foot space that was a shell. And we did get state funding, a $22.6 million to build it out. And that's our wellness center. And in that place we have women's and children's programs on the first floor and our urgent care because we were thinking we could decant the E.R., which by the way, hasn't worked.

00;19;43;05 - 00;20;13;06
David Perlstein, M.D.
And then we thought, all right, we were able to design a program that we thought, could it start to address those things that made it hard. It's a food desert up there, right there, just bodegas. So we actually had a Greenmarket that was put in and it with almost like a health food market. But on the first floor, our primary care programs for women and children, including WIC, OBGYN, women's imaging, and it's all co-located and it's a beautiful large space.

00;20;13;09 - 00;20;40;19
David Perlstein, M.D.
The idea was we really didn't want to hold people in a waiting room area, but we wanted to create a space where a family, if they were waiting for their family, they could have places to sit that were open. So it never looks busy until you go back and see people moving around. But we thought it was time to build a respectful place for patients to be seen and not just design something around profit.

00;20;40;21 - 00;21;04;18
David Perlstein, M.D.
So the programs you talked about  - the second floor  - are the the programs we're most proud of, which are the the teaching kitchen, the medical model fitness center. And yes, we have community space and studio space. And then on the roof there is a we have a farm. We partnered with Project AIDS and they manage the farm. That's where our our food comes from for the for the kitchen.

00;21;04;20 - 00;21;14;13
David Perlstein, M.D.
And we have a Greenmarket in the lobby. And then we also have been busy doing these great programs for the community. So, you know, it is possible.

00;21;14;15 - 00;21;38;24
Joanne M. Conroy, M.D.
It is, you know, getting the board and the community to appreciate that you actually have to move upstream to keep people healthier. And it was kind of the confluence of opportunities from state funding as well as kind of new programs that allowed you to have those resources to do something really different. You were sure that you could actually make a difference in the lifespan.

00;21;38;24 - 00;21;47;14
Joanne M. Conroy, M.D.
So have you been kind of following the data there, or is it really is it incredibly difficult to do that?

00;21;47;17 - 00;22;00;23
David Perlstein, M.D.
We are, right. So so we're just starting to actually have data that's meaningful. We're just able to now start to meet with payers to make deals because this is expensive and, and nobody wants to pay for it.

00;22;00;25 - 00;22;01;12
Joanne M. Conroy, M.D.
Yeah.

00;22;01;15 - 00;22;26;15
David Perlstein, M.D.
Because it takes a long time to change behavior. But the, the argument really comes down to, you know, if I can impact a patient and keep them out of the hospital, I've saved somebody's money. I certainly have decreased the trauma associated with being admitted. I would say the biggest mistake I've made in my career and the biggest positive thing I've done are the same thing. Just before

00;22;26;15 - 00;23;00;10
David Perlstein, M.D.
I became chief medical officer, I would walk through the ED and I'd look at the census and I'd see all these one day stays and two day stays of people who did not need to be admitted. And I set up a system that basically changed how we evaluated patients for admission. I put in the resources to treat people or get people into services on the outpatient, and we decreased our admissions from about 40% of our 90,000 a year ED to about 13%.

00;23;00;13 - 00;23;01;21
Joanne M. Conroy, M.D.
wow. That's fabulous.

00;23;01;26 - 00;23;08;08
David Perlstein, M.D.
It is and it's not. It is because it's the right thing to do. It's not because where do you get paid?

00;23;08;10 - 00;23;09;21
Joanne M. Conroy, M.D.
When they're in a bed.

00;23;09;23 - 00;23;24;08
David Perlstein, M.D.
So we killed us. Right. And luckily, as a pediatrician, I can say, look, we're doing the right thing. This trip is here, right? This is going to be permanent. We now have a track record of being able to do this. Well, we're going to get funded the right well. And I would tell you, the state's been really good to us.

00;23;24;15 - 00;23;43;14
David Perlstein, M.D.
We have received funding in order to keep our programs going. But the reality is, as a pediatrician, I could I could say, you listen, you know, what else do you want to do? And if you talk about social determinants and you've got to go back to the patient always. If I'm somebody who doesn't know where my next meal is going to be, I don't know where I'm going to sleep tonight,

00;23;43;17 - 00;24;05;24
David Perlstein, M.D.
am I going to fill my prescription to control my blood pressure? And if you have your blood pressure medication, you're going to remember to take it every day? Absolutely not. So ironically, it's kind of like SBH, right? We've talk about social determinants and saying, you know, it's almost like a Maslow's hierarchy. How can I be strategic when I'm basically have a negative margin all the time?

00;24;05;27 - 00;24;28;18
David Perlstein, M.D.
I don't know what my income is going to be in the next year. And so the reality is it also serves us because I don't know these things and profit can't be a goal for me. I can make the decisions around maximal social good. I can make decisions around doing the right thing. It's no different than anything else, right?

00;24;28;18 - 00;24;32;09
David Perlstein, M.D.
I already told you I can't cut myself to break even.

00;24;32;11 - 00;25;02;21
Joanne M. Conroy, M.D.
One question about actually integrating the community because your community has changed a lot and all the expectations that you may have developed for Hispanic and African-American predominant communities and now that are sub-Saharan African and Eastern European, how do you actually integrate all of those voices in terms of how do you identify the social determinants and how do you create programs that they'll use?

00;25;02;23 - 00;25;26;24
David Perlstein, M.D.
It takes trial and error. One of the things that we found is that you find the commonality. And honestly, the commonality amongst these folks are one: they want to have better lives. All of them. And all of them struggle with poverty and all of the associated problems that come with being poor. So we try to to really gather folks together around that commonality.

00;25;26;26 - 00;25;42;11
David Perlstein, M.D.
It's just like when you're taking care of certain populations that don't want blood products. Do you just say, forget it, I don't want to see you? Or do you work with the populations? Do the best thing you can in order to serve their needs. You do the latter, of course, because you're a provider, you're a health care provider.

00;25;42;14 - 00;26;09;29
David Perlstein, M.D.
So I would say that we struggle, but we also celebrate the differences internally because the hospital is also an anchor institution. Anywhere else we're a large institution. We have about 3000 employees and and a budget of almost 600 million. It's not a tiny place except in New York. It is. But I will tell you, our community makes up our staff.

00;26;10;01 - 00;26;35;13
David Perlstein, M.D.
So for many years we would celebrate each different group and we would find folks within those groups who wanted to run programs and we would develop these celebrations that would go on for a week. And it brought community members in. And it also highlighted that we were recognizing our differences while coalescing around the greater good.

00;26;35;15 - 00;27;00;13
Joanne M. Conroy, M.D.
You know, what you've done there is simply inspirational. And again, as we started the conversation, there are a handful of institutions across the country that are really mission driven and the way that SBA health system is And I want to thank you. You're doing such great work on behalf of your patients and the Bronx community. And I think we could probably talk for another 45 minutes about this.

00;27;00;13 - 00;27;22;08
Joanne M. Conroy, M.D.
But I want to be mindful of everybody's time. So on behalf of the AHA and Dartmouth Health and all of us in health care, I'm going to thank you for joining me in this discussion today. I would like to talk to you about your grandmother. My grandmother graduated from Smith in 1918, so they were the same generation and incredibly impactful.

00;27;22;08 - 00;27;35;00
Joanne M. Conroy, M.D.
And also I wanted to be a religion and philosophy major and I ended up in chemistry. So, yes, parents have an unduly strong impression on you actually decide to do as a career.

00;27;35;06 - 00;28;01;11
David Perlstein, M.D.
So yeah, I'll give you one last thing that before before we...my son is a is a Michelin chef who during COVID and he's in his thirties and he's been in that industry for a long time, very successful. He's now going to go and do a post back to get to go to medical school. And my daughter is in Anschutz in nursing school.

00;28;01;13 - 00;28;07;24
David Perlstein, M.D.
And these are two kids that I never thought would do this. So, you know, I guess there is something in the genes.

00;28;07;27 - 00;28;23;20
Joanne M. Conroy, M.D.
Well, you are a testimony that having a purpose driven career is actually very rewarding. And they've seen that in you. So thank you, David. On behalf of the AHA and everybody that's listening, I'll be back next month for another leadership dialog.