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VOICE OVER:
This is Residents in a Room, an official podcast of the American Society of Anesthesiologists, where we go behind the scenes to explore the world from the point of view of anesthesiology residents.
So as physicians, we tend to think of ourselves as resilient and we truly are because we have to be, but we're also exposed to a lot of sad things.
One of the big takeaways that I gathered was, you know, really forming deep, meaningful relationships with those around you.
You know, I wouldn't have to be vigilant for myself, but to do it for my colleagues, co- residents, fellows, whoever it might be.
They wondered that how small of an accident they could get in to just get enough time off for it to, you know, get a couple of weeks off.
DR. ELIZABETH MALINZAK (HOST):
Welcome back to residents in a room, the podcast for residents by residents. I'm Dr. Elizabeth Malinzak, a pediatric anesthesiologist at Duke University and the Chair of the Committee on Young Physicians. And I'm here again with a really amazing group of residents and one fellow to talk more about how family and career mix and specifically what happens when career stressors take over. We're going to get real about burnout. You met our guest in the last episode, but let's meet them again, Dr. Martinez. Would you just mind introducing yourself again?
DR. MICHEAL MARTINEZ:
Absolutely. My name is Michael Martinez. I'm a PGY five at Duke University. I'm a critical care anesthesia fellow.
DR. MALINZAK:
Welcome. It's nice to have a fellow Dukey here.
DR. MARTINEZ:
Mm hmmm. Thank you.
DR. MALINZAK:
Dr. Barrera, will you introduce yourself again?
DR. RYAN BARRERA:
Yes, my name is Ryan Barrera. I am a PGY three slash KA two at Baylor College of Medicine in Houston, Texas.
DR. MALINZAK:
And Dr. Plunkett
DR. HARRISON PLUNKETT:
My name is Harrison Plunkett. I’m a CA three. And one of the chief residents here at UVA Anesthesiology.
DR. MALINZAK:
Wonderful. So just to summarize, in the first episode we recorded together, we discussed Work-Life Balance. Before we shift gears to burnout, I just want to look back to that and touch on why it matters. I was hoping you all could kind of summarize your thoughts on why finding some way to manage or integrate your work life and your home life is so important not only for just you as an individual, but also for our specialty and for our patients. Why does this matter? Dr. Plunkett.
DR. PLUNKETTT:
I think that when your personal and professional lives aren't in harmony, it can create a great deal of stress that can be difficult to process and manage when you encounter so many stressors, you know, in our professional lives as anesthesiologists and in, in our personal lives, whether it's the death of family members or, you know, getting in a wreck on the way to work. And so if you can't find that harmony, I certainly find it difficult to manage the stressors that pop up. And being well as I interact with my daily life.
DR. MALINZAK:
Dr. Barrera is a fellow resident. What do you have to say?
DR. BARRERA:
I think when you're out of the hospital, at least personally, I don't introduce myself as a doctor. I don't tell people in anesthesia. I kind of talk about all the other things that make me who I am. And so I think when those two arenas of your life don't really come together very well, then, like Dr. Plunkettt was saying, it can be really, really stressful, they can really start to invade each other. You know your personal life and get your professional life and vice versa. I think it's very, very hard to care for patients when you are preoccupied with other things that are going on in your life.
DR. MALINZAK:
That is absolutely true. It can be really more challenging to keep your full attention on a patient if you're preoccupied with something going on in your personal life. Dr. Martinez, have you experienced that?
DR. MARTINEZ:
Yes, absolutely. I usually think of it kind of with the crashing airplane metaphor where when the oxygen masks finally pop down, you're supposed to put yours on first before you start putting it on the people around you or the kids. So for me, you know, taking care of myself, whether it be good sleep hygiene, eating well, whatever, exercising, whatever it is, I try and make that a priority. That way, when you do show up to work or you do show up for your shift, you're ready to go. Not always done every day of the week, admittedly. But, overall, I think it does add up and it definitely matters each day to the patients you take care of. So it definitely is important to take care of yourself first.
DR. MALINZAK:
You all shared some really good advice and tips on what works for you/ And I really enjoyed hearing about that in our first episode. But we also have to acknowledge that sometimes life doesn't work so well. We know that in our profession, burnout can be deadly. Physician burnout is linked to poor quality of life and reduced quality of care, not to mention substance abuse, financial loss and loads of other bad things. So for us, as anesthesiologists, well-being can literally be a matter of life and death. Does this thought keep you up at night and how do you guard against this ever-present threat?
Dr. Barrera?
DR. BARRERA:
Oh, this is definitely one of my bigger fears as a resident, as opposed to not a postdoc. that's not working or attending that you can't call if you really need help. But I think the burnout is a really big threat to all residents across the world, whether in anesthesiology or not. I think it's really, really hard to guard against because it's really hard to tell if someone is experiencing burnout. I think kind of big picture wise. The biggest thing that you can do to prevent burnout is kind of just the connection, you know, having connection to your fellow residents and the connection to your friends and family outside of work and kind of just feeling that what you do matters inside of the hospital and outside of the hospital.
DR. MALINZAK:
Absolutely. Dr. Martinez, I’d love to hear from you.
DR. MARTINEZ:
Yeah, I actually had a pretty unfortunate experience when I was a medical student. I was on a psychiatry rotation and I had this attending who was absolutely fantastic. I learned so much on that rotation. This attending taught me a lot and academically. A CV through the roof. Like, everything you could look for in an attending. And then a few months later found out that that attending completed suicide. And you know, it was a shock through the whole medical center. And you kind of reflect on you're like, you know, I didn't see anything, you know, like no signs whatsoever. So it's, it's a very cryptic diagnosis, if you will. And so from that point forward, I was like, you know, I one have to be vigilant for myself, but two, you know, do it for my colleagues, co-residents. Co-fellows, whoever it might be, because I mean it, it it's real and it affects a lot of people outside of just the victim in and of itself.
So that experience really kind of opened my eyes as to one how real of a problem it was and then to how widespread it it was. That attending was actually a psychiatrist of all specialties. And not to say that that specialty is less prone to it or anything like that. But you know, this attending, probably on a day-to-day basis, helped patients with very similar symptoms and and emotions that that attending was going through so that attending could know exactly what to look for. And yet still, you think they have great resiliency and all of those things, and it still crept up and obviously took a hold of that of that person's life. And from that point forward is like, wow, this is really real for me, and I hope no one ever has to experience that. So I make it a point of one taking care of myself so I can be there for my wife and kids, but two, hopefully that no other person in the field has to go through that and deal with that.
DR. MALINZAK:
Yeah, that's just an awful experience. And sadly, I think all of us probably know someone in the medical profession who's dealt with suicide. Burnout definitely contributes to it. Dr. Plunkett, I'd love to hear your thoughts on burnout as well.
DR. PLUNKETT:
You know, I think this is something that we are always cautious of and concerned with within our own residency and looking out for each other. You know, I’m thankful that the program that I'm in now, you know, residency is sort of behaved like a team sport and we are each there for each other and supportive on a number of different fronts. And to include being able to to flex and give time off for folks who have found themselves encountering and struggling with burnout so that they can, you know, have the opportunity to get well and improve their lives and be able to reenter training. And so I think that while I only know my program, I'm hopeful that's representative of most of the programs, if not all the programs that residents find themselves training in while becoming great anesthesiologists.
DR. MALINZAK:
Absolutely. And I think the ASA is is taking a closer look at burnout and recently passed a statement to support a culture of well-being for all physicians at this most recent annual meeting. And this statement kind of stemmed from the fact that the pandemic we're in has driven many health care workers just past the breaking point and has made burnout so much worse. So I think sometimes young physicians think of burnout as an issue we might face later in careers. But I I wonder if the pandemic has actually changed this. Is this something that you all are on the lookout for now, or is it something you think might pop up later? And how has COVID changed your calculus regarding this? Dr. Barrera.
DR. BARRERA:
I think this is definitely, you know the whole COVID situation and the really big changes that we've seen in our field in the past year and a half, have really put this in the forefront of my mind in the minds of a lot of my colleagues. I think we're very fortunate at my institution because we have a very good policy around COVID. If there's a patient that needs a COVID intubation or a patient that's COVID positive, that needs a case. A lot of times the attending will just do the case by themselves and just stay in the room, not having any learners or residents be be present just to have the minimal amount of exposure. We have ample supplies of N95 and … if we need them. And so from that. I feel very, very protected and very valued for my institution, but at the same time, I know I'm talking, I have, I have friends in other institutions and all throughout the country. And you know, some places aren't as robust as that. I mean, and I think if you kind of you're at a place where you aren't as protected from COVID and you're a little bit more on the front lines every single day, I could, I could see how that would make you even more burned out and kind of make you feel like you were devalued a little bit as a trainee doctor.
DR. MALINZAK:
Dr. Plunkett, how has COVID affected your residency program?
DR. PLUNKETT:
Apart from the virus itself and its impacts on our daily live, I think one of the things that I've felt most profoundly is how we connect with each other. You know, obviously, with the implementation almost exclusively of Zoom for meetings and education across the country, you know, some of the touch points that we have throughout the week to engage and find connection has certainly become limited. And so I think that often can create its own unique downstream effects for how we can find relief and be able to de-stress throughout the week when we're dealing with challenging situations that are also brought on by COVID and and just the rigors of anesthesia residency.
DR. MALINZAK:
Dr. Martinez, you're an ICU fellow. Do you think COVID has affected burnout more in the critical care community or in ICU fellows?
DR. MARTINEZ:
It has definitely contributed. Thankfully, my fellowship has not been a mini COVID fellowship. I do sympathize with some of the MICU colleagues just because they probably aren't having the same experience that they originally signed up for. Overall, this has definitely contributed to a lot of provider fatigue. And I will absolutely commend all of the ICU nurses I've worked with. They're really the ones on the front lines and they've had to deal with a lot. And undoubtedly that comes at a certain price and it can be extremely taxing, emotionally, taking care of patients who kind of in a way, a lot of times, won't take care of themselves. Almost universally, in my subjective experience, the people coming into my ICU are not vaccinated or they’re solid organ transplants and immunocompromised, with or without a vaccine. So it can be really challenging to come in to work every day and take care of a patient with with COVID, especially with the disease process. It's not a quick disease. It’s blocking up an ICU bed for weeks, and that's usually the best case scenario for them. So it is extremely challenging and tiring.
But thankfully, my fellowship isn't just about that. It's taking care of all kinds of patients in the cardiac ICU in the SICU, although we have had a lot of MICU overflow. So I actually say maybe to some extent my fellowship has been enhanced because in a way it's more of a medical surgical unit now due to the MICU overflow. So in a way, perhaps my my training has actually been enhanced by it versus just doing a couple of weeks that we would normally do and then MICU. So I try and look at the bright side of everything, but overall, it's definitely challenging. And I think probably in the long term scale is where we'll see more of this really play out. I can see people not working as long as they do, whether that's on a career time scale or even within, you know, months to weeks. A lot of a lot of nurses are moving to even just doing travel nursing. So it's really interesting that the dynamics and workflow, things going on within the ICU and other other areas of the hospital as well.
DR. MALINZAK:
I absolutely agree. It has been interesting to see how COVID has affected the workforce and how we're just seeing a drainage of health care workers wanting to leave or getting burned out.
So when it comes to burnout, do you all feel that you have a working knowledge of the science to look out for, both in yourself and in your colleagues? And what would set off alarms considering what you know about wellness and burnout? And then come, did your knowledge of this come from medical school, your program, your hospital? Where did you learn these things?
DR. MARTINEZ:
I feel like overall, the definition has kind of been ingrained for me, at least even since medical school. So thankfully, this is actually being talked about now, which obviously in the past it was not at all. So I think that's maybe a step in and of itself. But overall, the symptoms, you know, they tend to, I'm sure, vary to some extent within specialties. But overall, I guess the anaesthesia standpoint, we sometimes get these questions on our boards and it's, the things you would classically think, people are like not showing up on time or or all of those things, or like sleeping in or falling asleep on the job. That's actually like late signs. So I actually think it's more difficult to pick up on early in the game. And that is certainly true from my my experience in medical school. So it can be very cryptic and I think it's fluid as well. You know, it comes and goes. I don't think people are necessarily, it's not a cliff and you fall off of it and then that's it and then you're down there. I think people can ebb and flow over various hills and valleys, and it doesn't, some hills are higher, some valleys are deeper. And it can be really variable. So it's really challenging to just stick a label on someone or their emotions or their thinking. So it's challenging, no doubt.
DR. MALINZAK:
I absolutely agree, I think it would be really challenging to notice the science in other people. Dr. Plunkett, where have you learned about wellness and burnout?
DR. PLUNKETT:
I had the good fortune of working as a physician in the United States Navy for the submarine force. And as a unique organization, and many probably read, suicide is not something or something that is extremely familiar within the ranks. And the submarine force was no different. And working as a primary care physician for that organization, we certainly had our fair share of completed suicides and suicide attempts. And working to rake the ranks and trying to identify those who are struggling with commands. And so, I'm by no means an expert and and still struggled to try and identify those who are having a hard time within my program now here at UVA. But I think one of the big takeaways that I gathered was, you know, really forming deep, meaningful relationships with those around you. And then just trusting your gut and not being able, not being afraid to have tough conversations. If you have a sense that something is off and not well for that colleague or that friend, and being able to take them aside and and ask them point blank or things, OK, and with that meaningful relationship, you know, being able to try and crack those barriers that someone might put up to to ward off others from identifying that they may be struggling.
DR. MALINZAK:
Dr. Barrera, do you feel like you can discuss burnout or wellness in general with your colleagues or supervisors?
DR. BARRERA:
Yeah, I think with my colleagues, I can discuss burnout pretty frequently and pretty openly. I think for everybody, it looks just a little bit different. I think we all have days we're just really tired and we can't get enough sleep last night. You know, maybe the work life balance pendulum swung more towards personal life or something like that. So we were just tired. But I think burnout kind of goes a little bit beyond that. It goes into more of, you know, kind of a pathological state that. I had a friend shared with me, hopefully such residences with their permission, of course. But my friend was telling me that in their previous residency, they were just really, really burned out. They didn't look forward to work anymore. They really had no sense of accomplishment of personal well-being. And so they found one day when they're driving to work, they wondered that how small of an accident they could get into just get enough time off work to, you know, get a couple of weeks off. And, you know, kind of the severity of an accident that they would have to get into and not be mortally injured, but to not have to go to work for a few weeks. And they realized at that point there is something seriously wrong. And, you know, they made a lot of life changes that I think really turned it around. And they're they're much happier now. But I think that's obviously a very severe, very poignant example of burnout. But it's it's all around us, and a lot of people don't seem to realize it until it gets until it gets that bad, unfortunately.
DR. MALINZAK:
Absolutely. You know, there's a lot of shifts to thinking about burnout is more of a systemic issue rather than an individual issue. At the places where you were for medical school or that you're now for residency and fellowship, what elements of support systems are most helpful in dealing with wellness and burnout? How about at University of Virginia, Dr. Plunkett?
DR. PLUNKETT:
We have multiple resources for our residents that are frequently shared and serve as referrals. We have, you know, a highly confidential counseling for those who may be struggling with clinically a clinical level of depression or any sort of mental health dysfunction or challenges. We have coaching and more of sub pathologic, but you know, someone who may be challenging or facing challenges that they encounter frequently while working. And I think as we talked about earlier, you know, with the ABA's new policy about being able to take 40 days to deal with a clinical diagnosis like depression or anxiety, and that could be byproducts of being burnt out, are things that our program is utilized to try and support residents who have encountered difficult times for any number of reasons.
DR. MALINZAK:
Dr. Barrera, what about your program in Houston?
DR. BARRERA:
Yeah, I think that we're really fortunate to have so many great resources. The Baylor system to be it like 15 or 20 sessions of counseling. Our program, excuse me, is actually very, very good at giving you time off to go to doctor's appointments, things like that with absolutely no questions asked. I know that, you know, if there is an appointment that I had to go to, I would not doubt that I could schedule time in advance to go to it, which I think really helps my mental well-being and helps me feel that I can get help when I need it. They do couples counseling as well, which I think is really helpful. But I think the biggest thing honestly in my program is just the culture of the attendings. They're all very, very friendly, very open. In the pre-pandemic times, they hosted welcome parties, Christmas parties, all that kind of stuff. And now that restrictions are easing a little bit and things are improving a little bit, that's kind of coming back up. And it just makes us feel that we can come and talk to our attendings as not just supervisors, but his future colleagues and people that have been in our shoes before and can guide us through some of these challenging times.
DR. MALINZAK:
That's really great to hear, all of these things that are available because none of that really existed when I was in residency about 10 years ago. Dr. Martinez, you've been at a few different institutions. What sort of support structures have you seen that have been helpful?
DR. MARTINEZ:
Yeah. So thankfully, across both institutions, the resources have been pretty similar. All of them offer, or at least all the ones I've been to, have offered usually some kind of counseling, if not free, usually for a very minimal fee for several sessions. And there's also a lot of digital wellness programs that you can work through online and even just like interpersonally between departments at Baylor Scott and White in Texas, all of my attendings were super helpful if it really came down to it and I needed a day off. They would make it work between everyone to get that day off. And the same thing here at Duke. All of the resources are of a similar status. And thankfully, integrated into the program are some float weeks. So I'm technically back up if someone were to get sick. But at the same time, those float weeks, if no one's sick and I don't need to cover their shifts, I can take care of the things that I need to take care of. So I've been very thankful to have programs all through my training that really allow you to take care of yourself and your family in a positive way.
DR. MALINZAK:
So as physicians, we tend to think of ourselves as resilient and we truly are because we have to be. But we're also exposed to a lot of sad things. We make life and death decisions, and it's very common for us to second guess those decisions. So in the end, do you think burnout is about systems and culture or is it about individuals? Dr. Plunkett.
DR. PLUNKETT:
I think that both can play a part under certain circumstances. You know, I think there's certainly systemic or systemic stressors within our hospital system and just being a resident that can lead an individual to become burned out. But I think there's also, I think there has to be, some ownership of individuals with how some may be more susceptible to being burnt out, whether it's, you know, how they approach mindfulness and deal with challenges. I think that we could all be better about, you know, how we talk to ourselves in our own mind and approach those difficult situations throughout the workday. So for me personally, I think while there are plenty of systemic issues, I don't think that you can completely remove the individual from dealing with or becoming burnt out in today's culture.
DR. MALINZAK:
So if burnout is a systemic problem, what do you all think that institutions should be doing to better promote wellness? Any thoughts on this, Dr. Martinez?
DR. MARTINEZ:
Yeah, it's a tough topic. I would echo Dr. Plunkett's words. I think to some extent there are individual issues. Definitely, on a systematic level, institutions, you know, are not perfect. They probably will never be perfect. But it's tough to navigate this very dynamic field of health care, especially coming from the ICU where everyone is trying to die all the time. It can be extremely challenging navigating all of that all the time. So I don't know that I have a golden ticket to fixing everything. I think it just comes down to looking at everything on a case-by-case basis. You know, like Dr. Plunkett said, there are definitely people with risk factors that predispose them to burnout, especially regardless of specialty, regardless of the institution. But there are definitely, at the same time ,institutions that probably don't do as good of a job supporting those health care workers, whether they be nurses, physicians, whoever it might be. So I think it's it really has to be taken on a case by case basis for everyone to kind of come together.
DR. MALINZAK:
Dr. Barrera, do you have any thoughts on how we can change culture to advance wellness as a priority?
DR. BARRERA:
Yeah, I think there's, I think there's a lot of things you can do, kind of big picture, in terms of ACGME changes. I know we in anesthesia are probably a little bit more fortunate on this front, but, you know, the wording that residents only need like one day off in seven. And so a lot of times that ends up with residents working in a 12 straight days with maybe a Sunday off one week and a Saturday off two weeks later. And, you know, just a 12 day stretch of just, you know, 12, 13 hour ICU shifts or can be very, very taxing. And so maybe some language where you have maybe a little bit more than four days off a month, maybe five or six would be pretty beneficial to some of our colleagues that aren't so fortunate as us.
I don't have kids, but I think having some more robust paternity and maternity leave protection that doesn't extend residency and doesn't, you know, jam all your call into those two or three months that you're kind of making up would be really, really helpful, and that would really increase wellness among new parents. I think in, on an institutional level, there's, there's a lot of stuff that can happen. I know in our hospital it's it's a little bit hard for residents to kind of have spaces to work sometimes. And it's it's been a challenge trying to carve out a space for, you know, internal medicine residents or surgery residents or anesthesia residents to have just a quiet space to sit down and write notes or make phone calls. So having protected resident spaces, having compensation for overtime shifts or overnight shifts, things like that, I think, would really go a long way towards improving wellness overall.
DR. MALINZAK:
Yes, definitely. I think we're starting to see a culture change in terms of recognizing wellness and burnout as issues that you guys have talked about today. And I think we're starting to realize that we need to value living outside of just our professional lives and more into our personal lives as well. So I hope that that culture change will help with this.
So finally, before we wrap up, I'm interested in what resources work for you all. I'd love for each of you to share a resource you found valuable with our listeners. For example, it could be a book, a podcast, a YouTube series, social media account, anything that's helped you better manage your work and personal life that our listeners might find valuable as well.
An example I have found over the last year is using the app Headspace. I really enjoy using some of the meditations and other recordings that they have to help me get off to sleep. And it's really improved my sleep hygiene. Dr. Martinez, do you have any resources you want to share?
DR. MARTINEZ:
Yes. I actually really enjoy going on YouTube and watching saltwater reef aquarium videos. I, for whatever reason, really love seeing them, all the different corals and fish. My hope is to one day have enough money to, um, make one of those, have a little slice of the ocean. But for now, I’m resigned to just watching other people do it. And it’s really relaxing. At the same time, it’s really humbling. Because there’s ton of work, and or money, that goes into making that happen. So seeing it all come together when people have their display tanks up is really refreshing to me. I actually even showed some of the ICU PAs and NPs some of the videos that I watch. And we actually watched it on shift when I had a little down time. They really gravitated to it. And now every time I come they’re like “are we going to watch some fish videos?” It’s pretty cool.
And the other thing I do is kind of watch Roland Martin’s YouTube video channel. He’s a bass fisherman from like the 70s and 80s, won a ton of tournaments. And I really like watching him. He’s a great teacher and obviously a fantastic fisherman. He’ll like, you know, go out on whatever lake in Florida and he’ll just throw his line in and catch like and 8 pound fish and be like, “this is a decent fish,” and he throws it back in. An 8 pound bass would be like a personal best for me. I’d probably take like 50 pictures. And he just throws it back in. So anyway, it’s nice to have that kind of perspective, that expert perspective. He’s just done it all, and everything is not impressive to him, which I think is, maybe mirrors what I hope to be some time in the future as an intensivist slash anesthesiologist. So anyway, I really enjoy watching him. And at some point I’m sure watching enough videos will actually translate to me catching a big fish.
DR. MALINZAK:
Well I will have to check out those aquarium videos as well. I at least hope that someday you’ll be able to build one with your kids. I think they would like that too. Dr. Barrera do you have any resources that have been helpful for you?
DR. BARRERA:
Well I think first of all I need to start watching YouTube a little bit more, all those really interesting channels. I think one of the big things that we struggle with at my household is grocery shopping. And I don’t know how familiar you guys are with Texas but one of the big grocery story chains is called H-E-B. They have a really really good delivery service. You can just go on their app. There store is amazing. You just kind of select all the stuff you want and schedule delivery time and then bang, your groceries are at your doorstep. And it’s so nice to you know have fresh food that tastes good, that you can spend some time cooking together, and that’s relatively healthy without all the stress of driving to the grocery store, fighting for parking. You know all the mask and anti-mask things are going on these days. But that has really helped my personal wellness.
On top of that we also watch, I guess this is a YouTube channel, but it’s a yoga chanel called Alo Yoga. And they have a ton of free yoga videos … everything from like 20 minutes and an hour for all different levels. And it just really helps to relax and to calm down to. I’ve really enjoyed that.
DR. MALINZAK:
That sounds amazing too. I guess I also need to watch more YouTube. And I can second that Instacart and grocery delivery has changed my life in the last year and a half. Dr. Plunkett, I’d like to hear your secrets.
DR. PLUNKETT:
I don’t have anything nearly as profound as my colleagues here. I think, for me personally, doing some reading and studying the stoics and their philosophies and teaching and, without getting too deep, but reflecting on our own mortality and being able to sort of take things in stride I think is helpful for me personally. And understanding that there’s deep meaning in each moment throughout the day and with the interactions that we have. And so I think for me personally that has carried a lot of weight as I’ve faced the challenges of being a resident and a father and a husband and all the struggles that come with that on top of being an anesthesiology resident has been helpful for me.
DR. MALINZAK:
Well I think that was pretty profound too. I want to say I have learned so much from the three of you during this conversation. And I’m so grateful for the time you’ve spent today chatting with me. So thanks to all of you for joining us for Residents in a Room, the podcast for residents by residents. And we look forward to the next month with another conversation.
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VOICE OVER:
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