Please meet my guest who’s approaching life and the practice of medicine with love and respect, Michael D. Fratkin, MD is a builder, an innovator and a dreamer.
We discuss Palliative Care For The 21’st Century and “What Matters”.
Standing on a foundation of inspiration and burnout, Dr. Fratkin began creating ResolutionCare Network to build capacity for capable and compassionate palliative care in the rural Northern California community in which he made his home. He has been a transformative and provocative voice for improving the experience of people and families facing the completion of their lives while ensuring that the meaningful professional experiences of those providing care is of equal importance. Furthermore, ResolutionCare Network is revolutionizing healthcare enterprise development as a Certified B Corp launched with a crowdfunding campaign and using technology to connect people to people wherever they are.
Hanh Brown: [00:00:00] Well, I thank you so much for adjusting your time to make this work.
Michael D. Fratkin: [00:01:59] Sure.
Hanh Brown: [00:02:02] You’re in California right now, right?
Michael D. Fratkin: [00:02:05] That’s right. Northern California, about five, six hours North of the Bay area.
Hanh Brown: [00:02:11] You mentioned that the later chapters of life are human and not medical. Can you elaborate on them?
Michael D. Fratkin: [00:02:17] It is extraordinarily difficult. And these last hundred years snap the fingers compared to the whole history of human living and dying. It’s been harder than ever before to finish your life. Because it’s been very, very valuable.[00:02:36] All the progress we’ve made in terms of reversible disease, fighting infections, some infections, managing childhood illnesses with vaccines and an extraordinary variety of interventions, medically that can make a big difference to people starting or living in the middle of their lives. It’s been. [00:02:58] Extraordinary that way. It has fueled the sort of very American conceded independence. The sort of rugged individualism is well supported by the development of medical technologies that allow individuals to live better and live longer. However, given the inevitability that all good things come to an end, including life. [00:03:22] There’s a portion of life. The last part of life, that is a progress towards death and a movement away from independence and back to what has always done a sort of bedrock, if you will, to something which is interdependence, we must, and we require the support of people that we love, or people with certain skills to tend to our developing increasing needs. [00:03:49] That we’re no longer able to talk to ourselves as we become older and the portion of our life in which we are much older and reducing our functional capacity for independence as if it’s such an incredibly important thing for most of human history. In fact, I’ve done a little bit of research on the inner tubes. [00:04:10] It turns out that there’s been about 109 billion human beings. That have walked crawled and made their way through a life of which 102 billion of them have died somewhere along the line. And I assert that back in the day before the sort of modern medicalized response to changes in human function. That we actually understood quite well, what it meant to care for each other. [00:04:37] In fact, we weren’t surprised the fact that our lives come to an end. It was part of the fabric of our experience as we were growing up and developing. In fact, there probably wasn’t many children who made it out of childhood without experiencing the death of siblings in their household. Uncles grandparents and others or adults living a normal lifestyle of 40 or 50 years. [00:05:04] That was the norm. So people saw death as intimately woven in to the experience of living. As we medicalized dying, medicalized aging, we started compartmentalizing. The way that our society works. So it’s that people, when they have the greatest need for interdependent caregiving, it was not absent because children live all over the country and people move all over the place and then themselves preserve and protect their independence with such passion. [00:05:37] I’m just too busy to drop everything. They’re not evil. But they really are captured and captivated by this idea that they must work harder for their own independence while the people that source their life are no longer able to support that kind of output in life. Our society has had mixed. Capacity to build a social fabric that holds people economically and with the pace of social needs that they have. [00:06:06] But that’s always a tension in our society to provide what’s needed by people who are dependent on others to continue to enjoy a reasonable quality of life or a basic standard of living. So it’s never been harder for people to get old. It’s never been harder for people to die because of the compartmentalization and medicalization of the aging process. [00:06:29] And because of this sort of loss of connection to what we always knew to be true.
Hanh Brown: [00:06:33] You know in the age where there’s technologies that breeds the connection and being social. But you know what the reality is, we’re losing that intimacy, that connection, that loyalty. Among family members.
Michael D. Fratkin: [00:06:49] We built a society on pretty shaky design principles when absolutely everybody loses their ability to maintain independence and absolutely everybody experiences alterations in their function while they move towards their death.[00:07:05] And absolutely everybody does die and we built a fabric of a society that actually doesn’t hold that very important truth to be so. And so of course, people as the Asian people, as they have deteriorating independence struggle because we haven’t built an interdependent society. We built one that’s balanced on the head of a pen. [00:07:28] This independence, obsession that we have in our culture.
Hanh Brown: [00:07:32] I wanted to add to what you were saying is that the interdependency that we lose at the tail end is very unfortunate because you spend 80 plus years of your life building that dependence of your family, the nucleus family, and then launching them into the real world.[00:07:49] But there comes a time where that launched. And that dependency we had to reconnect. Okay. And that reconnection society doesn’t lend itself does not even encourage that. I don’t think. And I think that’s why there is a gap between the younger and the older generation. What do you think.
Michael D. Fratkin: [00:08:06] I agree entirely.[00:08:08] And it’s the reason for our work, what we’ve done. We moved into the places where we see there’s this huge gap, not just for aging individuals, but any individuals that are struggling with serious illnesses that may limit their life. When they’re struggling with medical circumstances, that impact their quality of life and their duration of survival. [00:08:30] This is the place where a palliative care intervention leans in. We can’t change the underlying social fabric beyond you and I having sticky conversations about the sort of underlying misaligned principles, such as independence versus interdependence. But what we can do is look at our world and figure out what skills have talents do I bring? [00:08:54] And what can I put together that might lean right to where the greatest need is. So as a rural living country doctor, up here in a community, that’s a substantially economically disadvantaged and populated by native American groups, Latin American groups. Some other kinds of groups of folks that deal with the disparity and access to all sorts of things based on their rural positioning, as well as other social factors, I needed to do something important and I was inspired. [00:09:28] By working with people that are very old or because people that are very sick and working with my fellow human beings that are grappling with the nature of their mortality. And the good news about that is when you show up with people as the person you are and attend to what it is that they’re facing every day opportunity is to support healing, connection and interdependent functioning. [00:09:54] Just to reveal themselves in a beautiful calculator, to being with people, provide some container for whatever it is. And so that’s what resolution care network was built for was to provide palliative care services with a team, to people in their homes, using some technology tools like video conferencing.
Hanh Brown: [00:10:16] Awesome, now that brings me to the next question. Telemedicine, how has that impact your business? I guess before and after COVID what role did that play positively or reserve any improvements that you see?
Michael D. Fratkin: [00:10:28] Yeah, well, I mean, I launched resolution care network on a crowdfunding campaign in 2014. It was built on the concept that golly, gosh, maybe this smartphone in my pocket has some functional value care of people who are going through hard things.[00:10:45] So we’ve been doing telemedicine for six years or so. And in doing so we’ve gotten quite good at it. We’ve discovered lots of the unique qualities that make it actually better than real life. Is this for the practice of palliative medicine. As we approached the coronavirus pandemic, we were taking care of about 40% of our people using video conferencing as the tool on March 19th. [00:11:10] When the shelter in place order occurred in California, we went from 40% to 100% video conferencing overnight. We went from all of our staff working in the office. To 100% of our staff working from their homes. And we realized some very, very interesting things. Number one, the people we care for really didn’t notice, they were essentially attuned to the use of this as a part of their care structure. [00:11:39] They missed our staff coming out and sitting on their couch and eating their cookies, but they didn’t miss all the anxiety that came with those kinds of home invasions. Right. People have some feelings about somebody coming into the home and some authority, a nurse, a doctor, a social worker, the chap, they didn’t miss that anxiety. [00:11:57] They didn’t miss the ease or the difficulty of scheduling an appointment and traffic making it late or other, such things. They didn’t miss. Not having to go to the office or to see a person in the clinic didn’t miss any of that. In fact, they just adapted quite easily and with great satisfaction, improved satisfaction, and all their needs were getting met by our doctor or nurse or social worker, a chaplain or community health worker and our care coordinator. [00:12:22] It was just happening via video conferencing or telephone. So they did great the organization. The operation wearing my CEO have experienced about a 30 to 40% increase in efficiency. Because people weren’t driving all over the place to go see people in their homes. There’s some other interesting dynamics about doing this, but we saw all this efficiency and for our staff, while at the one hand, it provided them the room to cope with the stresses and strains and changes and children at home and homeschooling and all of the burden that all of us have had to kind of navigate through the COVID-19 pandemic. [00:13:01] It gave them much more room to deal with that and adapt. But they also found themselves missing the, putting the arm on the shoulder, the handling of the Kleenex over these last six months, now that we have about 95% or more of our work happening by video conference and the rest by telephone, they’ve actually dropped into understanding and starting to explore, how does they get their needs? [00:13:27] Met the caregivers. How did they feel good about the work that they’re doing when they can’t get that warm body to body contact? They’re exploring more and different forms of intimacy that can come through only this kind of mechanism. And our organization has thrived.
Hanh Brown: [00:13:47] Did you see a difference in recognizing or reading the loved ones disposition without being physically there?[00:13:56] I think what you’re saying is, has been mostly one-on-one. So how were you able to get past not knowing the entire disposition and how do you go about prescribing, how to treat them?
Michael D. Fratkin: [00:14:08] What’s actually really interesting and I’m not trying to be cute. But it actually works better than real life when you take a person.[00:14:16] And usually their daughter goes to take a half a day off of work to drive them. And in a rural environment, sometimes an hour to get to a client, that person let’s say it’s a mom or a grandma who has to get ready. In her home, that means getting dressed. That means getting showered. That means all of the things that, that individual values or finds to be necessary to go out your mouth. [00:14:42] And in the older population that’s substantial. So it may be a couple of hours of preparation and maybe a half a day off of work for a daughter or some other caregiver to drive them through traffic. If it’s an urban setting or over miles to get to a hospital. Parking lot. And then to get the Walker or wheelchair out of the trunk of the car and get grandma out of the car, into the wheelchair and then roll them into the clinic where they shoved that clipboard again. [00:15:10] And your face. This may be your third visit to the hospital clinic, lab x-ray department in a month. The sit in the waiting room where it’s always been unpleasant. When the person next to you, coughs or sneezes.
Hanh Brown: [00:15:22] Especially now.
Michael D. Fratkin: [00:15:23] especially now, it’s always been unpleasant to be forced to read popular mechanics or a 10 year old people magazine or to listen to God-forbid Fox news on the TV that’s blasting.[00:15:36] And to look around in that clinic, waiting room at the other people, and wonder how sick are they? Or they look terrible. Do I look that terrible? And then 20 minutes after your appointment, time to be hustled back into an exam room that doesn’t have any windows, but it has some diagram of the sinuses sliced in half on the wall. [00:15:56] And you’re sitting there waiting for the doctor for another 10 minutes. And when the doctor finally comes in. You may see the doctor like this with their back turn to you while they’re typing away, managing their own agenda of, Oh my God, they’d better get their documentation done. They better check all the boxes that under the checklist and Oh, by the way, there happens to be a person in the room. [00:16:17] And then when that’s done. And the doctor stands up to put her hand on the door knob. That’s when you remember the one thing that you absolutely needed to ask, or maybe just after the doctor leaves the room and then you reverse the whole thing and you go home and you’re exhausted and you don’t even know if you got your needs met.
Hanh Brown: [00:16:35] Right? Right. No, I hear you. I hear you.
Michael D. Fratkin: [00:16:39] With video conferencing for grandma and her daughter. As I send them a link, we train them how to use it. They click on the link and the daughter might just step into a conference room where she works for 30 minutes and the grandma might be at home or the daughter by go home and bring lunch to her mom.[00:16:58] But either way they click on a link. They’re sitting in their own environment. There hasn’t been all of that crazy activity. And they’re relaxed. In fact, one of the things I tell the people be careful, as I said, we don’t take care of any patients. We only take care of people. They can show up as the person they are in their natural habitat. [00:17:18] And quite honestly, I’ve made this a very comfortable place to work from. This is my home office. I’m the same way. I’m relaxed. I show up as the person I am in a set of skills and experience and valuable knowledge to share. But I’m comfortable. I’m not stuffed into a white coat. The stethoscope choking me in a clinic where everybody’s yelling at me and the phones are ringing that pressure a much more relaxed, right?
Hanh Brown: [00:17:42] Yeah. You’re more available and you’re relaxed in your own environment. And so are the loved ones. So it puts everyone at ease.
Michael D. Fratkin: [00:17:49] And the proof is in the pudding, the way that they respond, both in the encounter and the way that they report, how they feel about this work is substantially better than real life.[00:18:01] From that point of view, a person to a person on a level playing field, without all that drama and industrial structure around them, it’s actually more intimate. Even though I can’t reach over and put my arm around you and give you a hug as much as I’d like to.
Hanh Brown: [00:18:16] So explain to me like the process entail. I mean, I know what it is, but how does one initiate palliative care and how do they reach out to you?[00:18:24] And then what are the steps involved? And I don’t think this replaces their current doctors, it’s just, you’re utilizing those treatments or services from their current doctor. To prescribe to, I guess the now and the later part of life. Can you describe the whole process?
Michael D. Fratkin: [00:18:41] Oh, sure, sure, sure. Yeah, no.[00:18:43] Palliative care is an extra layer of support that happens at the same time as the care you get from your primary care provider or the same time you get your care from your gerontologist or geriatrician or the same time you get care from your cardiologist or your oncologist. We. Are extra layers or that focuses on you as a person, rather than a person with an illness or disease or an optimal medical management strategy. [00:19:11] We look at people as the person that they’re living a human and medical experience, and we sort of balance out. And empower and inform people to make their own decisions about and understand their own choices about what they do or they don’t want to receive, or how they want to interact with the rest of the care. [00:19:31] We do a lot of coordination, transportation, making sure people have food, making sure people are seen and heard and we’re responding to their isolation. So the way that it works in the best situation is that they’re informed. Um, uh, 21st century physician recognized it, that in addition to all the medical stuff in the field, it’s a very serious illness. [00:19:51] There are other things that emerge expertise around symptom control is very valuable and primary care doctors and cardiologists don’t have the kind of dedicated expertise in symptom management. That we do understanding what’s going on in a complex medical environment, in the best of circumstances and inspired primary care specialist, physician will recognize people need more support than these quick 15 minute industrial kinds of visits to navigate the human experience. [00:20:21] They focus on what’s the matter with you. And we focused on what matters to you and that blend can deliver people to more empowerment and greater quality of life. And actually in many circumstances, a longer survival with a better quality of life. So in the best circumstances, we get the doctors to understand when to send people to us and we add our care there’s at the right time. [00:20:45] Now that happens. Unfortunately, very rarely doctors are immersed. In the medical model of care. So the idea of what matters to a person is kind of a big leap from what’s the matter it’s a kind of insecure and kind of scary leaper, intimidating leap to enter the world of how a human experiences their life, rather than focusing their attention on the best possible treatment for stage three B breast cancer. [00:21:15] With these molecular markers and this particular list of possible choices, all the toxicities and what they have to monitor and how often they get your pet scan. And they’ve got a lot on their mind. Right?
Hanh Brown: [00:21:26] That is so true. What you just said, because when you are in that mode of getting treatment and you have an illness, you think of yourself as less.[00:21:35] You starting to think that you are less you’re ill, there’s something wrong with you. And then some, and then you have all the so-called physicians, professionals of different disciplines, poking and poking and testing and waiting for test results. I mean, you hold this position. You hold me just feels something wrong with me. [00:21:54] So that’s very unfortunate. And I think what you described, where you come in and say, what matters to me at this point and forward, how do I want to live out the later part of my life? I think that’s important. You turn it around into something that I still matter, even though I’m ill with this, but I still matter. [00:22:10] So that’s your focus.
Michael D. Fratkin: [00:22:12] that’s for sure. I mean, I don’t think there’s anything intrinsically wrong with anybody who lives alive and then finish this alive. How long life ought to be. I don’t know, I’m not qualified to assess that, but I don’t think there’s anything wrong with the idea that as people age, or even move through life, that sometimes things happen to them that sometimes diseases find them or emerge from their physical domain.[00:22:41] But that doesn’t tell me that psychologically, emotionally, relationally, spiritually there’s anything fundamentally wrong with them. In fact, that’s my assumption is that there isn’t. And when I remind people that that’s the case, they sometimes follow me along to realize that they’re actually okay. Even though they’ve got cancer, they’ve go hard to see as they.
Hanh Brown: [00:23:04] I see that it’s so important that when you say, even though it’s a big deal, even though cancer.[00:23:11] Even though dementia or so forth. It’s unfortunate that we, human beings were consumed with that even though, because even though illnesses is what’s going to end our lives. But what I appreciate what you’re doing is that you’re turning that even though until that, you know what, it’s not only what’s matter with me, is that okay? [00:23:30] I matter, I am going to finish life strong despite of the Evansville. So I think that’s wonderful because they’re leaving with dignity. Not leaving with defeat, right. Even though it’s going to make them feel very defeated. But they’re not, they’re leaving a legacy behind. So I think that’s wonderful.
Michael D. Fratkin: [00:23:49] People have a choice. They can say, I am, what’s wrong with me or I can say I have what’s wrong. That’s true.
Hanh Brown: [00:23:56] Exactly. I am. Or I hear.
Michael D. Fratkin: [00:23:59] right. I have what’s wrong with me. It’s a reality. These medicines need to be taken because they’d have a benefit. But I, inside of all that, and not just the physical body, there’s more to me than.[00:24:12] What my body tissues or even brain function does, there’s more to me than that. There’s everything I’ve learned and everything I’ve seen, everything I’ve dreamed of and all my disappointments and pain, there’s all my trauma. There’s all my joys and trials. All of us.
Hanh Brown: [00:24:28] wisdom and wounds that you are now due to your wisdom and your wounds along the way.
Michael D. Fratkin: [00:24:34] Exactly. Exactly. And boy, do people enjoy being seen for the person that they are. And the life that they’ve lived, even when it’s tragic and messy and horrible, they appreciate being seen as they always experienced themselves as a complicated human being. They enjoy that and it’s an invitation for them to seek healing.[00:24:59] Or to invite the healing that sort of somehow just naturally comes. As people get stripped away from their life, from their physical being and that all that independents, they realize how important and how lacking the interdependence and connection that they have with the people around them.
Hanh Brown: [00:25:18] And the more dependent they are in their spirit, even though they are.[00:25:24] Independent at a place in life, but now as they are in their, let’s say the later part, they come to realization how much more the need of the pendant to your spirit and the afterlife.
Michael D. Fratkin: [00:25:36] This is the joy of bringing acceptable interdependence. So people who have diminishing abilities to sort of live in the illusion that they were ever really independent in the first place, we lean in to see them in the way that they see themselves.[00:25:54] And then we support them to define, well, what’s most important to them right now. What does matter? Usually people said it matters that. Any suffering or symptoms are prevented, avoided or relieved. That’s pretty common. People said that it matters that the people that love them and care for them have all the support that’s available around them. [00:26:13] As well. Most people said they want to finish their life in their homes. A few people say I’ve got some loose ends and unfinished business. Some people say they might climb Mount Kilimanjaro. [00:26:26] Sometimes people want to just have the autonomy to say that I am finished. I don’t want to be churned through a medical system. That’s always throwing more duct tape and bubblegum and baling wire around my physical being. I’ve lived my life and I want to be provided with a container or a nest. In which to finish my life. [00:26:46] And some people want to go the full Monty. They want the whole enchilada of the emergency room, the ICU, the intubations, the surgeries, the procedures, until that some people won’t. I have no investment that they choose a ton of medical interventions or care or none at all. I just want them to be seen as the person that they see themselves. [00:27:07] And we support them and navigating and figuring out what are their preferences? What do they want, where would they draw the line without any investment that we somehow know better for them? Because they’re the only expert there is in the life that they live.
Hanh Brown: [00:27:22] Absolutely. So I know palliative is not hospice, but can you just go through and identify the distinction in case folks may not know.
Michael D. Fratkin: [00:27:31] Oh, yeah, no, that’s a very important question. Palliative care is a sort of the general category of Madison, a specialty of medicine that focuses on quality of life using a team in order to support people and their families. As they navigate searing silvers, it can be valuable in any stage of illness, but it’s quite valuable towards the end of life.[00:27:53] Hospice is a special category of palliative care. That really specializes in the very last part of life in the last few weeks or months of life. There’s some very unique circumstances and needs that emerge for people in their families, where the balance of how much medical intervention might be valuable to me and how much attention should be placed on my quality of life of living. [00:28:16] The bounce shifts to where the question of independence is sort of finished that the goals shift from any increased duration of survival to really focusing on the here and now, right? It doesn’t happen overnight. Despite there being a day where you are not in hospice and that a day that you are. It’s a kind of a transitional slope of hospice focuses on the, and it’s structured around a Medicare hospice benefit. [00:28:44] That’s very rigidly defined now, just upstream after, just before you decided you really don’t want to go to the hospital. I don’t wish to do the routine screening stuff. You don’t want to take the preventive medications and you want to stay out of that environment just before that. You may see great value and go into your cardiologist and adjusting medicines. [00:29:05] Cause it might make the swelling in your legs much better so that you can walk her out a little bit more. You might be interested if you get an infection or a cough or a fever, you might be interested in that chest x-ray and some antibiotics to turn that around so that you can restore at least most of what you have before you got it. [00:29:22] You might wish to take a radiation intervention to help the pain from your cancer. Or even a cancer chemotherapy drugs to suppress or push back against the cancer so that you can maintain as much normal function as possible for quite some time. While you’re still moving towards the moment when hospice becomes the best service for you. [00:29:46] That’s upstream area of care, palliative care that provides support and balance and coordination so that people can have. All of it. They can have the medical interventions that they feel are valuable as well as a lot of attention to the nature of who they are and what they’re going through during that period of time, there’s all kinds of relational and family healing that can emerge. [00:30:10] There’s all kinds of empowerment that can go on. People can define the preferences that they have and the lines that they would draw and they can support. Quality of life, of even duration or living when we’re added.
Hanh Brown: [00:30:24] I see that also an opportunity to celebrate honor and healing. Like you say, there’s a lot that’s going to happen during that window of time.[00:30:33] You can continue to celebrate and. It could be moments where you are celebrating and crying and resentment and healing. I mean, it’s just, yeah.
Michael D. Fratkin: [00:30:44] Life is lived so much for the first time in an intentional, reserved away. Most people live their life. They don’t really think about the life that they’re living.[00:30:53] They’re just limited.
Hanh Brown: [00:30:54] Just like you said, we’re independent focus, we’re task oriented and we’re focused in our moment lives and the busy-ness and really not the quality or even the length, not until we get into like senior living.
Michael D. Fratkin: [00:31:07] When an illness or a collection of illnesses, lights, a pretty hot fire under your butt.[00:31:15]It turns out all those other things really start. To be important. And the beauty of pigs really actually starts to emerge paradoxically when the stress comes out, at least with a little support, sometimes the worst in people comes out as well, without support. We try and help them own their own experience and make their way through.
Hanh Brown: [00:31:38] Absolutely. I love it. I mean, I really appreciate this conversation on a personal level. It makes me think about relationally. And even for my own family, we have our struggles right now with my mom and dementia, my sister with breast cancer and stage four.
Michael D. Fratkin: [00:31:56] All these really, really difficult things. I mean, really difficult things.[00:31:59] And you want your mom to have the best caregiver. You want her to have the best sort of response at medical, and then you want your sister to have the very best available breast cancer treatment. Wouldn’t it be great if you also have, for both of those situations, the comments of support that saw you as a caregiver for what you’re experiencing, as well as them for what matters so that, so that they were empowered to drive their own process going forward. [00:32:29] And it’d be great if their quality of life was front and center to at least some portion of the health care delivery.
Hanh Brown: [00:32:36] Absolutely. It really is. Do you have any other topics that you would like to share.
Michael D. Fratkin: [00:32:42] Like to invite anybody who’s interested in visiting our firstname.lastname@example.org? There’s a lot of really interesting material, constantly reworking and redesigning it.[00:32:55] If you would consider, please signing up for our newsletter. It’s as simple as a little pop-up thing on the website, we only send the highest quality high value. Materials, a lot of storytelling and sometimes podcasts or other sorts of outlet, but sometimes some pretty glorious stories written by our staff members about the people we’re caring for. [00:33:19] And sometimes stories written by the people who we actually are caring for. So yeah, I want to build. Like a community of people that support us while we’re supporting other people. And then if anybody happens to have a million dollars or 10 lying around and they want to invest or donate, we’d be happy to entertain.
Hanh Brown: [00:33:41] Yeah. No. Repeat your website again.
Michael D. Fratkin: [00:33:44] Www dot resolution care about com. The email is email@example.com. If anybody has a personal communication, they’d like to send to me, my personal email isMichael@resolutioncare.com and we’re honored to connect and share whatever value we can was, uh, your audience as well as that can become part of our community too.
Hanh Brown: [00:34:10] Absolutely. Well, thank you.
Michael D. Fratkin: [00:34:12] My pleasure.
ResolutionCare Network: https://www.resolutioncare.com/