083 Connecting The Dots Between Inadequate Payments and Resources to Burnout

Susan J. Kressly, MD, FAAP, is board certified in Pediatrics and Clinical Informatics and is a Fellow of the American Academy of Pediatrics. She received her medical degree from Temple University School of Medicine. She served her residency at St. Christopher's Hospital for Children and stayed an additional year as Chief Pediatric Resident.

Dr. Kressly began practicing in the Doylestown area in 1990 and has been an involved medical community member since then. She is a past president of the PA Chapter of the AAP and several national AAP committees. She served as medical director for Office Practicum EHR for over a decade.

Dr. Kressly enjoys the beach, reading, Scrabble, playing with her grandsons, and volunteering advocacy for women, children, and wildlife in her spare time.

While retiring from clinical practice in August 2020, she continues to influence children's healthcare nationally. 

"If we give pediatricians the right resources and appropriate payment to be able to serve the families, we can do amazing things. That is what's killing us, the lack of appropriate resources. Yes, all the administrative burden and crap is getting in the way, but as pediatricians, you know, you make a difference.

I can jump through a few hoops, but we must eliminate some ridiculous hoop-jumping and administrative burdens that add no value to care. We have to get back to allowing pediatricians to add value to provide care to the patients they are privileged to serve, filling our cup and strengthening us.

Linked arm in arm to change the world with our patients because we don't stand to advocate without surrounded arms linked with the patients and families we care for. We're not here to promote us. We're here on behalf of them. The kids sent me. This isn't about me; this is the kid sent me because they're looking at me longingly; please, sir, may I have some more?

And I'm tired of begging for porridge for my kids. They deserve it. And I want to get to the people who dole out the porridge so that the kids get the fair share and we can distrib

Transcript

Susan J. Kressly, MD, FAAP, is board certified in Pediatrics and Clinical Informatics and is a Fellow of the American Academy of Pediatrics. She received her medical degree from Temple University School of Medicine. She served her residency at St. Christopher's Hospital for Children and stayed an additional year as Chief Pediatric Resident.

Dr. Kressly began practicing in the Doylestown area in 1990 and has been an involved medical community member since then. She is a past president of the PA Chapter of the AAP and several national AAP committees. She served as medical director for Office Practicum EHR for over a decade.

Dr. Kressly and her husband, Greg Anderson, reside in Sanibel, Florida, and are now empty nesters. Alex, the youngest of their three children, manages social media for Capital Health. Stephanie works for the New York Public Library, and Meredith is the Director of a new Goddard preschool.

Dr. Kressly enjoys the beach, reading, Scrabble, playing with her grandsons, and volunteering advocacy for women, children, and wildlife in her spare time.

While retiring from clinical practice in August 2020, she continues to influence children's healthcare nationally. 

"If we give pediatricians the right resources and appropriate payment to be able to serve the families, we can do amazing things. That is what's killing us, the lack of appropriate resources. Yes, all the administrative burden and crap is getting in the way, but as pediatricians, you know, you make a difference.

I can jump through a few hoops, but we must eliminate some ridiculous hoop-jumping and administrative burdens that add no value to care. We have to get back to allowing pediatricians to add value to provide care to the patients they are privileged to serve, filling our cup and strengthening us.

Linked arm in arm to change the world with our patients because we don't stand to advocate without surrounded arms linked with the patients and families we care for. We're not here to promote us. We're here on behalf of them. The kids sent me. This isn't about me; this is the kid sent me because they're looking at me longingly; please, sir, may I have some more?

And I'm tired of begging for porridge for my kids. They deserve it. And I want to get to the people who dole out the porridge so that the kids get the fair share and we can distribute it how they need it. "

Connecting the dots between inadequate payment and resources to burnout.

[00:00:00] Dr. Bravo: Hey, George. It's good to see you again. 

[00:00:03] Dr. Rogu: How are you doing? Dr. Bravo. Today's Tuesday afternoon. We have another excellent guest today. We have Dr. Sue Kressley, a very dear friend of mine, and her topic today will be connecting the dots between inadequate physician payments and lack of resources leading to physician burnout.

[00:00:20] Dr. Bravo: So, as you know, Susan Kressley is a leader and a legend in the pediatric community, having started her own practice, leading it for many years to a successful retirement. And she's also been an innovator in the MedTech space, and she's a frequent guest on our podcast and at the dear front of the podcast. So welcome, Sue, and it's a pleasure to always see you and converse with you. 

[00:00:46] Dr. Susan Kressly, MD, FAAP: Thanks for having me, gentlemen. Working well with some of my dear friends is always exciting and informative. 

[00:00:52] Dr. Bravo: Thank you. So what are you up to now? Is that a natural background, or is that a fake background behind you?

Because I'm kinda jealous. 

[00:01:00] Dr. Susan Kressly, MD, FAAP: Yeah. So, that is an actual photo of what it looked like outside my house in Sanibel, where I'm retired from clinical practice, but indeed not retired from. Pediatric advocacy before Hurricane IAN it's not quite as green anymore. But we are resilient on the island of Sanel, just like pediatricians are resilient, and despite a lot of difficult circumstances, even eight months after the hurricane, we are rebuilding, and it's still a privilege to be able to stare at the water and put my feet in the sand.

[00:01:33] Dr. Bravo: Nice. What are you up to right now that you're no longer practicing? 

[00:01:39] Dr. Susan Kressly, MD, FAAP: So, a lot of things, as you know, I'm one of those people who, when asked to volunteer and advocate, my answer is always a resounding yes. But many of my efforts right now are at state, regional, and national AAP efforts to push the envelope and try to give pediatricians what they need to take care of the patients they're privileged to serve. 

[00:02:02] Dr. Bravo: Why are you and Dr. Jackson, whom I greatly respect as the dean of U M K C? So concerned about community pediatricians? 

[00:02:11] Dr. Susan Kressly, MD, FAAP: The bottom line is that the pediatric relationship with patients and families is fundamentally about relationships in a community setting. And it is not about transactional. Care whether it is checking boxes or waiting in a long line to be called as the next available appointment to see just one other quote provider.

It's really best for children's outcomes and family outcomes and societies. Eventual health outcomes are about those relationships that exist between pediatricians and the families that they serve. And the more we move to consolidation, and we move from the relational, conversational, supportive, collaborative environment of patients and families and pediatricians working together for better health. Too a corporate environment of widgets and task making and metric building. 

We lost the personal touch, and it does a couple of things. We all know about the placebo effect, right? There is something to be said for someone seeing you, seeing who you are, valuing and making you feel cared about.

That is easier to happen in a personal relationship or small community setting than in an institutional one, as well as our pediatric trainees. Not knowing and can't see what that community-rewarding general pediatrician practice looks like. They only see the inside of the extensive hospital training system, and they can't even imagine what it's like to have. Ongoing relational experiences where they really make a difference in the lives of many people in their community and can create a better and healthier community. And so, you know, I often tell students, residents, and our patients that if they can't see it, they can't be it. So they're not being exposed to it.

People like us devoted themselves to sitting in the community with families, lifting them up, and supporting them, both physically and mentally, as possible to be as healthy. The residents, trainees, and medical students aren't seeing that, so they don't even know it exists.

So what happens when we move from this? Community-based relationships with people that matter. It's about people, not transactional happenings, coding, or meeting metrics; this hurts our profession. It hurts our souls, and it ultimately is gonna hurt the kids and families that we so desperately are dedicated to trying to

support.

[00:05:06] Dr. Bravo: What are the perils when a mega system owns a medical home? The mega system concerns the most profitable procedures with significant margins, right? What are we concerned about when we hold our practices and are part of the community? 

[00:05:22] Dr. Susan Kressly, MD, FAAP: About caring for the people within our community. Right. 

A different time than when we all opened up our practices. We have to acknowledge, and I really applaud, our younger Earlier career physicians who are just trying to follow their heart and do what's right for themselves and their patients because it was easier when we did this than today.

It used to be that if you served patients, did the right thing, and gave great care, the business side of the medical practice would be okay. Some people were better at it than others, but you could make a living and make a difference simultaneously. Right. Make a living and make a difference.

For many young pediatricians, it's a choice. Do I make a difference, or do I create a living? And that is a crushing blow to our souls as eager medical students of why we chose to go into pediatrics. To face that decision is just; I feel sorry for our younger colleagues. But we have to help them create better solutions to continue serving the community.

And we're seeing people go back after they've sold their souls for a couple of years; they see a better way but are trapped within the trappings of a system to be able to innovate and give patients what they need. 

I would push back at those bean counters and say, we're intelligent people. Yeah. We got here cuz we're smart people because we're inquisitive. We ask questions, and we like to learn. Yeah.

Sure. When I opened up my own practice 15 years into my career, it was because I saw a vision of doing things differently, and I wanted the power to serve patients how I felt they deserved. And I wanted my kids and grandkids to be cared for someday, right? I wanted to paint the picture with my own brush, right?

I didn't have all the answers. I was naive. But we're inquisitive people. I asked a lot of questions. You ask a lot of questions, and you make a few mistakes. But one thing I never did was devalued what I brought to the patients and families I served because that was the core and the underpinning of everything that I did and what you guys did for your prac and do for your practices.

[00:07:43] Dr. Rogu: I keep hearing from you, the families we served. That's a remarkable statement. That's what was taught to me by my seniors. We are certain the patients are there; we're there for the patients. 

So herb, what happened to that pediatric program you helped build and why?

[00:08:02] Dr. Bravo: Well, it's what Dr. Kressley is alluding to. Health system management concerns margins and profits, not people or relationships. So when I came to Prince William Hospital in 1995 to start the hospitalist sedation and pediatric emergency room department, that hospital had a terrible reputation for caring for kids.

And my partners, who were adult ER doctors, did not like caring for kids. So we built a powerful quality program that the families loved. Until the community hospital was sold to a more enormous empire NOVANT out of North Carolina, NOVANT had a vast footprint all over North Carolina. They quickly came in and dismantled the pediatric program.

Why did they do that? Because it is not a money maker and they have no connection with the community. When they couldn't make it make money off of it, they sold it to UVA. So today, more than 20 years after we built up this program with every community pediatrician involved, it wasn't me; it was community pediatricians who put it up.

We're back to taking care of kids, and there are a hundred thousand kids in that one county like we did in 1995. With no pediatric resources, there comes a moral injury because the hospital is asking, but they're not asking; they're forcing the neonatologist to cover the emergency room. So, as a neonatologist, you know that one, you don't want to go to the ER and get contaminated with R s RSV and bring it back into the NICU, and two, are you gonna choose whose life you will save?

The one in the C-section? Or the one coding in the er because you can't be at two places simultaneously. But the hospital doesn't care because they'll write a check for a million dollars when that happens, and they'll move on. It's just a cost of doing business. Right. But the moral injury that comes when you, as a physician, know that it's just not suitable for a neonatologist.

Go a pedia to the emergency room. Dumping the hundred thousand kids in Prince William County needs to be corrected. These a hundred thousand kids live in my county, which is just next to it, Loudon County, and 200,000 kids live in Fairfax County all into one ER at Fairfax County, which is 30 miles away, or a good hour's drive in any given day.

That's not good care. That's not good for the community. But it's all based on margins. What makes the most money is the moral injury we're seeing in our profession. Yeah. 

[00:11:01] Dr. Rogu: Well, what also is happening with the extensive systems is that they're buying up these little community hospitals and have the little er.

So if the patient needs to be admitted, they ship them 20, 30 miles away to the mother ship, the children's hospital, 

[00:11:15] Dr. Bravo: but they're outta capacity. So what do you think about that kind of moral injury? When I'm asked to do something that I can't sue? 

[00:11:24] Dr. Susan Kressly, MD, FAAP: Yeah, so let's just say there's a difference between no margin and no mission because you need some margin or you have no task. Totally profit-driven at all costs. We all need to at least have some kind of profit margin to stay in business and serve our communities., there is a direct correlation between having inadequate payment as pediatricians. With overwhelming debt when we start, that's a different conversation.

Mm-hmm. Or we'll have that later. There's a direct correlation between inadequate payment and needing more resources to serve our patients, like not having the appropriate er, and not having the proper staffing on a hospital unit. We know what those patients need, and the need is more significant post-pandemic than ever.

Now mental health challenges and the clearer social determinants impact child health. 

We go into the clinic every day and see the need of our patients and our families, and the system needs to systematically give us more resources and pay to do what we know is right.

So every day. We go home from work, and we should be feeling. So grateful for the privilege and opportunity to make a difference in the lives of families and kids, and so many times, we go home heartbroken because that family sat there. I clearly saw what they needed, and the system won't let me provide it because of all kinds of decisions that create barriers to doing what is suitable for the community's people.

[00:13:12] Dr. Bravo: Right. That's right, that's right. We hear all the time, Sue, from our guests that pediatrics is primarily a woman's specialty. Now they're leaving three to seven years into their career after putting 11 years in training. They go; they mostly go to a health system because they cannot afford to go outside of the health system.

And that health system will help them get loan forgiveness, and then they'll slap them with unconscionable non-competes. And within three or seven years of seeing patients and feeling like they just can't care for their patients the way they want, they throw their hands up when they quit.

We cannot have a workforce go through this cuz we will need more people taking care of kids. There are no mothers, no teachers, and no pediatricians. There are no healthy, thriving children. What could we do to turn this tide around? 

[00:14:13] Dr. Susan Kressly, MD, FAAP: So let's be clear. Medicine as a whole is now more than 50% women. There are still some biological caregiver caretakers nurturing female instincts. It's not absolutely; there are lots of men with it too. But we clearly, if you look at the caring professions of child health, whether it's early childhood educators and daycare people or teachers, Or nursing is pretty much, you know, still a female-dominated field.

Medicine is becoming that as well. And in part because when you look at the economics of investing in medical education with the return, the delayed, you don't make any money for years. And then you're digging yourself out of a debt hole. Plus, it seems overwhelmingly impossible for women who want to balance being a mom, a spouse, having a professional career, and running a business.

And so people are struggling, and they still go in, and I see medical students and, even some of my patients who really wanna be me and be a pediatrician, like, I wanna do this. It fills my soul to make a difference and care for kids in the future. And that still tugs at male and female heartstrings like in training.

But at some point, people are making hard decisions about business decisions of, whether I can support myself and a family on the kind of income that comes out of the debt and then the ability to earn a living on the other side. And in some ways, men are more intelligent in today's world, and saying, The ROI is not there. I'm not going there. 

Women are still mission-driven women. I say, but I'm gonna somehow make it work. And then they get seven years in, as you say, and their souls are crushed, and they're like, I can't have it all. I need help to do what I want. Now. They've tied my hands, and I can't practice in the tri-state area where I've started raising my family.

I have to find something else to do in my life. I don't know what else to do. So they get out, and they look for other ways that are adjacent markets. 

Somebody told me last week, and it's true, but I was horrified when they looked to start a practice model and sat down with some business colleagues who are not in medicine.

They were told. It makes more sense as a pediatrician for you to open up a Super Cuts haircut store. You have a better chance of making a return on your investments quickly and making a promising career for yourself and your businesses than opening up a pediatric practice to care for patients in your community.

That is incredibly sad. Yeah, but that's, that's the reality. It is. And people are leaving. 

So we have to figure out how to support all business models. Look, some places are, they're gonna be extensive health systems. They're we need them to care for the specialists. And the specialists in pediatrics need to be paid more. That's a different story. But we have to figure out kids don't get to pick where they live. And some kids live in sparsely populated, Places in Wyoming and Montana and deserve the same care as kids who live in the inner city, Chicago, or the Upper East Side. Kids deserve to have excellent care, no matter where they live. If they don't get to pick where they live, we have to financially support them and look at models that allow pediatricians to be economically solvent. Whether they're a solo practice in the middle of nowhere, they're in a desert in the central inner city, which is also underserved, or they're part of,, a more extensive system in whatever flavor it may make it happen. It is not us versus them. We have to figure out how to support everybody and raise all boats. 

[00:18:12] Dr. Bravo: Absolutely. Well said. Mm-hmm. You have alluded to this several times. I'm still a little sh shell shock; it's a travesty to me that we invest 11 years in training a professional only to burn him out in seven years.

Because we do invest in Medicare-based residency training. The government subsidizes medical schools. The parents of these kids sometimes invest in it. The kids that are going through medical school borrow money. So as a society, we invest in producing these doctors only to destroy them within three to seven years.

It is really, really hard to wrap my head around that. Extremely sad. Do you think, as you've alluded to, the amount of student debt these poor kids are coming up with is 300,000 plus half a million? Do you think it's time to change the policy at a national level? If someone goes into community pediatrics in their own neighborhood, In the way practice forms style that they choose, and they stay in the 10 years, shouldn't they have the opportunity to have their loans forgiven? Just like if they would, if they go join a teaching hospital? 

[00:19:32] Dr. Susan Kressly, MD, FAAP: Absolutely. Or let's figure out a way to not have medical school costs so much. New York City has figured that out. But let's be clear; only some listeners will understand this. People come out in massive debt, and quite frankly, I was $196,000 in debt when I came out of residency training in 1989, which was crazy back then.

Crazy. Well, that's because I took out loans because my parents said, you wanna go to grad school, girlfriend? It's on you. Okay, I'll own that. There were two things different. Part of that was because the interest on the health education student loans floated with the treasury rate, and the interest rate in the s you remember, really ugly.

But I could work hard and pay that back. I could moonlight; I could figure it out. I could get financing. You could still make that return on investment. It took me a long time to dig myself out of a hole, but I could. You can't do that anymore. It is impossible to cap that return on investment, even if you're willing to work yours. Behind off. 

But we either have to figure out a way to have it cost less to go to medical education to have equity and accessibility to people going into the profession. Think about this, what this would look like if you removed some of those barriers, and what the healthcare workplace would look like if it was a manageable hurdle to figure out how to pay for medical, medical education or.

Loan forgiveness, on the other side. Now, let's be clear: many big organizations teach hospitals that have nonprofit or other stuff or statuses or an arm of their organization, so they can take those residents, those graduating residents, and have them do lo loan forgiveness with some service.

We're in the same neighborhood community, trying to do the same thing. And as private independent practices, we need the set status to do that. That is stacked against supporting community care in the community for larger institutions. So to me, going into pediatrics period, We're underpaid.

We're the lowest-paid medical specialty except for public health. And look at where they are right now. I want to avoid sitting at the bottom with them. They need to be elevated too, but we are the lowest-paid specialty, and we have the highest ability to impact the health of the future.

There is something wrong with that. If you pick pediatrics, people aren't choosing it because they can't afford it. Some medical students would love to do what we've dedicated our lives to doing. But they know they can't make the math work with what they can make on the other side, so they choose another specialty.

So let's figure out a loan, forgive forgiveness. If you go into pediatrics, period. Full stop. If you were 

[00:22:40] Dr. Rogu: to figure it out for us, how would you figure it out? 

[00:22:44] Dr. Bravo: She just said, I do. She just said pediatric. 

[00:22:47] Dr. Susan Kressly, MD, FAAP: Enter pediatricians you serve. You do a pediatric residency, and you give. 10 years to clinical pediatrics where you have an N P I, and you are seeing patients in any clinical, I don't care if you're a specialist or whatever, your loans 

[00:23:01] Dr. Bravo: in any community, you're doing community pediatrics.

You're a medical home. Mm-hmm. Yep. Your loans are forgiven. 

[00:23:08] Dr. Susan Kressly, MD, FAAP: Loan forgiven. If you see patients and you're submitting a claim now, you also participate in Medicaid and chip if touched to that want to be atta. Okay. That increases access. Don't put a threshold on it. We did that with meaningful use.

Let's not go there. Pediatricians can't impact the number of kids in their community who need to be served by individual insurance. We don't. We don't get to pick that, either. Right? But if we help kids, then the system should forgive our loans. You know what's very. 

[00:23:38] Dr. Rogu: sad, Sue? Just this year around, we had five.

Pediatric residents interviewed with R B K Pediatrics wanted to take the job. Three of them actually came to us as children. Two of them shadowed in our office, and they went to a system, and they're working in an office just like ours, but it was sold out to a designer down the street. That annoys me to no end.

Yeah, that's not right. 

[00:24:05] Dr. Susan Kressly, MD, FAAP: Nope. Nope. Cause of their own. Cause of their own. So we had to find the right audience to listen to our story. We have to develop a proposal with the business case and fiscal note because you can only talk to bean encounters with the correct data to make the case.

We have to, we have to look at it from the lens of making it make sense. And then we have to elevate pediatrics, and we have to promote primary care. Start by not making us dig ourselves out of a hole from day one. 

[00:24:36] Dr. Bravo: Right, right, right. And I say we don't mean testing public education in America, and we should not be trying access to a pediatrician in America.

And we are. We. We are. That's a problem because pediatrics is the most significant return on investment in healthcare dollars spent. 

[00:24:59] Dr. Susan Kressly, MD, FAAP: Right. Not only healthcare dollars spent, let's be honest. When you go, you have good care and a supportive medical home. , it decreases the spending in the judicial and education systems.

It increases the working tax, paying people on the other side. It is a return on the investment. The problem is, We need to catch up in investment, the people who make the financial decisions, and a lot of healthcare networks. It's a return on investment this year.

Prove to me within, maybe, they'll give you 18 months. Prove that you'll save me money and a return on investment in 18 months. I'm sorry when you. Bring a child into this world. It is an 18-year investment f in ways you have yet to learn. It may be that person who gets you on the Moon, Cures cancer, and figures out how to change that investment.

We can't measure in 12 to 18 months, and we keep as pediatricians at the table trying to play on their terms. We have to prove the business case of why investing in children matters. I have an exciting proposal for that. Let's make kids vote. Reduce the voting age to age two, or at the very least, parents get an extra vote on behalf of their child.

Yes. 

[00:26:31] Dr. Bravo: I would; the only thing I would disagree with you there is my father would still say he's investing in me, but no, it's not just 18 years. 

[00:26:39] Dr. Susan Kressly, MD, FAAP: My father may rest in peace. And I lost them at both my parents in their fifties, which is one of the reasons for those of you who say, like, Sue, like you're only in your early sixties, why aren't you seeing patients.

I lost my mom at age 53 and my dad at age 59, and I watched them forever say, when we retire, when we quit, when we retire, and they never got to do it. I took that lesson to heart and said if I can and can retire, I will do it. Not because I want to just sit on the beach, swim with manatees, and read books. However, I do like that it gives me time to do things where I can advocate for others and have the free time to invest in causes that matter and give it my passion and energy while I'm still young enough and able to do that.

[00:27:26] Dr. Bravo: You have decades of experience advocating. For the pediatrician and their well-being, I really honestly think we are at an inflection point where either we solve it, or the momentum will be so far that children in America will be seeing nurses for vaccinations, not NPAs, not PAs, nurses at the community health center or the health department, wherever that is.

What are our solutions? What are our options? Do you? I think you've enumerated one. We need to get rid of the student debt. Yeah. One way or the other. Two, we need to ensure that brilliant, very talented people are willing to give up their youth and invest in 11 years of education; it is still an option for them to become pediatricians.

And three, we must value that investing in a medical home solves our healthcare problems and many other societal ills. Is that about right? What you're telling me that we need to do and we need to 

do it now?

[00:28:44] Dr. Susan Kressly, MD, FAAP: Yesterday would be better, but I'm all right now. But I also think that.

It, it's exciting. There's so much talk about burnout and moral injury, and I was in a recent conversation in a leadership group where we were talking about what we could do to support the well-being of pediatricians, and within 10 minutes, the conversation started to talk about keeping the mental health and the wellbeing of our kids.

And somebody at the table said, Like, weren't we discussing supporting pediatricians? And I said. It's critical. The answer is the same for both. 

If we give pediatricians the right resources and appropriate payment to be able to serve the families, that is what's killing us. Yes, all the administrative burden and crap is getting in the way, but if you know, you make a difference.

I can jump through a few hoops, but we have to eliminate some ridiculous hoop-jumping and admins that adds no value to care. We have to get back to allowing pediatricians to add value and provide care to the patients they are privileged to serve, which will then fill our cup and strengthen us to go.

Linked arm in arm to change the world with our patients because we don't stand to advocate without surrounded arms linked with the patients and families we care for. We're not here to promote us. We're here on behalf of them. The kids sent me. This isn't about me; this is the kid sent me because they're looking at me longingly; please, sir, may I have some more?

And I'm tired of begging for porridge for my kids. They deserve it. And I want to get to the people who dole out the porridge so that the kids get the fair share and we can distribute it how they need it. Yeah. 

[00:30:48] Dr. Bravo: That's awesome. That's so ins inspiring. Thank you, that is very, very well said.

Thank you. Thank you. Also, thank you so much for your time. I know you're freaking cast, and we're looking forward to more conversations. I hope you're close to the beach and you get to enjoy the rest of the afternoon. 

[00:31:08] Dr. Susan Kressly, MD, FAAP: I will. And in the meantime, every day when you walk outta your office, hang on to that one little piece where you felt like you mattered to a kid in a family because that is going to be the only thing that keeps our heart beating until we can get off life support and get back to doing the best that we can for every patient that we take care of.

Right. 

[00:31:32] Dr. Bravo: Great. Thank you. Thank you.