Radical Recovery: The Path to Sustainable Careers in Healthcare

Episode Introduction and Recovery Theme 0:00

Welcome to a special Heartline Echoes episode where we revisit some of the most impactful conversations from Heartline changemaking in healthcare. This rerun isn't just a replay. It's an opportunity to reflect, reconnect, and reignite the ideas that continue to shape the future of healthcare. Whether you're hearing this for the first time or returning for some fresh insights, let's dive back into this powerful discussion. Enjoy. Welcome to Heartline, conversations with healthcare changemakers following their heartline.

I'm your host, Dr. Andrea Austin. I'm an emergency medicine physician, coach, and educator. I believe that healthcare needs to improve the quality care that patients receive and that supporting the workers is at the heart of this transformation. All right. Well, welcome to the revitalizing doctor podcast. And today is a very special episode because this is part of a mashup. So part one was over on the emergency mind. So my colleague and friend, Dan Dorcas's podcast. And the theme of this mashup is recovery.

So please, if you're listening now, I would go ahead and pause and hop over to Dan's podcast, The Emergency Mind, and listen to the segments on micro recovery. And then you're going to hop over to my wonderful friend and colleague, Dr. Cheryl Martin's podcast, The Mindful Medic. And on that episode, we talk about meso recoveries, this idea of how do you recover after a shift, the post shift, and even the couple of days in between the next shift. And on this episode, we are going to talk about longer-term recoveries or macro recoveries.

Defining Macro Recovery and Personal Burnout 2:00

And to set this up, the reason I was interested in talking about this topic, especially with these two brilliant minds, is I've done what I would consider a macro recovery. And I'm still working on what exactly that definition is, but at least for this episode, I'm going to call a macro recovery anything from what would not be a standard break in your schedule in between shifts. So maybe let's look at a scheduled vacation. So maybe five or more days off in a row, all the way up to a longer break that we would define as maybe a sabbatical.

Well, maybe you're fortunate enough to be able to take a year off or maybe you decide to go into a fellowship or something completely different than what your normal day-to-day work involves. And the reason I was interested in this topic is I've shared on this podcast, another podcast, that 2021 was a really transformative year for me. And I had hit a wall that I had never hit as hard and as long as I did in 2021. And I quite frankly questioned whether emergency medicine was a sustainable field for me.

And I felt pretty confident at that point that in order to answer that question, I needed to take an extended period of time off. So what that looked like for me is I stopped working clinical shifts for about three months and I normalized my sleep. All of my work that I did was Monday through Friday with weekends off over the summertime, which is a wonderful time in general, including in Southern California. And I noticed during that time that my creativity and clarity, those are the two words I would really attach to that period of time, came back to me.

And I ultimately did come back to emergency medicine, but I came back incredibly different as a person and then what my work life looked like following that as well. But I don't want to keep having this soliloquy. I want to open this up to I'm gonna start with Cheryl actually first because I think Cheryl has had periods of her career that she's taking longer breaks that I'm describing Yeah, so I now have more of a recognition of the space that you were in, had. And it's interesting how we've connected.

And I suspect part of that bond is because I was probably in a very similar space, you know, four or five years previously. And that's, you know, it would have been about the same time in our careers. And, you know, I've spoken about this before, so I'm not going to go into great detail, but I did step away from emergency medicine for a period. I was doing a little bit of locuming. I limped towards the end of my specialist training. It wasn't quite the great pinnacle of the antique of the mountain that I had hoped for at that point.

I did a lot of other things. I reclaimed I suppose a bit of my life outside medicine, my sport, I looked at other opportunities within medicine and sports medicine. I became a yoga teacher, one of my bucket list things to do. So I also would say that it took me quite a bit of time, so more time than I expected to recover. through that period. And there was a point, and I'll be honest, where I remember having a conversation saying, I don't know if I want to go back there for a career that I have spent 15 years dedicating my life to and that I actually love.

I couldn't actually see myself back in the fire. And that's the way it felt to me at that point. I feel very differently. We're now quite a few years on from that. And I started by dipping my toe in, and now here I am, you know, in a different place, but doing this job with many of the things that we touched on in the last episode, with boundaries, with niche, with, you know, attention to what my periodization looked like within and outside work. And I think, again, anybody who's listened to my podcast knows that this is probably a professional mission for me now.

Again, I'm going to put out the burnout term there. You know, I had burnout. I had burnout. And I see many colleagues now seeing, you know, and I think I called it a bit of burnout, and I've had a few colleagues say it a bit better. You are deep down the well, can I just say, if you are emergency physician, saying you have a bit of burnout.

Cherylu2019s Career Break and Return to Medicine 7:00

You know, it's Dr. G styles. And look to your right, look to your left, and colleagues are, one of them is going to know. And I've had a lot of people come up to me now and say, ah, I know where you were. I realize this. And the concern about this is the risks with that are that we are going to have colleagues leaving the profession or reducing their hours in the next 12 months. And we've got some good data to support that is the case. And so I think we have to get smarter. And maybe this is, I don't think it's, I'm unique in the opinion that I actually think full time clinical emergency medicine isn't a sustainable career long term.

So there you go. I'll put that out there and I might sit with that and see how that lands for you. I see Dan's. Yeah, that's got you thinking what is coming up for you when I see that. Yeah, I think my vision of myself has changed quite a bit over the last several years. And inherent in that is this question of sort of like, what is my purpose? What is my goal? What is my calling? What is my, and I'm going to mispronounce this word, but ekigai, ekiyagi, one of those, right? Which is like the overlap of these four circles of what are you good at?

What does the world need? What do you get paid for and what do you love doing? And to me, that sort of compass is like pointing towards that Venn diagram in the middle, that icky guy, about being like, what is it that I'm supposed to be doing? I think that when I was just coming out of residency, my vision of that was that that was a full-time emergency physician period and that anything other than that was somehow like maybe a failure or if not a failure that maybe it was just not living up to my potential.

And I think I've come to change my stance on that quite a bit, both as I've done a bunch more internal work and also as I've had a chance to interface with a wide variety of really elite teams, the Emergency Mind Project and my work with the Mission Critical Team Institute. And when you look at these other elite teams and what they're doing, very rarely are people only doing one thing like that full-time, full-bore, full-time-on. Most professional sports teams have on-seasons and off-seasons. most groups in a lot of the different communities will cycle in or cycle off of a particular assignment.

Andrea, I know you and I have talked a bit about what it's like being deployed versus coming back and the differences and how that strikes you. And what we see a lot of is that very few groups set out with the attitude that you should burn at full speed for full time forever until you're just done. that's sort of the model that we've sort of inherited in the medical universe and in emergency medicine. I don't think that really is the best way to do it. At least it's not the best way to do it for me.

And as I've come to that conclusion, you sort of go back and you take a stance and you're like, all right, well, if that's not it, then maybe I need to reevaluate this thought that anything other than that is failure. Okay, fine. If I reevaluate that thought, well, what do I really want to do? What are the parts that I love? What feels like I'm serving the universe? And what feels like I'm learning to master myself? And what does that look like? And the space in there has become a lot bigger than I thought it was when I was just starting out.

Now I haven't taken a sabbatical or shifted massively like that, but I have pretty much every year since I've been at a residency altered the percentage of time that I'm full-time or part-time, altered my total FTE and changed the way that I've done my work. Most notably more recently as I've come to transition to do more and more of my time and energy in this space of elite level of human performance, which is less in the direct clinical service realm and more in sort of the broader realm of human performance.

And I think that probably if I had to guess what the next many years are going to look like, that that compass is going to continue to need some retuning as I learn more about myself and more about my place in the universe. And I hope that I can continue to see that less as a failure and more as a sign of strength and following whatever guidance I can follow. Yeah, circling back to what Cheryl said, that she doesn't think that anyone can or should do emergency medicine full-time. I recently have thought about that a lot, and I had a great interview with actor Shannon McNamara, which that episode will have come out before this one.

And we really chew on that, you know, I'm talking specifically about emergency medicine because that's what I know best, but I do think it links to other specialties that this phase of medicine has never happened before. And I can tell you, and I'm sure you guys can have similar feelings, that the way medicine, specifically emergency medicine is practiced now, by the way, the presidency is different. The pace, the expectation for door to dock times and then the other metrics, the crowding, the system failing.

I mean, I will at least speak for the systems that I work in. They have not bounced back from COVID. Primary care clinics are at reduced capacity still. Many clinics closed and many clinics have pivoted to all telemedicine or still doing a lot of their business via telemedicine which has resulted in more patients coming to our emergency department. Staffing shortages have gone up. I mean, the list goes on and on and on.

Dan on Purpose, Career Shifts, and Elite Performance 13:00

The point is things are actually harder and our shifts are different than they were even a decade ago. So what Shannon and I got to is we also got to the same conclusion. to practice medicine the way that we think is right, to show up with, you know, to pull a line from Brene Brown with a soft heart and strong back. I personally cannot do a full Cadre of shifts, which for most of us working eight hour shifts in America, we would define that as maybe 14 or 16 shifts per month. I know that is not possible for me anymore.

And that something falls off the bus when I try to push myself that hard and man, a lot of guilt around that for me. So taking the break allowed me to get back to what I consider homeostasis of how much sleep do I actually need. When I work on a project, I can now tell if I'm working reading and writing at a level that is my optimal. I now know, like I've actually gone through a couple of weeks that have been too busy. For me, and I've found my concentration and my clarity decreasing, which is a warning signal that I need to make some tweaks.

I need to turn down some responsibilities or I'm going to end up where I did in 2021. I'm writing down too many things here that I want to, yeah, there's a lot in there. I'm thinking about that period of your thirties, your forties, your fifties when you've got all these other things like work happening as well. And it is that kind of critical tipping point. And I think, you know, You're listening to your colleague, Dr. Naomi Lawrence, and my colleague in the UK, sorry, in Australia, who set up creative careers in medicine.

You know, on that platform, I will see doctors every day trying to pivot and out of what they're doing, reduce hours. I had a really interesting conversation on that because I do think this job is different today in terms of the demands. But I'm also conscious that we have all put a lot of time in the bank in terms of building up our expertise. This is going to end up being three questions, but I think that some of my younger generation of colleagues, some of my colleagues are actually, they get me hope because they are good at setting boundaries, maybe a bit better than I was.

They're thinking creatively about what they want their careers to look like. But I think the other thing I have been criticized is if I'm working less than full time in this job, you know, am I able to maintain my skills is a question. But I had a colleague say to me, well, you know, I feel like I've done all of this expertise and building up and that I have something to draw on doing less now. And I don't know, but maybe if we like Dan is giving us a pathway to actually just maybe train smarter.

So maybe we can do that with limits and still make this sustainable. So I don't know. That was a lot of thoughts I've just given at you, and I'm going to get you to pick up what you would choose there. So to clarify, is the question about when we go down in the number of shifts or take a break, How are we assuring that we still have expertise, that we're still confident? So I, Dan has mentioned the guilt there, but I've also, I mean, I think personally, I have questioned my own, and again, I've spoken about this on the podcast, I have to get more deliberate, I think, in maintaining my skills if I'm there less often on the clinical floor.

And, you know, to COVID, I think we have seen that through changes. I do feel that a lot of your job as you become a specialist does become directing traffic, and then you're occasionally pulled in. to do those leadership roles and i know my technical skills are depreciating and i think that is the natural history of our jobs and careers as we go you know from. the kind of young gun to the wise mentor and, you know, that compassionate leader and develop those other skills and definitely clinical professional judgment, all of those other non-technical skills are improving.

But I wonder if we are, I mean, if we are harsher on ourselves in that regard. And also if we're going to have less errors in generations coming forward, you know, what that might look like in terms of the skills that we draw on. Dan, what's your thoughts and reaction to that? I think there's some really good questions in there. I don't think that 15 is a magic number. Unless you work 15 shifts, you're not really capable anymore. That's probably not true. Human beings probably aren't designed where 15 a month is a magic number that they have to hit.

There's probably some number where afterwards, if you work less than a certain amount, then you probably need to do other things to keep your skillset sharp, which you probably need to do anyway in a lot of ways. We have other models of this that we're able to draw from. So often in emergency medicine, we sort of pretend like we're inventing the entire universe around us when actually lots of other smart people have thought about similar things. So how do other groups do it? If you look at elite sport, they have an off-season protocol, and then a spring trading protocol, and then an on-season protocol.

You could imagine a universe where you're like, okay, you're going to take a sabbatical, phenomenal. Here's your re-entry package, which looks like this amount of training, this amount of sim, this amount of whatever, this amount of reintroduction, and now you're back up to speed. Phenomenal, let's do it. There's no reason that if we want to have a more syncopated style like that, we can't figure out a way to do it.

Why Emergency Medicine Feels Harder Now 19:00

A lot of the folks, You know, we, Andrea, you and I were recently at the high performance resuscitations team conference in Chicago. And one of the questions that came up there from some of the groups with more military backgrounds was why don't you all do that? Why don't you all have a cycle on cycle off system that allows you to sort of like. You know take advantage of the natural periodicity of existence to like set yourself up for better success and. I think the answer why is probably historical a lot of reasons like it's just not how we've done it and so therefore we don't do it that way.

I also think we run the risk of pretending like we're the only ones thinking about these ideas and that probably to our detriment. And I think you've shown that through your podcast. I think the other thing that we were talking about earlier is, you know, we've never had a surplus of staff to really afford us the luxury to do many of these things. And now we are at a situation where we have even less opportunity to do that because we are, staff rosters are, you know, they have been decimated. And I'm also conscious when we're training, there's a lot of work and service provision that needs to be done.

And with decreasing staff and less supervision and less actual opportunities. And we were talking about this. I mean, we love this idea of peak performance, but sometimes, some days, you know, we're aiming for mediocre performance and that is good. That is a win. Yeah, absolutely. I want to maybe pivot a little bit and provide a framework or at least some questions for the audience to chew on as well. There's no clear roadmap on how many weeks of vacation you need, when you should have a sabbatical in your career.

I am aware of one very large medical group that staffs emergency departments that has a built-in sabbatical at the 10-year mark that they offer their partners can take a year off. And I think he don't quote me on this, maybe 80% of their salary. And they built that in that around 10-year mark, they have a sabbatical program. What are some maybe use that it's time to consider a longer break and do we have any thoughts or can we draw from other fields that we're aware of on when that's. that may need to happen.

Is the 10-year mark a good one or is it just completely variable? But if it is variable, how would you know as an individual? This is beyond a vacation to Hawaii for a week. This needs maybe six months, maybe a year. I think a lot of us, when we go through a period of burnout or struggling in some way, it's like, okay, I'm going to book a vacation to Hawaii. I'm going to max out spa days and that'll be it. That'll be the fix I need. Or I'm going to go to this wellbeing conference and it's going to be amazing.

And when I come back, it'll be fine. How do you know that that's not actually what you need and that it is this longer break? I can only speak from my own experience here and I think initially I thought that I just needed time out and do nothing and there probably was a brief period of that. But I was very quickly redirecting and I think I just needed to shift focus and change how and I think it's going back to reality with your priorities, your values, your why. I think Dan had said that. And I think I'd lost touch with that.

I don't know if I ever really was in touch with that. You've said before that I did that work around, I suppose, personal work. It's our colleague Cherie Johnson's book. I mean, if you read, there's a lot in her book, The Thriving Doctor, but a lot of those practices, a lot of those contemplations, that was a couple of years work for me. I hadn't previously done it. And I think that, And with retrospect, I wish I'd done that sooner. Maybe I still would. I might still have been where I ended up. I still could have been in the same place.

And I think the other thing to say is I might be there again. I don't know. But I think the other thing is I'm not scared of that man and I think we spoke about that because I feel I have some tools and I also feel I can give myself permission to change and to pivot and to be okay with that and maybe not to judge myself so harshly but also knowing that I think my colleagues are incredible.

Skills, Staffing, and Sustainable Clinical Work 24:00

They're our most valuable asset in healthcare, but they're also creative and smart and brilliant. And I would encourage them to go and do whatever they would like and they can be good and brilliant at. And I'm seeing that a lot, but I would rather, my idea is that We, you stay in medicine and you know, we keep doing the best work we can and use your skills for our patients. You know, it's that time you spend 20% of your time doing that thing that gives you that meaning and purpose. And then maybe you can, you know, with cause, cause no job is perfect and it's going to be hard some days and there's going to be some things you're, it's really going to suck.

And that's okay, but is there enough of that other thing? And how can we actually think moving forward, get creative in how we create careers for people that are sustainable? And I think sabbaticals are one way to do that, encouraging niche. And it doesn't have to be medicine. Maybe that thing for you is podcasting. Maybe it is teaching yoga. And I actually see a complete shift. I see a culture shift. I see that happening now. So maybe we are going to come to a spot where this is sustainable when it's going to look different in the next 10 or 20 years.

And as I say, I'm encouraged by the generation coming, not immediately before me, not immediately after, but the ones coming now, because I do think they think differently about this. So to pull Dan in, I know you haven't taken a sabbatical, but you have had periods of your career that you were pulling in a term from our friend Naomi, turned down or up your shifts, kind of this nabology of your career. So what was the cues for you that I need to turn down my clinical shifts? I'm going to take a slightly different approach to that, which is that one of the things that I found that's incredibly helpful in making some of those longer, broader decisions is being aware of the biases I'm taking into that decision.

And some of those biases are historical, right? The good doctor is the doctor that does X, because that's what I've seen before me. Okay, well, that's true. I've seen other people do that, and I have mentors that have done X, Y, or Z, but that doesn't mean those are the only ways, and that doesn't mean those are the right way. And I think that becoming aware of when I was making a decision because it was a decision that I was making for myself and my universe versus a decision I was making because I was trying to satisfy externalities that didn't really matter to me as much as I thought they did is really important.

And one of the things that's been so crucial for that is having a close group of people to really explore freely these ideas with. Right. And most of these people for me that serve this role are not in medicine, but they've known me for a long time. Some of them are in medicine, obviously, Andrea, but a lot of the folks that, that serve this sort of, you know, this, this personal think tank for me, aren't, and they're folks that. have known me for a long time and that I'm able to be honest about what I'm feeling, be honest about what I'm thinking, and ask for unmitigated advice.

And sometimes that advice is, you know, Dan, you're being an idiot. You're pretending that this is the only way to do something, but it's not. I don't know why you're doing that, but you're doing. That to me has been an incredibly helpful tool in really challenging what I'm thinking and the mental models I'm using to operate under. It's not always the easiest thing to do within the context of your exact space that you're working. And I don't think that's any reflection on where I work. I just would imagine that anytime you're having these bigger thoughts to do it within the context of a group where you're also serving in that group is somewhat challenging.

It has some externalities to it and some other things that you have to satisfy. But to have a separate group where you're able to really explore these other options, what would it actually look like if I did this? Well, what would this kind of be like, I think is really important. I also got a series of pieces of advice as I was leaving residency, some of which turned out to be very different than what I found as I kept going. I think that when you train, you train with a group of people who have chosen a particular pathway.

That pathway is typically academic and it's typically a full-time academic pathway with some exceptions. And so the set of pieces of advice you get come from those experiences. And that tends to be skewed in one particular way. Now, I am incredibly grateful to the folks that trained me. They are amazing mentors and I am unbelievably lucky to have gotten to spend time on the floor and off the floor working with them. But I think it opened up for me a lot more when I started seeking advice from people that had also gone in completely different directions.

Yeah, I love that that sometimes when you're faced with these really difficult decisions looking to your tribe and I would like to highlight, you know, there's a difference. Renee Brown talks about this. There's a difference between calling people. and really seeking counsel. So if you're asking everybody what you should do, are you using that to substitute listening to yourself? There's a difference between polling and counsel. So I would encourage people to think about that. And I've gone through periods of my life where I relied heavily on people outside and I was definitely polling and then going to make the decision with what the most senior person that I held on a pedestal said versus integrating that with my own knowledge of myself.

So I a hundred percent think you should talk to people and get counsel. But at the end of the day, you really do know yourself best. And I a hundred percent trust every individual to make the best decision for themselves at that time.

When to Take a Break or Sabbatical 30:00

And also, you know, recognizing what Cheryl just said that Yeah, that may not have been the best decision, but I do believe it will be part of your life story and be important going forward. I really like that idea of return to sale because I think that is a real key piece of the recovery. have to be able to, and Dan has spoken about that internal self-awareness, but knowledge of self is work and it looks different and the self you bring each day is going to change over time. And what recovery looks like for you today and what performance looks like for you tomorrow, we'll have to adapt with that.

But the more you have these skills and cultivate these skills, you can tune into it. As we're wrapping up, I'm going to kind of answer my own question about, you know, how do you know if it's a vacation or sabbatical or, you know, really changing up your clinical mix? I think you know when you are your best self, when you actually are feeling like yourself. And that sounds simplistic, but what I mean by that is when I go through periods of burnout or exhaustion or working too much, I don't feel like I'm in my body.

I feel like I'm a zombie moving. And so I started to kind of have that feeling again in spring of 2022. And I did find that COVID surge particularly exhausting in winter of 2022, even though there were fewer sick patients, but there were more patients coming in with COVID, at least in San Diego. And I did go on a vacation and it was a vacation by myself and I did a lot of writing and reading during that time and it actually was enough. When I came back, I felt like myself again and I didn't have those automatic negative thoughts when I went into my shifts.

So that was for me very different than in 2021 When I went on vacation, I felt better. And one hour into my shift, I'm right back. So that would be something that I would leave as a tangible piece of advice to our audience is that when you leave, go on vacation or you have a long weekend and you're right back to that bottom feeling, then something probably more significant needs to happen. And then pulling into what Dan and Cheryl have said, that's when you start talking with other people because man, what too many of us do when we get to that place is we have shame.

Around it that how could I possibly take a break? How could I possibly leave? I work so hard to get into medical school. How could I want to take time off or consider a different career path? Revitalize. We always like to end and this is the end of this mini series on recovery. that we covered micro recoveries on the first inter-race home and then meso recoveries and now this macro recovery process. Is there any words of wisdom that you'd like to leave our audience with today? I will turn it over to Dan with any closing thoughts on this recovery piece.

I think it was Andrea at the beginning that said, you know, we're a work in progress and I think that's really true. To me, as you look across these three scales, the underlying super skill is introspection and self experimentation, is being honest with yourself about what you're feeling and and exploring and realizing that you might not have the right answer. I certainly don't have a perfect answer to this for me right now, but it's an active area of inquiry and an active area of processing for me where I'm working and experimenting.

And the more that I'm doing that consciously, I think the better that I'm going to be on all of these scales of recovery. Yeah, I mean, I've written scribbling here fancically, just things that pop up, but I agree being, it's spraying curiosity, self-compassion, you know, being able to acknowledge that this is our journey, is a work in progress. And, you know, I think what you've just mentioned earlier there, Andy, about You know yourself now that self-knowledge, but I know when I want to escape from something, you know, that's not, or when I'm focusing just on the destination and not actually the next step, then I've got to re-reflect, reconsider, you know, refocus on which direction I'm going next.

Yes, as we close out, the message I want our listeners to take away is you are worth it.

Self-Awareness, Counsel, and Recovery Signals 35:00

You are worth your recovery. So many people do not believe fundamentally if they really ask themselves what they are worth. That bubble bath, that meditation, that walk alone without your family or your children, you are 100% worth it and you're worth that vacation and you're worth taking a sabbatical if you need it. So our friend Naomi says, you don't need permission, but you need permission. All three of us are wholeheartedly giving you permission to turn down, pause, reset, Come back or don't come back you know it is your decision in your life and with all the staffing shortages that's not the message that your department head is giving you.

I need to push back and tell you that you can take that break. And i truly believe that that is what health care needs to do right now the way out of the staffing shortage. Is to actually embrace that we need radical recovery can maybe that's gonna be the name of this i like that this three parts it radical recovery and it now is not the time during the staffing shortage. to ask people to dig deeper. We actually need to ask our administrators and start expecting that they acknowledge the way out of this is not pushing harder and asking for more, more coverage.

I actually on my soap box now as we close out, but I actually think that the answer right now is for department heads to say, I'm going to tolerate a longer door to dock time. Hmm. We're going to get away from that 30 minute expectation. That was something set in place before these staffing shortages. And it is an artificial number that was drawn out and a lot of people agreed upon, but it is no longer working for us. And we're sorry. And we're going to work on trying to figure out a solution to get it back down to that.

But right now. I'm throwing that number out the window. That would be my approach if I was in charge right now, that we have to stop pushing people. They're leaving. So stop making it harder and embrace radical recovery. Thanks for listening to this unique episode. Please check out part one, which was on micro recoveries with Dr. Dan Dworkus on the Emergency Mine Podcast. Part two was on meso recoveries with Dr. Cheryl Martin. The two of them are so amazing and I am so thankful to have them as friends and colleagues.

I really hope that you take some time to think about your own recovery and reach out to your friends, especially those outside of medicine that may have a better sense of what normal recovery looks like because most of us have been programmed that we can just run on empty.

Radical Recovery and Closing Takeaways 38:00

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