Philip McCarthy | Sep 24, 2024

[00:00:00] Speaker A: Hello again, Philip. Thank you so much for spending your time with us. What drew you to the neurology space? [00:00:05] Speaker B: Yeah, started in medical school, we were given the option to do a rotation probably during the second year. And during that second year, it took some time to do an away rotation. Neurology during Grand Rapids, Michigan, and getting. Experiencing firsthand neurology and using the physical exam to gather the differential, and then using different things to support that thought of what you think someone has. And there's not a whole lot in medicine that relies more on the physical exam than neurology does. And I feel like that's a great way to get a personal connection. That's what drove me mostly to neurology. [00:00:56] Speaker A: Building that personal connection with people. Can you just talk a little more about that? [00:01:01] Speaker B: Yeah. So I think you listen to their story, and then there's an interesting aspect where you can see the physical manifestations of disease in neurology that adds a lot to their story. And in some cases, you know, the complaint is. Is vague, like weakness or headache or something, where they're telling you. And until you touch the person or look at their reflexes or see how strong they're. [00:01:29] Speaker A: When you're being with those patients and when you're trying to have a genuine patient connection, what have you seen be the most impactful in order to do that? [00:01:41] Speaker B: I think that's time. Time is the biggest factor for forming that relationship. There's different healthcare scenarios where you're given more time. I feel like a lot of, you know, primary care doesn't get a lot of time to see their patients, whereas some specialists get more protected time. So we get like an hour to see a new patient, half hour for follow ups. And that's a lot different than what some specialties get, which is 15 minutes. [00:02:14] Speaker A: 20 minutes, especially with, I mean, I can imagine with the influx of patients that you would be seeing, too, like, how are you able to give them all that equal amount of time and attention, you know, with all the different things coming at you? [00:02:27] Speaker B: Yeah. Without having that time in neurology, there's no real way to get a good story from listening to the patient, as well as doing that, that physical exam. And oftentimes, you know, it takes communicating back to the patient what your findings and suspicions are to gain a little trust and form a relationship. And that common denominator is time. If you don't have time, it makes it really hard. [00:02:51] Speaker A: I can see what has been a patient experience that you still think that you still go back to as you're practicing. [00:02:59] Speaker B: I was working on the neurointensive care unit, and we had a patient that had come in with stroke like symptoms. So they were weak, they were having problems breathing, but they were still awake. And by the time they got to us, we did emergent imaging and found that they had multiple areas where they had blood in their brain as well as their brain stem. And then this patient had a history of renal cancer, and then renal cancer metastasized. And, you know, it was a conversation with the patient who was cognizant enough to know what's going now. Unable to understand the questions, but not able to express themselves, they continue to have breathing issues, swallowing problems because of where their brain stem was injured. And there were conversations with family about intubating and sedating and seeing the outcome. But having again, that time to talk to the patient and the family. What was going on was emergent. Yes. But the patient was stable enough where you have that gift of time to say, hey, bad things are happening in the brain, the outcome isn't likely to be good. We could intubate you, but it's unlikely that you'd come off of this breathing tube. What are your goals? Cause I'm sure, you know, the diagnosis of cancer is new. This understanding that it's metastasized is new, and then now those areas are bleeding in your brain. Let's make a life decision right now, you know, which is really hard. But I think having the time to talk through with the patient and with the family and everyone's on the same page offered a good transition for that patient. At the end of the day, which, you know, those last few hours are pretty emotionally charged, but I think because everyone had the same understanding of what was gonna happen, we saved suffering in the patient and then suffering in the family, because, again, with that time, everyone had the same understanding what was gonna happen and what was going on. Thank you for sharing that was an impactful situation where, you know, the end result wasn't ideal. [00:05:24] Speaker A: Yeah, thank you for sharing that, because that's so unfortunately, real and not common, but it happens. And so I'm also just really struck with, as for you moving from patient to patient and seeing. I'm not saying that this is a common occurrence, but you see this more often than your regular person. How do you exercise empathy? [00:05:48] Speaker B: Yeah. So it's like kind of banking and then understanding where you're going to spend some of that empathic energy. Yeah, there's a lot of little things that can take your empathy, and I think it takes different situations to understand, you know, where, where can I appropriate this so that at the end of the day, I've helped someone without going home and feeling like I have nothing left to give. I think that's common in healthcare is that, you know, we give so much of ourselves in that interaction that it's hard to go home and give it to people that, you know, love us and we love them, but it's a hard way to continue to give that emotional energy. So, and that take that, I think comes with experience. And I think it's a little, maybe more natural because you can read a book about it all you want, but it comes down to understanding what your limits are because everyone's different, even doctors are different. You know, people are going to have different tolerance levels about. [00:07:00] Speaker A: And so when you're shifting, like, as you were saying, when you're shifting from work to home and back to work, how are you able, as you're saying, like, preserve that empathy for your family, for the people that you love, and also in the same sense of not bank it for patients, but like ensure that you are still full enough to give and receive. [00:07:23] Speaker B: There are some people who are really good about separating. So change in environment, you change from the hospital to home. That's an entirely different situation. You don't even think about work when you go home. I think that's a lot easier for, to a degree, for impatient and shift type work because, you know, a lot of times you're not bringing your work home. You can get it done in the hospital if you're in the clinic. Sometimes, you know, you're doing work from home or you have the ability to take work home with you to finish. And that makes that separation a little bit harder. And from the inpatient perspective, you know, you meet these people sometimes, you know, now the traditional way of how medicine goes, you're nothing. You don't follow these people outside the clinic. We have, there's no more like traditional neurologists where you do clinic. And then you also round on people in the hospital. You stay in the clinic and then there's another person who's rounding in the hospital. That's the same part of your team, unless you're in a very small community hospital. But my understanding is that that is far and few between now. But, you know, when you establish a relationship with people, you're following them up, sometimes for years down the road, and you're dealing with things that come up with their life along with their disease. So it's hard, I think from that perspective, to leave that stuff behind and never think about it because, you know, how often does work affect someone who's not in medicine, you know, who's interacting with people just to a different degree. And for me, I think in the first part of my training, I was having really hard time separating that, having it cut and dry, like, this is work, this is home. And with my now wife, you know, that separation was hard because if I had a bad day at work, it oftentimes led to a bad day. If I had bad conversations like the one I just gave you as an example, it was hard to engage at home and, you know, be like, yeah, in retrospect, you know, you can always go back and think about that and think, oh, I did help people, but in the moment, you know, it's still raw and you're just going through life thinking, you know, what's, why are we doing this? So I, you know, but again, I think that comes with experience, and I think you have to have a good mentor in medicine to help guide you through that. I don't think, you know, if you're going to try and figure it out by yourself, I think you're going to have a really hard time. [00:10:16] Speaker A: Yeah, I mean, I feel like this week has been, I personally have heard the saying a lot. Like, if you want to go fast, go alone, but if you want to go far, go together, you know, having a mentor, as you're saying, in a team, I actually have a question about that. When you're going through talking with patients and ensuring that your empathy is intact, how often do you feel you rely on other partners within your care team to do. To have that patient interaction? [00:10:46] Speaker B: So we have an epilepsy monitoring unit, and that's part of our role where we are in the hospital interacting with patients, and we have great support there with nurse practitioners and residents and fellows. And sometimes as part of that supervising role, we're able to kind of provide our understanding what's going on. And the nurse practitioner, the resident, the fellow can relay that to the patient who are there as a reinforcing agent at times, gives them a chance to give difficult news and educate patients on that news, where you can stand back and watch them have that interaction more than being actively engaged in it. So I think that's a different aspect of having empathy and empathizing with patients, with your learners, stuff like that. I think any, you know, that's why I'm in the epilepsy is because there's a variation in things you can do. I think having a variation in your patient interactions is also healthy, and that's how I can kind of balance some of those where it goes. I know my clinic weeks are going to be heavy because it's just me, but those inpatient times, it's easier because sometimes you can distribute those conversations to others. [00:12:06] Speaker A: Yeah. Oh gosh. Yeah, I can definitely see that. Just the impact of being able to shift and variation really, really helping and making an impact for you so that you can make an impact for others. So then I guess along the lines of impact and just patient access as a whole. What is a common misconception that you've heard or that you felt from your patients about access, or even people at large who are trying to come into the hospital and they have questions like what are some just common issues in that sphere that you've seen and faced? [00:12:36] Speaker B: Yeah, I think if we're looking from the clinical side, like outpatient, a lot of that's access issues and I don't think it's necessarily misconceptions. So many different groups scheduling things that people have to trickle down through, like plankos. Yeah. Until they hit the right spot. And there's a lot of places where people can get stock, whether that's insurance travel. Like if we're in a relatively good access area, grandpa, we have public transport, but some people come from outside of Grand Rapids where they don't have access to that. So that's a barrier. We're downtown, so a lot of people come from rural areas too, that do have transportation, but they find parking and more of this urban setting difficult. [00:13:39] Speaker A: Yeah. [00:13:40] Speaker B: And to be honest, our hospital isn't super great with getting even into the clinics because we have an elevator from the parking garage and then an elevator across the hall that goes up to the towers where the offices are. And sometimes people will just be sitting in that garage elevator going up and down, thinking that the number for P six is where their appointment is supposed to be. But in reality, you gotta go across the hall. So I've run into probably like at least three of those people a week when I'm coming home. [00:14:20] Speaker A: Oh gosh, that sounds like the hospital. So I'm from New York, Long island specifically, and we, I remember I was trying to get my mom to a doctor's appointment at like seven in the morning, and she was so anxious and so I'm trying to calm her down and we're trying to get into the hospital, but it's amazed, like we were trying just finding, I mean, thankfully we had a couple security guards helping us try to find our way, but we end up like, trying to look through this hospital. Turns out they have a sister building across the street, which is where she was supposed to go. And so gotta bring her all the way over there. And it's just. It was just a lot. But yeah, I like physical barriers you'd. [00:14:57] Speaker B: Never getting, you know, because nobody builds a hospital the size that it needs to be at the beginning. And then everything's added on just for this room. [00:15:07] Speaker A: Oh, yeah. [00:15:07] Speaker B: A lot of times that doesn't make a lot of sense organization wise, but maybe geographically, right? [00:15:16] Speaker A: Like, yeah, I guess the floor plans made sense like 20 years ago, but right now. Oh, man. So I guess getting back to just neurology as a whole, when you're talking to people about neurology or you're meeting people or hearing things online, what is a common misconception about neurology and epilepsy that you feel people have? [00:15:38] Speaker B: Yeah, I think a big misconception is that people with epilepsy are disabled or they can't do things or they have. And then I think a separate part of this is mental illness. And I think that's a big misconception too. Epilepsy goes hand in hand with anxiety and depression. [00:16:07] Speaker A: Yes. [00:16:08] Speaker B: Which isn't a surprise because epilepsy is a chronic illness. With chronic illness comes anxiety and depression. But, you know, a lot of these people, at least 50% to 55% of the population can respond to two medications for epilepsy. So those patients can go on to, you know, still be in the workforce. [00:16:32] Speaker A: Yeah. [00:16:33] Speaker B: As long as your seizures are controlled based on your state regulations and laws, you can go back to driving. You know, these people have families. You know, they have kids that grow up. So some patients I get who have epilepsy, we're in a center where we deal a lot with patients who are refractory to medications. So they're on three, four medications, getting surgeries, epilepsy. And they're pretty disheartened and upset with the diagnosis, understandably, but there's still room to go. It's not a dead end. You know, it's like any disease. Do you have it or do you have epilepsy or does epilepsy have you? Sort of thing? And I think that's a mindset that people have to think about, especially when they're at the beginning dealing with us, because we, you know, you see some young kids that come in and you like 18, 1920, and you're talking to them about this and I, they're like, well, what happens to my driving? What happens to me playing sports? What happens to me going to college? Can I still do my engineering degree? Can I still go to medical school? And the answer to all those things? Yeah, it just takes time. We have a lot of neurologists that have epilepsy. [00:17:58] Speaker A: Wow. [00:18:00] Speaker B: There's one of our prior mentors here. I never got the chance to meet him, but he was a, I believe, and I hope I'm not messing this story up, but he was a neurology resident, and we have an annual meeting in the American Epilepsy society. And his first seizure was within that, during that conference. So he had a lot of people there witnessing the event. Yeah. And he had a part of his brain removed for his seizures. So he's a big advocate for, you know, understanding what deficit is going to be if you remove a part of the brain. We have a bunch of other options for that, but that's like your hands on experience, knowing what's going to happen, how it goes, and then dealing with the effects afterwards. So his ability to communicate with epilepsy patients is phenomenal, let alone advocating for them in a group setting, as well as talking to them in a personal setting, too. [00:19:09] Speaker A: No, I just. I mean. Wow. Talk about. I mean, I can't even wrap my head around that, having your first seizure. I mean, in a way, it's kind of a blessing in disguise if you're gonna ever have a seizure. Right. [00:19:23] Speaker B: Except we being freaked out by seizures, I think a lot of times can imagine, like, if he was having this happen, they're just whipping out their notebooks and watching, writing things down. Like, what part of your brain do you think that's coming from while he's, like, in the middle of a seizure? Yeah, but, you know, we. Not to say that we don't take seizures seriously, but it's more of a comical approach that I could see going through a conference and having that. Yeah. [00:19:50] Speaker A: Like, really, you have to tell me more. Like, where? That's. That's so interesting. Oh, yeah. No, that's. I mean, that's very, very inspiring. And just especially. Yeah. When you're 1819 going to college or wanting to learn how to drive or all of these things, can you talk a little bit more about that mindset? Especially as you're saying when you're meeting these refractory patients who are on three, four different medications and things haven't worked, how are you. Yeah, how are you able to cultivate that mindset for them or help them cultivate it? [00:20:21] Speaker B: Yeah. So I think most people realizing that you know, with those. With those patients, multiple medications, they're still having seizures. So, yeah, driving is off the table, but, you know, there's a lot of other options to get around if you have a good family support system. Some people are fortunate to have that. Public transport is always an option. Some of these people live in a more centralized location where having a car isn't as important as in other parts of the United States. So that makes it easier. It's hard to broach the concept of continuing to go to school if they have limiting seizures. I think it's still very possible. But then the more medications you add on people that act on the brain, like anti seizure medications, tends to lead to more fatigue, dizziness. Some of the medications can cause some cognitive issues. However, seizures that continue can also result in cognitive symptoms themselves. And what I'd say to that is there's not anyone that would tell you no, if you're going into a career where you can do that safely. If we're looking at commercial airline pilot, that's, you know, that's a much different conversation. [00:21:51] Speaker A: Yeah. [00:21:52] Speaker B: Which I have had, you know, rare conversations with patients who wanted to go to flight school or wanted to go to the Air Force. And you're having that, those, their life aspiration, and you're seeing them for the first time with seizures, saying, yeah, that's you're not going to be behind the cockpit of any kind of commercial flight or Air force flight. And so that's kind of crushing for them to see that. But at least then you can give them hope for, you know, a different career path. And even if that's engineering or something that's related to, you know, you can. Maybe you don't get to fly them, but maybe you can help build them. [00:22:36] Speaker A: Yeah. [00:22:37] Speaker B: And it's just a different approach. So it's kind of counseling those people that turn around negative into more of a positive and look at it in a different way. And a lot of times, yeah, that's still hard when you're giving them the first evidence and the first kind of like, yeah, you're gonna have a. It's gonna be impossible to do that. [00:22:57] Speaker A: Oh, that is tough. And I just, I mean, there's part of me I like that empathizes, obviously, with the patient building yourself up to that. And there's another part of me that empathizes with you having to tell that to them. And how many other patients have you had? What is something about this career that you were surprised about when you were really a couple of years into it? That you were like, wow, I did not know this when I first started, when I first decided. [00:23:26] Speaker B: Biggest thing I realize is the importance of having support, support for the patient as well as support for yourself. And I guess what I mean by that is that a lot of times these patients are going through a very difficult time, whether that's dealing with multiple medications or they're going into a hospital setting where we're monitoring them to move towards surgery for their epilepsy. And that means, you know, it comes down to everybody who's in the hospital. Nurses, janitorial staff, technical staff, everyone who's interacting with that patient on a daily basis can add to a positive experience and a positive outcome. And it made me look back and realize that there's even little things that can make a huge difference to someone's day more. Not necessarily what I can do, but what other people are doing. And I think that comes from the culture that we cultivate here. I don't think it's just an epilepsy or neurology itself, but hopefully in healthcare that you're in the hospital to help people. Yeah, sometimes your day sucks, but you just have to say something nice to somebody once. And this is the one time you're interacting with them for the day. Or, you know, if you're a nurse and you do 312 or something and you're in, this is one of your patients for the. For your week or your shift. So you're seeing them three days in a row. You know, they're great at getting to know people and to have that personal relationship, and that's very important for helping these people get through it. And it's also very important for us, as you know, epileptologists, nurse practitioners, pas dealing with these, dealing with the illness aspect of it, to have a big help from the social side, too. I think the more you get interested in the disease and fixate on the disease, I feel like the further away the person gets. So you can hone in on what you're seeing from the data and information side, and it's hard to pull that person back into the picture, but then you have staff that helps you with that and that. I think support for the patient, support for you family is of the utmost importance, I think, for these patients because they're advocating for them. [00:26:10] Speaker A: Right. [00:26:11] Speaker B: If you've got a family member in the hospital, there are more times than not communicating to the nurses more than the patient is. At least that's what my experience is. But, yeah, but the reason is because they want what's best for their loved one who's in the bed and maybe doesn't have the ability to communicate that as much as they do. And I think that goes to healthcare workers, too. Having a really good, supportive home, family, and things to look forward to when you go home, you know, like a loving partner, if you've got pets, if you have a hobby, medical school in residency, thinking, yep, this is all I'm gonna be. This is all I'm gonna do. And you'll, you know, I'm sure there's people in the middle of it right now that are finding out that if that's all you identify as, it makes going forward and back and forth to work really, really difficult. If you've got something that you enjoy outside of work and can look forward to, you know, I think that's better than that. You can be a great clinician and a great doctor without giving 110% of yourself and your energy every day to this. Sometimes it's better if you can separate yourself out and compartmentalize a little bit. [00:27:37] Speaker A: Yeah, just. I mean, it's just because I'm just now thinking, like, full circle back to when we were starting about, like, just the empathy. Like, there's only so much of you that you can give until you don't have enough of it and you can't pour into yourself as much. And so especially for your patients and, like, how, if that's what you want to do, like, how are you best to do that job if you can't help yourself? You know, it's. It's. It's ironic, almost, in the way that you, like, have to refill yourself and step away from the job in order to do the best at the job, especially at the job that you want to do. [00:28:13] Speaker B: It's interesting, when I, from residency to fellowship now, you know, I've been practicing at my criminal institution, trained here. So now that people. I know everything for six years now, being out kind of doing my own thing, I still have the support of my now peers to ask questions, but I get excited to come in every day, and I hope that people in healthcare can leave feeling like they did a great job and to be excited to come back. [00:28:50] Speaker A: Yeah. [00:28:51] Speaker B: And, you know, see the next patient, help the next person, talk to the next family instead of leaving feeling drained and then not happy to come back. You know, I. I think maybe that's easier in subspecialties than it is in primary care. And I'm, you know, reminded of that by my wife, who's a physician assistant, and she gets. She gets a 15 minutes appointment, the 30 minutes ones that turn into seven minutes that they only have. So I feel guilty sometimes that I have so much time to see these patients, and she doesn't let me forget it. [00:29:42] Speaker A: Just gonna rub it in every now and then. [00:29:43] Speaker B: Yeah. Yeah. [00:29:45] Speaker A: Cause if you're not poking fun at me, like, what are you doing? You know, like, come on. Yeah, you gotta. Thank you so much. So I'm looking at the time, and I don't want to take too much of it, but I do have one question that I always end with, if you were to go back, and I've kind of already answered this, but I'm interested to hear, if you were to go back to the beginning of your story, to the beginning of you deciding, becoming a doctor, what would you told yourself? [00:30:11] Speaker B: So that's a really interesting question. When I was young, you know, I worked in the healthcare setting as a certified nurses aide or a CNA, and then I worked as a medical assistant. So in the hospital setting, I worked in the neuro or in the ICU, in the cardiac telemetry unit and infectious disease as, like, a clerk kind of data gathering, and then as an MA in an orthopedic office. And when I told people, you know, I was applying to medical school and trying to get in there, they often would say, why? Oh, my God, these are doctors. And I'd give them the answer, you know, because I want to, you know, be invested in taking care of people. I found that fulfilling while I was working in the hospital setting. And some of them didn't buy that. They didn't like it. They were like, yeah, good luck. And I. Now someone else said, there's so many hoops to jump through, why bother? Type of thing. And some of the people I asked, they were like, I wouldn't. I wouldn't do it again. It takes a lot. If you talked to me while I was in the middle of my residency, that probably would have been my same answer, too, because I think there's a certain attitude in training to get into medicine. You know, you're. I feel like you're pretty sheltered from. In those years of medical school, everything's bright, shiny, new sort of thing. You see, you start learning, and then those other years, you get experiencing patients and stuff, still working with residents, and, you know, you're shielded by. You're still in your curriculum type of thing. And then once you get into residency, there's a lot of mental strain that I think is put on people and not a lot of flexibility. So you're expected to work, you're expected not to complain, and you're expected to have no issues. And the people who are training you often will say, well, that's how it was when I was training or, you know, now you guys have an easy sort of thing. And I think a lot of that is what grinds down on people. And then you ask them, you know, would you do it again? The answer is going to be no. You know, and, and I think that's like anyone who's in a traumatizing situation or struggling together, you know, if you go back and ask, hey, would you want to do that again? You know, who's, who's going to say yes, right. But, yeah, I hope that there's a, you know, I'm in my institution. I'm trying to get involved with resident fellow education, and I think that it's. That that's the way to change that path for people. You shouldn't be afraid to go into residency because these people are trying to teach you. They're trying to help you learn. And learning through fear isn't a good way to learn. [00:33:38] Speaker A: Yeah. [00:33:38] Speaker B: Learning through comedy and laughing and understanding situations and having a connection with people, that's the way to do it. And I hope that this generation of people that are moving through residency will be able to change it and turn it around because it takes a culture change. The last thing I want to do is perpetuate the idea that, oh, that's how I went through residency. So I make you do it, too, and then just give them the thumb and, you know, which I don't. I don't. Because if someone's bringing a concern to you as a, as a colleague or a trainee, you have to listen to that concern, just like you do with your patients. [00:34:22] Speaker A: Yeah. [00:34:23] Speaker B: And I think a part of that, again, is time. We don't give time to our learners. We don't get. There's so many things that are pulling away at teachers in the setting because they're still doctors, they're still doing their job, and there's a lot of responsibilities pulling their attention. So we have a lot to foster on learners. And then just like, you know, if you're on the phone and your kids, you know, trying to pester you or something, it's like that, you know, you don't give them a lot of time. Just give them the business and give them to go away. And. And I think that has more of a profound impact than people used to realize, especially if you're just trying to learn. And then when I went into fellowship. That experience was a lot different because I could. The first year I did, I was able to, you know, check the boxes. You're offered a lot of things in your institution for a learning perspective and people who are willing to teach and sit down and talk to you. And then the second year, I had the flexibility to make it what I wanted. So I was able to get deeper into things that I found interesting in ways that I could help kind of foster how I want to take care of patients and learn from those people. So I think it's. I remember a graphic that was drawn in a rotation I have with some neurosurgery people, and they had a drawing in their resident room that was a big hill, and there was excrement coming down this hill, and there was an attending. So someone who's done with their training is working. They're on the top of this hill, and they're just kind of shoveling this. And as it rolls down the hill, you have a senior resident. So someone who's towards the end of their training. [00:36:27] Speaker A: Yeah. [00:36:28] Speaker B: Junior. So in the middle, and then there's a trough. And the trough is the person first starting. There's a mountain of things coming towards them. But then on the hill, there's, like, the other side of the trough. On the hill is the medical student. They're protected by the institution stuff and all that. And I feel, like, kind of realistic, but I hope it changes eventually because everyone can find a way to help, and no one's in healthcare for themselves. At least that's what I'd like to think. And when I look at fellowship to now and I look back, for me, I think it's worth it. If you asked me at the end of residency, I'd have a different answer. But after fellowship and finding my niche and what makes me happy and how I can impact patients the most to feel good, at the end of the day, I would go back and do it again. Wow. [00:37:38] Speaker A: I appreciate you, like, outlining that story, because without that context, it's really hard to come to that. Yes. And be like, you know, I would have done this, but, oh, man, it's like, it ain't over till it's over. And, you know, it just. You have no idea when it's actually over until, you know, you're done. [00:37:57] Speaker B: Yeah. It's hard to see the proverbial light at the end of the tunnel until you've gotten there. [00:38:03] Speaker A: Yeah. And even when you're there. Thank you so much for your time. Really appreciate it. I know your day is busy, but really appreciate you just taking your time and telling your story. It was so refreshing. Learned so much. [00:38:19] Speaker B: Yeah. Thank you very much. I really appreciate talking with you as well. Thank you.