Addressing Provider Professionalism Concerns, Part 2

How can medical staff leaders address concerns around provider professionalism? Sharon Beckwith, CEO, MDReview, speaks with Don Lefkowits, MD, FACEP, physician at Denver Health and current president of the Colorado Medical Board, and Sara Cameron, CPMSM, CPCS, Director of Medical Staff Services at Hospital Sisters Health System, about the steps that medical staff professionals should take when addressing concerns over provider behavior and creating a culture of accountability. They discuss the importance of having a code of conduct and ensuring that providers understand its terms and how to engage providers about their behaviors in a constructive and collegial way. Sponsored by MDReview. 

Listen to Part 1, where the panelists discuss some of the challenges posed by provider professionalism concerns and how to track those concerns.

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Transcript

Speaker 1: 0:14

Support for A H L A comes from MD review, which provides exceptional external peer review and consulting solutions. They focus on integrity, objectivity, confidentiality, and timeliness to provide clients with an incomparable resource. For 20 years, MD Review has helped leading healthcare entities address key strategic challenges related to medical staff services, credentialing, quality, risk management, peer review, and compliance. For information, visit md review.com.

Speaker 2: 0:48

Thank you all so much for joining us for part two of our podcast, talking about, uh, professionalism and physician behavior. I'm Sharon Beckwith. I'm the c e O of MD review, and I'm happy with me today, Dr. Don Lefkowitz. Dr. Lefkowitz is an emergency medicine physician who practice here in Denver for about 40 years, and now, uh, practices at Denver Health in the adult urgent care. And he is also currently president of the Colorado Medical Board. I also have Sarah Cameron with me. Sarah Cameron is a dual certified, um, by NAMS Medical Staff Professional. She's on the NAMS board. She's a director at large, and she currently serves as a director of medical staff services for hospital sisters health system in Illinois. So, very pleased to have both these people with us today to be able to talk about this subject. And for those of you that are just joining us and didn't get a chance to hear part one, we just talked a little bit about professionalism and behavior in physicians and why it's so important to the culture of safety, um, within an organization. And today we really wanted to talk about now what do we do? How do we address it? So I'm gonna let Dr. Leko start us off.

Speaker 3: 2:01

Thanks, Sharon. Uh, g glad to be here. And, uh, thank you for listening in. Um, you know, we, we, we talked about how, uh, unprofessional conduct, uh, con confrontational behavior, things that we see occasionally, uh, with providers can, uh, affect the culture of safety, morale, even retention and recruitment of new providers. Um, and, and so h how do we either head it off at the past by making sure as we credential providers, they're not likely to bring that type of mindset to your medical staff, or if they're already credentialed and it starts to happen, how to intercede in a way that is both, uh, respectful of their independence and, and their careers, but also lets medical staff, other medical staff, as well as nursing staff, other ancillary services, know how seriously the medical staff leadership takes, uh, collegial behavior. And the fact that there, there, it's, it's clear the intention is to do something about it and, and make sure that the message is it's just not gonna be tolerated. Um, and we talked in the previous session about a code of conduct, but that's a great place to start. Um, and there are, uh, plenty of references for what a code of conduct should include, but it really should be specific and detailed. Um, you know, uh,<laugh>, uh, I've, I've heard some physicians, you know, the, the simp, it should be one word sentence, don't be a jerk. Um, well, there, yes, that's true, t be a jerk. Uh, but there's a lot more to it than that, obviously. And so your code of conduct should be a, a fairly detailed description of what expectations are, uh, because you wanna make clear to new providers, and even with re-credentialing of long-standing providers, uh, that the expectations for collegial, supportive, professional, respectful, uh, relations are, are the expectation and the norm. And, and you can include in it the reasons why it's important, but it's really important to be as detailed and specific as possible. Now, once you've created that code of conduct, the second thing that's critical is that you ma have to make sure that every credentialed provider on, uh, practicing under the roof of your facility has read it, has taken it to heart, and has provided the, uh, medical staff office with a signed copy that they agree to abide by that, uh, the principles li uh, that are detailed in the code of conduct. I can't tell you the number of times that we've brought out over my years as, uh, chief of staff and, and, uh, director, uh, uh, chair of the Department of Emergency Medicine that, you know, we, we'd sit down with a provider who, and say, look here, you, you know, you've, you violated a number of these, uh, e elements of our code of conduct. And they'd say, what code of conduct? I don't, I don't remember anything about a code of conduct. And then we'd bring out their copy and their signature would be on the bottom of the code of conduct, and they'd look at and say, I don't ever remember signing that. You know, and, and truth is a, a lot of office, uh, based physicians, even hospital-based physicians, have their staff complete their, their application for appointment or reappointment. Uh, I, I'm, I hate to say that somebody else is signing the forms, but it's, it's certainly possible. Um, so, uh, it's important that the, that they acknowledge that they understand the contents of the code of conduct and sign a statement and are aware of the fact that they're signing a statement that they agreed to abide by it. And, uh, uh, as we talked about previously, when, when you think you, you may be credentialing somebody that's on the bubble about whether they may bring, uh, some behavioral issues to your medical staff, it have'em sit down with the department chair or, or the chair credentials or the chief medical officer and sign it in their presence and, you know, shake hands on it or a fist bump that we do nowadays because of the pandemic. But the, so there's obvious agreement that yes, I understand what's in the code of conduct, I understand why it's important, and I am signing that. I agree to abide by all the elements of it. Sir, I'm not sure, uh, if you've seen similar behavior, but o obviously from your perspective, medical staff office, you deal with this all the time, I'm sure.

Speaker 4: 6:21

Absolutely. And I'm sure, um, all of the attorneys with A H L A were cringing at the thought of somebody else signing somebody's credentialing paperwork. But I will tell you, it probably happens on a monthly basis. We become aware that somebody had filled out something. And, you know, even looking at privilege forms, we go, why did this doctor request that privilege? And then we follow with the physician and he goes, oh, I don't need that. My, my office manager filled that out. So we know that it happens. We know that, um, they don't see everything we haven't, and that's why I talked about in the last one, I know it's been your process and your facilities and my process that we go over it again at the time of orientation. If, if this issue is as important to you as it should be at every organization, you need to be putting a light on it and making sure that you're setting those expectations early and that you're holding the providers accountable to the things that they sign. When you bring them in to talk about things, have them sign it again. If they say, yes, I will agree to work on, you know, not losing my cool out on the floors. Okay, well sign this again, saying that you're gonna do it. They'll remember signing at that time. Um, you know, and there's so many ways you can address a provider behavior. There's so many pathways you can take. There's, um, it, it really is something that's very up for, um, interpretation by different medical staff leaders. Um, sometimes we send people to the wellness committee if we think they have a lot of stress in their life. Mm-hmm.<affirmative> sometimes a, a simple collegial intervention, um, works sometimes a third collegial intervention works. But, um, I wanted to share a quick little story. When I was, um, working in the Pacific Northwest, we constantly got complaints about this one provider. Clinically, she was astounding. Um, but the complaints were not egregious. They were more like, she's just so unfriendly. She's so unfriendly. Nobody wants to work with her. She's so unfriendly, not rude, just not, not warm and fuzzy at all. And we brought her to wellness committee and we talked to her and we said, you know, what's going on? She's like, nothing. I'm just not someone who comes in and is high fiving the staff. And how was your night? Let's talk about your kids. And we said, that's fine. You don't have to do any of those things. But I had a, we had a psychiatrist on the wellness committee, and that psychiatrist said, when you walk in the building, I want you to just smile at every person who you make eye contact with. She's like, well, I don't make eye contact. He's like, well, let's start there<laugh>, when you make eye, I want you to make eye contact and I want you to smile at people. He said, I'm not gonna track it. I don't expect you to track it. I just want you to consciously start trying to do it and see how your relationships change. So I wanted to tell, tell that story cuz sometimes it just is as simple as teaching someone that making eye contact and giving someone a smile is all you have to do. Even if you don't care what their kids are doing in soccer, just make sure that they feel seen and acknowledged. That's it, that's all it took. She had no more complaints in the years that I was there. So it really is sometimes a very simple fix. It's giving providers the perspective that other people have of them. That's been a big one. Um, sat with a surgeon one time and he said, you know, I, I don't agree with this. I don't believe I did any of these things, but I'll acknowledge that that was that person's perception, that people's perception is that I'm not friendly and compassionate and very easy to work with. So sometimes it really is as simple as just saying, do you realize that people perceive you as arrogant and pushy and, and they can do a slight modification, but it's very hard to convince providers to take that look within themselves at their own personality and identify opportunities to make it better. So it's all in the crafting of that conversation with the provider.

Speaker 3: 10:01

Yeah. You know, setting and maintaining high expectations for professionalism and collegiate b behavior. Um, you know, it, it's, it starts with your medical staff leaders. Uh, I I, I have witnessed, uh, within my department when, when it's clear that that's the expectation that's set by medical staff leaders, um, I mean, not as, it, not only is it clear to the providers, but it provides a, a, a better environment for nursing staff because they feel like if they have a concern, they feel more comfortable raising their concern. Um, and, and, and obviously that's, that's a critical element of the whole process of ensuring that you have, uh, have a professional collegial environment for everybody to work in. Um, you know, and it, and I think it also starts with the recognition that you, you need to intervene early. It it, you know, you don't wanna say, ah, he is just having a bad day, or, yeah, let, let's see what happens. Or, um, and, and that's something again that, um, we, we need to support our medical staff leaders, whether it's a department chair or section chair or, or even prof, more senior professional colleagues who are acting sometimes in a mentorship role for, for newer members of the medical staff. Mm-hmm.<affirmative>. Um, it, it's, it doesn't necessarily come naturally to medical staff leaders to stop somebody and say, it looks like you're struggling. Uh, uh, uh, nurse, uh, you know, staff is concerned. Uh, you, you seem tempered. Uh, you, you don't seem your usual self. Um, and that's the best place to start an intervention, uh, because it, it, it has this, it has more of a sense of, I'm approaching you because I care about, of course, patient safety's important to me. Uh, of course patient satisfaction's important to me, but what's really important to me is that you are successful Yeah. In your workday, so that you feel satisfied with the work that you're doing, both professionally and emotionally. It's never a good day when you leave your shift, whether you're a hospitalist, an ER, doc, uh, I c u doc, no matter where you are a surgeon, it's never a good day when you've had feel like you've done battle with a patient, a family member, a nursing staff. Even if things aren't going your way, if you, you know, walk out, uh, thinking, boy, that was not satisfying because you spent most of your day battling with things, uh, with, with people or with processes. Uh, and, and, you know, and so figuring out how to provide your medical staff leaders with some training on, uh, per perceiving when, when physicians, uh, providers are struggling. And that, how to make that first outreach to say, let's talk about how you're being perceived and maybe you're not even aware that you're being perceived Right. In a way that's less than collegial and professional and, and kind and caring, but you are. And let's talk about why that's happening. Well, and maybe, I know you, you deal with medical staff leaders and, and probably many of them are new to the role. Uh, maybe some of them haven't even volunteered<laugh>, but are, are sort of pushed into the role because that's what they need to do. Uh, h how do you pro provide that kind of support for somebody whose preference would be to say, I don't really wanna have that conversation today?

Speaker 4: 13:42

So to your point, um, many, I, I think a lot of medical staff leaders get into it thinking it'll be a lot of meetings to attend. They don't realize, but they realize quickly that that also includes meeting with providers who have professionalism is issues or peer review issues. And, um, that's our job to educate them before they accept the role that this is part of it. Part of it will be having collegial interventions, especially if you're talking to the department chair of surgery, he's obviously gonna have more interventions cuz we have more behavior issues and surgery, not to knock any one group. Um, but again, to your point, it really does require two levels of training for the medical staff professional. You first have to train that medical staff leader each and every time because as I said, each and every intervention is very different. If you're bringing somebody in who's been on staff 10 years, and this is the first time they've ever had a blow up, you're gonna come in and you're gonna say, are you doing okay? It's gonna be more of a supportive role. If you're bringing someone in who has, you know, two events every year for the last 10 years, you are not gonna be quite as compassionate. Something's not going on with that guy. That, that guy just might be a jerk. But, um, there are also ways to address that conversation with him and make Kim see the, um, the lens that others view him through. So you do have to start with coaching the coach and then, um, be a support to that coach in that moment. Um, again, I'll go back to it's about keeping really good documentation of all prior events. It's about having great documentation about the event that's being reported. It's about gathering any witness statements or others who might have observed things and getting their support in it so that you can hand this all wrapped in a pretty package to that medical staff leader who's gonna participate in that conversation. And he has, he can walk into it with a lot of things. If you work with a program who's, um, helps you with your professionalism tracking through your event reporting database, there's some companies out there who do that and then they adjust it against that data from other organizations. It's very powerful to walk into a meeting with a provider and say, you know, we've been here a few times already. We're here to talk about this newest incident, but we also pulled this data from this organization who helps us track our patient safety events. And you are in emergency medicine, you're, you know, an outlier. You're in the top 1%, um, for the number of complaints you receive. That's really great data to use and a powerful tool if your organization uses that. But, um, you really have to craft each and every collegial intervention the same way. Cuz most department leaders or medical staff leaders, their instinct is to go, okay, I'll run to the lounge and catch'em at lunch and just be like, Hey, somebody made a complaint, would you knock that off? I really do think that's the extent of a lot of those collegial interventions. And it, they need the training to know how to better approach that conversation and how to respond with the different deflecting that they might get and, um, give them the tools to be compassionate yet set expectations. Um, that that's key. They need to know that they walk in and they show compassion, be their peer, but the expectation is this won't happen again. And if it does, then this, and finally, documentation. People do such a terrible job documenting. Um, if we keep this spreadsheet and we see that there was an event three weeks ago that has no follow up from the department chair. We've sent him that packet of here's the prior events, here's the current event, this is my recommendation per policy. The next step would be to set up a meeting. Let me know if you want me to set up that meeting. I'm gonna follow up with that department chair and say, did you have a conversation with him? Did you want me to set up that meeting? And if he goes, yeah, yeah, I ran into him in the lounge, we just kind of hashed it out, then my response is going to be, I need you to write a summary of that conversation and he needs to provide me written documentation so I can close the loop on that report and say, yes, he was, he did have a discussion with the department chair. Do I love that the department chair didn't follow the process? I told him no, but at least he had the conversation. I can document the conversation. And then finally, every time, even I think even if it's a subtle collegial conversation with a provider, follow it up with a letter. I draft them for my department shares all the time, send it to'em in an email, and then they'll send the email and copy me. Um, but it's having a strong m s P to draft those for you. Document those, that letter goes in the file. Now you've documented that you had that conversation As things escalate, um, those documented conversations are the tools that you need to move a provider who doesn't fit into your culture of safety off the medical staff. If you haven't documented it, if you haven't sent follow up letters, that's a very hard uphill battle to, to move that provider out of your organization.

Speaker 3: 18:31

And, and there are other tools that I think back over my years, uh, uh, as department chair, you know, we had access, for instance, to, uh, uh, an external, uh, source for, for training in how to deal with difficult patients. Um, and we oftentimes would find a provider who did great, but when there was that challenging patient, uh, you know, the one that would get back in their face or didn't take advice or signed out against medical advice, um, that's when they'd sort of lose the cool and, and things would escalate. And so we would provide them, you know, that that provider with additional training in how to deal with difficult patients, how to deal with drug seeking behavior, you know, how to deal with psychiatric patients or, you know, whatever it is, that that may be their training. Uh, I mean maybe their, their their sort of, uh, achilles heel, uh, that additional training.

Speaker 4: 19:24

How smile at staff.

Speaker 3: 19:25

Yeah, yeah, exactly. Um, right. Um, and, and, and the, the message there is we want you to succeed. Yes. Uh, we're, we're not, we're not. Step one isn't how can we discipline this provider? Right. Uh, you know, step one is what's going on. And step two is, how can we help you succeed in, uh, in providing care, uh, or in interacting with other staff in a way that's perceived as professional and collegial, because that's gonna lead to their own long-term success. Obviously. Um, you know, I I think it would be remiss if we didn't, uh, address briefly the fact that we're, uh, we're talking about, uh, behavior, professionalism, behavior issues, computational behavior in a time when there's never been a greater stress on our providers. Uh, a term that's come up, uh, fairly recently, uh, this term moral injury, the, the, the, uh, the really deep seated, uh, effect that caring for patients in a pandemic when, uh, and it, and it was present when the pandemic first started because of, of fear. Fear of getting sick yourself or getting family members sick, frustration and not having things to offer in the way of treatment, uh, knowledge that, that so many patients were gonna lose their lives. And, and it was pretty clear, uh, that this had a, a profound effect on providers and it was only natural that they would become a little less caring, a little more short-tempered, uh, sometimes show up to work, depressed, stressed, anxious, uh, and all those things are bound to manifest in behaviors that n that for them probably are even different than what, what their usual behavior was before all that. And now this term, you know, this, the term moral injury even applies more. So now when, when there's a whole new round of providers caring for patients who are critically ill, perhaps not even gonna survive. And it's, uh, in a patient who could have avoided the illness altogether. Yeah. And, um, I've had a few of those in my urgent care and I, uh, only a couple. I know providers who've had many, many, many, and I, I mean, I, I recall leaving work that day just sort of heartsick and, but, but depressed, sad, and angry, all wrapped into one. And I had to think back about how, how I wonder how I was perceived. Was it mm-hmm.<affirmative>, did it show that I was so frustrated and angry and upset about this? And I, and hopefully it didn't, but my guess is somebody probably noticed that I was not in a good frame of mind to give compassionate care.

Speaker 4: 22:15

I think I, I will tell you this didn't happen at my, my organization, but I had another M S P, um, who's a friend share with me that one of the providers at her hospital actually came to the medical staff office one day and said, do I have access to E a p or the wellness committee without a referral there? Yeah. And the reason he was asking was because he saw himself discriminating against patients who had not received a vaccination Sure. Versus those who had gotten vaccinations. He said, I feel like I'm treating them differently. And I, I don't think he actually had treated them differently. Maybe less compassion in one room versus another room. I think the treatments were fine. But he, he wanted to seek out help and advocacy because he didn't like that that was, um, you know, his mindset was just that this was so avoidable, and yet you're here. He said to him, is this anger? And he said, no, it's disappointment. It's just disappointment that we're here. Um, disappointment that we're so overwhelmed, disappointment that some of his favorite nurses have been driven out of the profession. Yeah. So, um, I think we, everyone's suffering in the pandemic. Everyone, there isn't anyone who's life isn't affected, but we really need to pause and, uh, specifically honor these clinicians who have just been at it for 18 months now. And, um, so morally frustrating, like you said, but I think the job of a medical staff office, medical staff leaders, is to be an advocate for the physician, even if he is a jerk. Even if he's a guy who comes in crabby and is rude to everyone. E more than ever, that is the time for medical staff leadership to step in and say, what can we do to make you more successful? Maybe you don't see it, but people see it. And this is people's perception and what do you need from us to help make you better? And that's how we start every collegial conversation, even on the, even the ones who we see every quarter of the year for an issue, we start the conversation with, here we are again. You've, you did so great for a while, but just slid back. How can we help you get back to where you were, um, when you were on the path of, of resolving some of this? Yeah.

Speaker 3: 24:23

And, and to be able to make clear the broader benefits of an improved work attitude. Um, and, and, uh, you know, there's no downside to a highly professional and yet collegial, caring, and friendly nature by providers, it's only upside. Right. And, and as you know, as we mentioned earlier, it's upside for the colleagues who work with you, the nursing staff who work with you. It's an incredible upside for patients for their satisfaction, but most importantly for their outcomes. Right. Uh, and for family members, uh, you know, who, who will, who will either leave the hospital, uh, with a scowl and a and, and anxious to tell their 10 closest friends what a negative experience they had, or hopefully more positively to tell 20 of their friends what an a positive environment. It was stressful. We were worried, and yet the care was kind, professional, caring, and, and you know, what better way to, you know, to, to get word of mouth, uh, marketing, uh, about your, your facility? But I always come back, you know, in situations where, where I've been dealing with physicians like this, I, I still find that the most helpful, uh, uh, approach is to come back to their own personal satisfaction. That if they want to have, they've invested so much in their, in getting to this point in their career, uh, you know, through training and residency and, and long hours and, and stressful work with sick people and exposing themselves, they've invested so much. And, um, the frustration of not feeling emotionally and professionally satisfied, uh, just snowballs. And the opposite is even more true. That, you know, I refer to it as the joy of medicine. Um, it, and, and this is a hard time<laugh>, I have to say, to be experiencing the joy of medicine. And sometimes you, you need to be reminded, uh, of the privilege that providing care, uh, in, in hospital settings is, and that if you create, uh, by your own behavior, collegial, friendly, professional interactions with everybody mm-hmm.<affirmative>, Uh, you know, whether it's ancillary services, nursing services, or colleagues or consultants, whomever it is, and especially patients and their family members, if you're able to approach it in a way that creates that kind of environment, you will be far more satisfied at the end of the day, both emotionally and professionally with the work that you've done. And you can envision, even as hard as it is, is on occasion, or maybe regularly, you can envision that I can do this for 30 years or 40 years, uh, because the satisfaction that I get from it outweighs the, the struggles and the hard times. And that satisfaction rests more than anything on who I get to work with. Yeah. The patients that I get to take care of, the family members I get to communicate with, and most importantly, the staff that I work with, uh, who are my colleagues, my friends, and who support me, and I support them. And at the end of the day, I'm satisfied because I've created, helped create that positive, professional, collegial environment. And, and when you relay it, I think I have found, when I relay that to, to somebody who's struggling with some aspects of their interpersonal relationships, they can internalize it in a way that says, it's o it's, you know, it's almost like a selfish reason to do it, because I'll feel better about myself and that therefore my work experience will be far more rewarding.

Speaker 4: 28:13

Yeah. Yeah. Absolutely. Do we wanna maybe kind of make a list of key takeaways considering our audience's, um, healthcare Lawyers Association? I'm, I'm trying to think of the key points that we wanna make sure that they take away. For me it's documentation. Um, I work extremely closely with my organization's counsel. Um, I, if you've ever heard me speak before, I know Sharon knows this. I keep a very detailed tracking, um, sheet for any concerns that come up and for providers, and that has been a savior when I work with my attorneys to just be able to send them that timeline of the events that took place and the interventions that took place, and the policies that we referenced in each of those. Um, documenting every conversation that takes place, even if your department chair is just sending your med staff professional a quick email that says, talk to Don in the physician lounge today. He says he is gonna knock it off. You know that, that's fine. I'll save that email to the file. Um, so for me, key takeaways is documentation, documentation. And not just because you might get to that point where someone loses privileges, but because the more you document, the more effective each collegial intervention will be along the way, because you have that kind of glimpse of the history glimpse of prior, um, uh, intervening actions that we've taken. So, um, document, document, document set expectations. If the, if the behavior continues, the expectation is that this will happen. Um, that, those are my big takeaways, I think, for addressing provider behavior. And get your CMOs out of, um, doing those collegial interventions. Let your C M O do the C M O job, which is removing barriers for providers to access the healthcare they need for their patients. That's the CMOs job. The CMOs job is difficult when he's also dealing with provider behaviors. He can't have that separation of business and, um, personal. So leave that to the peers of the provider, even though the C M O usually has privileges. He is a peer, but he also works for administration. So try try to keep those, doing the interventions as elected medical staff leaders and peers.

Speaker 3: 30:21

Yeah, it's, it's a great summary. You know, a a very clearly stated, acknowledged code of conduct, uh, empowering your medical staff leaders and training them in recognition of behavioral issues, particularly when there's a pattern to the issues and how to intervene early and intervene in a way that's supportive, non accusatory, but also is firm enough to know that they're just behaviors that can't be tolerated and, and why it's in the best interest of patient safety, patient outcomes, staff satisfaction, and their own personal satisfaction to have a positive outcome created by a change in behavior that people now perceive as collegial and professional.

Speaker 2: 31:07

And one of the things I really heard from kind of both of you today is this whole concept that what we're trying to do, um, medical staff and medical staff leadership is to support the provider and to, um, make providers successful. Right? That's really what it's all about. Because that is then, um, very helpful and valuable to the organization. It's very costly to get rid of physicians, to return physicians. Now, there are times when you need to, you need to just get rid of the bad apple who sort of toxic to the environment, right? But I think that what, you know, what I've really heard today, uh, is that having these types of interventions, you can really, um, support the provider, show them your support and help them to succeed, which overall helps the organization succeed. So, um, I again wanna thank, uh, Dr. Lefkowitz and, uh, Sarah just for sharing your knowledge, sharing your expertise with us. Um, I think you both have, um, just a vast amount of experience in this area, and you have the different perspectives, right? One of a physician leader and one as a very experienced M S P. And so I think it's so helpful just to hear how you approach things, um, what you feel is important and just to hear your takeaways from this conversation. So again, thank you everyone for joining us. Um, we hope you've enjoyed the information that we've shared with you and thanks. So

Speaker 4: 32:33

Thank

Speaker 1: 32:42

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