Aren’t All Pharmacists Clinical?

The Journal of the American College of Clinical Pharmacy recently published an editorial in 2023 asking the question, "Is the “clinical pharmacist” designation still relevant?"
Podcast Host Nick Dorich, PharmD, PQS Associate Director of Pharmacy Accounts,  interviews the author of this article, Dave L. Dixon PharmD, FCCP, Professor & Chair, Dept. of Pharmacotherapy & Outcomes Science (DPOS) at VCU on this episode of the Quality Corner Show.

The origins of "Clinical Pharmacist" are discussed, as well as what it actually means to pharmacists and the general public. The merits of the title are also weighed and the requirements of clinical pharmacists are reviewed.

To read the article visit the JACCP
Is the “clinical pharmacist” designation still relevant?

Chapters

• 2:02 Introduction
• 6:25 History of the Terminology "Clinical Pharmacist"
• 11:53 What Makes a Clinical Pharmacist?
• 14:23 Team Based Direct Patient Care
• 16:11 Next Steps
• 21:17 Closing

Transcript

00:00:01:02 - 00:00:21:08

Dave Dixon

At the employer level before thinking about posting positions. The clinical staff Pharmacist I still don't quite understand what that means. It's, you know, they throw clinical in there and I get in sort of this idea that they're going to appeal to applicants right to the Z clinical title. Well, what does it actually mean? I don't think it means much of anything.

00:00:21:13 - 00:00:46:09

Dave Dixon

And so that's where, you know, really it's not so much the title, but what are the competencies needed for that position? What are the rules? Responsibilities? What does the day to day look like? And the same can be said for the clinical pharmacy specialist. I mean, such a mouthful when you look at these ads. Clinical pharmacy specialist in infectious disease, it's just an infectious disease pharmacist like let's call it what it is.

00:00:46:11 - 00:01:02:04

Dave Dixon

Let's not confuse people. Our healthcare colleagues in medicine and nursing the public. You don't know what clinical pharmacy specialist means. And so I think the employer level, we can do that.

00:01:02:06 - 00:01:27:07

Intro

Welcome to the Pharmacy Quality Solutions Quality corner show where quality measurement leads to better patient outcomes. This show will be your go to source for all things related to quality improvement and medication use and health care. We will hit on trending health topics as they relate to performance measurements and find common ground for payers and practitioners. We will discuss how the EQUIPP platform can help you with your performance goals.

We will also make sure to keep you up to date on pharmacy quality news. Please note that the topics discussed are based on the information available at the date and time of reporting. Information or guidelines are updated periodically and we will always recommend that our listeners research and review any guidelines that are newly published. Buckle up and put your thinking cap on the quality corner show starts now.

00:02:02:18 - 00:02:31:21

Nick Dorich

Hello Quality Corner Show listeners. Welcome to the PQS podcast, where we focus on medication use quality improvement and how we can utilize pharmacists to improve patient health outcomes. I'm your host, Nick Dorich. Now Pharmacists go by many titles and descriptions. One of the most common titles seen commonly in hospitals, clinics, other care settings, of course, for job descriptions and usually delineating oneself apart from being a community pharmacist, is the title of clinical pharmacist.

00:02:31:23 - 00:02:57:15

Dorich

We'll get into the origination of this name or title or designation and what it means, what it meant when it started and why it all started. Admittedly, this episode is meant to be a bit controversial, and I will say that it's a conversation or a topic that I've addressed many times throughout my career as a pharmacist. I have a very passionate opinion about it, and I know others in the pharmacy community do as well.

00:02:57:17 - 00:03:26:22

Dorich

Others have shared their thoughts in some way, shape or form. But recently an editorial was published in the Journal of the American College of Clinical Pharmacy that gave a great description, background and maybe a plea as to how we need to use that title going forward. So we invited the author of that editorial on to the show today, and that author and our guest is Dave Dixon, chair, Department of Pharmacy Pharmacotherapy and Outcomes Science at Virginia Commonwealth University School of Pharmacy.

00:03:27:02 - 00:03:44:23

Dorich

Dave, welcome to the Quality Corner Show. And how are you doing today? 

Dixon

I'm doing great and thanks so much for having me. Looking forward to the conversation. 

Dorich

Excellent. Well, before we get into talking about what is a clinical pharmacist and what that designation or that what that title means, Dave, we need to know a little bit about you.

00:03:44:23 - 00:04:13:12

Dixon

And so so can you give us a background on your career in health care and then what it is that you do today in your role at VCU? Sure. So I got my doctor, a pharmacy degree from Campbell University in 2006 and was really interested in the idea of practicing in a clinic alongside other health care professionals. So I did a one year primary care residency at the Charles George VA Medical Center in Asheville, North Carolina.

00:04:13:14 - 00:04:38:10

And then I went on and spent five years at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, where we developed clinical services in the military care setting. And I really enjoyed having students on rotation. I had some opportunities to do some adjunct faculty work at other schools and then eventually made the leap here to VCU School of Pharmacy.

00:04:38:10 - 00:05:07:03

Dixon

And I've been here for 12 years. I now spend about half my time overseeing our department of about 30 faculty. I do still practice here at VCU Health and Preventive Cardiology and, you know, teach a little bit, you know, very active in our organizations. And so I stay plenty busy but really have enjoyed my time here EKU excellent, Dave.

00:05:07:05 - 00:05:28:17

Dorich

Before we get started, I have to call out that your North Carolina ties. Some of the best pharmacists I know are also related or have spent time in North Carolina. And I'm not biased by the nine years I spent in North Carolina myself either. But good to know we've got someone from that great state that's there. And for anyone who is also curious, Dave is a very well-respected and published author in the space around cardiology and many other topics.

00:05:28:17 - 00:05:48:09

Dorich

I know I've read a number of articles and published studies throughout the years as it relates to Dave's work, so definitely check out some of his work. Aside from the editorial note, Dave, we're going to go ahead and get into to today's conversation about what it means to be a clinical pharmacist. But before we do that, we're going to we're going to pause.

We're going to hear a brief message from the PQS.

00:05:52:20 - 00:06:17:08

Breakdown

Now it's time for the breakdown as quality corner show host little as three main topic questions. Our guests will have a chance to respond. And there will be some discussion to summarize the key points. This process worksheet for the second and third questions, which will wrap up the primary content for this, the 14. After that, it's to end on a closing summary, usually containing a bonus question.

Now that we've described the process, let's jump into the questions.

00:06:24:24 - 00:06:48:06

Dorich

All right, Dave, we're ready for today's questions. We're going to cover three primary topics or ideas that we want to explore about what it is, what this title designation is for clinical pharmacist. Now, let's start off with the history of it. The terminology of a clinical pharmacist has been around for quite some time, probably tied to the genesis or origination of the PharmD program in the pharmacy curriculum.

00:06:48:11 - 00:07:17:02

Dorich

But can you help explain for us where the term came from and then what was its original intended use? 

Dixon

Yeah, so that's a great place to start. And I think the easiest thing to think about is first defining what do we mean when we say clinical, right? So if you look the word clinical up in the Oxford Dictionary, it will say something like relating to the observation and maybe the treatment of actual patients rather than say the theoretical or laboratory study of how we take care of patients.

00:07:17:02 - 00:07:42:09

DIxon

So what I think about that context, so I think about what pharmacies do on a daily basis. I don't know any pharmacists that are really doing a lot of theoretical work, right? They're taking care of patients. And you're correct in that this concept goes back to the 1960s, really. And if you dig into the literature, you will find, you know, my editorial is not the first to address this topic.

00:07:42:11 - 00:08:19:13

Dixon

And it really did have to do with sort of this shift that happens away from the medication products to getting the pharmacies to engage with patients. It wasn't all that long ago that pharmacies were actually trained and told not to talk to patients. So I think that along with, of course, the immersion of the doctor of pharmacy degree and then that degree eventually becoming the standard degree for pharmacist to practice and pharmacy as a profession, really wanting to advocate and push for its role.

00:08:19:14 - 00:08:48:07

Dixon

That involves more patient interaction and taking care of patients. And so then we end up with this dichotomy of clinical pharmacists and then I guess, non-clinical pharmacists. And so that's, you know, initially part of some of the concern is if you have this designation of clinical pharmacists then and what does it mean for everyone else? And this has been something that, as you mentioned, the beginning I have thought about for a long time.

00:08:48:09 - 00:09:10:12

Dixon

And I actually started working on this editorial during the pandemic. So I have sat on this, I've written parts of it, I put it away, I came back to it to really try to do the best job I could to tell the story and to at least start a national conversation about it. 

Dorich

Dave, before we get on to the next question, I've got a quick sort of follow up to you.

00:09:10:12 - 00:09:41:16

Dorich

Are for you is part of how I look at this topic is how the public how patients view pharmacies and to some extent thinking or identifying that, yes, every pharmacist that is managing a patient's medication use and is working with their providers, working with the patient, there's an aspect, all of that is clinical. And if we're having the general public, our patients view all of us pharmacists as clinical pharmacist, clinical providers, to me that seems like that's it's a sort of rising tide lifts all boats.

00:09:41:20 - 00:10:04:12

Dorich

Is that kind of the mindset that you're coming from where this isn't about separating pharmacy, but more so to some extent galvanizing the public around what it is uniquely that a pharmacist does. Is that somewhat your thought process? 

Dixon

Yes, absolutely. 

Dorich 

And the public doesn't know what a clinical pharmacist is. 

Dixon

Right. That does not something that the public ever thinks about.

00:10:04:12 - 00:10:37:11

Dixon

And I mentioned this in the editorial where early my career would introduce myself and I'd throw in that clinical terminology and it just didn't resonate with them. And so now it's I'm the pharmacist I work with your help, your heart health team, and I'm here to help you with your medications. They're like, okay, great, I get it. And so certainly trying to unite the profession behind this idea that the work that we do, while it can vary, it is fundamentally about taking care of patients and it has a clinical component to it.

00:10:37:14 - 00:11:12:16

Dixon

If you are evaluating in order for medication to make sure it's appropriate and it's the right medication for the right patient at the right time, that still requires the pharmacist to to logically and clinically think through. Is that the right medication for that patient? And so I think to me, we're getting more bogged down in this dichotomy in our profession is at a I think a tipping point as we start to advocate for things like provider status, reimbursement for the services that we do provide, we need to have unity.

00:11:12:16 - 00:11:32:05

Dixon

We need to have a united front in order to make that happen. 

Dorich

Excellent. Well, Dave, I want to ask some questions specifically about what you wrote in the editorial. And folks, we will include a reference or link for the editorial in the show notes. It's about a two page PDF, give or take with the references that are cited or sourced in the editorial.

00:11:32:05 - 00:11:50:03

Dorich

So it's a very quick read. So if you're if you're listening to the podcast, now would be a good time to pause the podcast. And if you're driving in your car or something like that, don't don't start to read the article. Now while you're driving or operating and got a vehicle to do it while you are seated and not into any other activities, but give it a read.

00:11:50:05 - 00:12:22:16

Dorich

A lot of great points, a lot of great information. But Dave, one of the items that you call out in the editorial is clinical pharmacist. And what that has meant in some of the different kind of training requirements are elements, some for some period of time that this was based on. My clinical pharmacist is someone that has the pharmacy and then eventually that changed to, well, maybe it's you got to have that pharm.d plus board certification, but you pointed out some of the ideas or concepts about that where you know that those may be elements, but obtaining that degree, obtaining that it's not the be all, end all.

00:12:22:16 - 00:12:45:17

Dorich

So can you dive into that topic further for us and why that may or may not be a good descriptor for a clinical pharmacist? 

Dixon

Yeah. So fundamentally things are very different today than they were 20, 30 years ago. As you mentioned, the doctor pharmacist, the terminal degree to become a pharmacist, it's the only degree we have. And also, you know, I'm involved in the education and training of future pharmacists.

00:12:45:17 - 00:13:14:04

Dixon

And I think about the training our students are receiving today is a far cry better than what I received as a pharmacy student in the early 2000. And so I think that know that as health care and pharmacies are progressing so rapidly and we think about what pharmacies do day in and day out, again, it goes back to the point of really trying to galvanize our profession to to really achieve our true calling.

00:13:14:04 - 00:14:03:09

Dixon

Right. Which is to optimize medication use and, you know, if you are someone that has a doctor pharmacy degree and you go straight into practice, great. You know, we are being encouraged now through the accreditation bodies that our students graduate in their practice, right? So that means for a lot of generalist pharmacist roles, our students should be able to walk right into those roles, ensure just like other health care professionals, if someone has a passion about a particular specialty, whether it's cardiology, infectious disease, or maybe managed care, or if they want to run their own community pharmacy, great, There is absolutely nothing wrong to go on and pursue postgraduate training to help you reach that goal. But then at the end of the day, whether you've done postgraduate residency training or not, whether you're board certified or not, you are still a pharmacist and you are still taking care of patients and optimizing medications. And so that's was really the central point I was trying to get across. 

Dorich

Now, you do know that there's an additional or last requirement with the definition of clinical pharmacists, and that is that clinical pharmacist must, and I'm quoting from the editorial, must practice in team based direct patient care environments.

You also note further in that paragraph that this is where things get complicated. And I have to assume that the rise or change in technology here, you know, now in 2023 versus what it was in 2003 versus 1983 to base care, it means very different things in today's care can be functionally available in many different ways. So is that where you were going in that and where do you want to kind of point out some things from our colleagues to accentuate that one?

00:15:04:16 - 00:15:36:02

Dixon

Yeah, absolutely. And the other aspect here is, is team based care, sure, can it be everyone in the same room with the patient. Sure. Can it also be health care professionals that are not co-located there in different locations working either through the electronic health records using telehealth, which you are alluding to in your comment, even just picking up the phone and speaking with the medical provider or the prescriber, to me that that is doing engaging with the health care team.

00:15:36:02 - 00:16:09:04

DIxon

And I think that's where we have to approach this from a broader perspective and not think about team based care is all it can only happen if everyone's in the same room. And as you mentioned, as technology evolves and telehealth really begins to pick up, I think we're going to see more opportunities for pharmacists in in all settings, particularly community pharmacy practice, to be able to have, you know, a new ways to connect with other health care professionals, to work together to take care of the patient.

00:16:09:04 - 00:16:32:19

Speaker 1

And that's ultimately what it's about. 

Dorich

Excellent. Great point, Dave. Now, kind of our my last question for you, and I'm thinking about the future. Hey, what do we do when folks read this editorial? Do they do they go to their employer? Do they go and talk to their patients about this? What's kind of the next logical step? Or maybe I know a lot of folks are maybe looking for a solution and call to arms.

00:16:32:24 - 00:16:56:01

Dorich

What is the next step? Is there a better term or is it simply us trying to define it? Is the failure point itself. So what comes next? And what do you hope to see, you know, spurred on by by people reading your editorial here? 

Dixon

Yeah. So I think that there could be there's two options here, right? I think that we could certainly revisit how we're defining it.

00:16:56:01 - 00:17:20:12

Dixon

And I think if you look at the response editorial to my paper, that is that was co-published from Jerry Bowman, who's the editor in chief of that journal. I think he did a nice job of providing, you know, not a counter perspective, but another viewpoint of, yes, we all have diverse roles and functions as pharmacists. Let's celebrate that.

00:17:20:12 - 00:17:49:10

Dixon

That's great. There's nothing wrong with that. And maybe we know if we're going to continue with this idea of clinical pharmacy, we need a better definition. In my opinion, I think it doesn't provide as much value to redefine it. I think that at the end of the day, our organizations have to come together to get behind that. I'll go out on a limb here and say it would be great for A.P. to be the American College of Pharmacy.

00:17:49:12 - 00:18:14:11

Dixon

How awesome would that be? Yeah. And if you look at our organizations, they're clearly trying to, you know, be the home for everyone, right, for all pharmacists. And so I think that that's one approach at the employer level. If you're thinking about posting positions, the clinical staff pharmacist I still don't quite understand what that means. It's, you know, they throw clinical in there and I get it.

00:18:14:11 - 00:18:34:05

DIxon

It's sort of this idea that they're going to appeal to applicant right. And see clinically in the title. Well, what does it actually mean? I don't think it means much of anything. And so that's where, you know, really it's not so much the title, but what are the competencies needed for that position? What are the roles, responsibilities, What does the day to day look like?

00:18:34:10 - 00:18:57:20

DIxon

And the same can be said for the clinical pharmacy specialist. I mean, such a mouthful when you look at these ads, clinical pharmacy specialist in infectious disease, it's just an infectious disease pharmacist like let's just call it what it is. Let's not confuse people, our healthcare colleagues and medicine and nursing the public. You don't know what clinical pharmacy specialist means.

00:18:57:22 - 00:19:22:19

DIxon

And so I think the employer level, we can do that at the sort of academic level. And thinking about training future pharmacists, I often will hear a student say, I want to do clinical work. That's really unfortunate because I don't really think they really know what that means. And it's also insinuating that there are things that pharmacists do that are purely not clinical.

00:19:22:19 - 00:19:44:15

Dixon

And a lot of times right, that connotation is negative and it's biased toward community practice, which is where, you know, about half of all pharmacies practice, you'd be greatest. I would say, you know what? I want to be a community based pharmacist. I want to work in my community. I want to make my community better or I want to be a critical care pharmacist because I really like that setting.

00:19:44:17 - 00:20:07:22

Dixon

I like that environment. Both of those roles involve clinical work, and so I think those are just a few things that I think we could start to do to move the needle in the conversation forward. 

Dorich

Excellent. I, I think this is a great topic, a great conversation. And the way that I look at and maybe you can confirm or deny and you know, we're talking about this as it's black and white.

00:20:07:22 - 00:20:23:11

Dorich

There's a right way and a wrong way to do it, but it's not right. There is absolutely. There's a lot of shades of gray. And I think somewhat the point you're making is that it's not as black and white as saying clinical pharmacist, you're not clinical pharmacist. So this to me really is about unification of the pharmacy profession.

00:20:23:15 - 00:20:51:24

Dorich

We're trying to get more opportunities to expand pharmacies, provide services for pharmacists to be paid and recognized for these services. Pharmacists are underutilized, and rather than providing a unified front to the public with other health care providers and patients were somewhat caught bickering amongst ourselves about what the heck we call ourselves. And is that sort of the thought process here where it's, folks, we need to get past this and we need to be talking amongst the larger world and not just amongst us as pharmacists?

00:20:51:24 - 00:21:11:19

Speaker 1

Is that is that where your head's at? 

Dixon

Yeah, absolutely. And you know, as pharmacies, right. We're detail oriented people. We love getting into the details and we can debate this definition all day long, but that's really not going to move the needle forward at all. It's not going to move us forward as a profession. So let's save the semantics and the academic debates.

00:21:11:21 - 00:21:34:03

Dixon

Let's put this aside and let's let's move forward. 

Dorich

Excellent. But, Dave, I think and appreciate you for jumping on for this episode of The Quality Corner Show. It's a pretty big deviation from what we typically talk about at the show, but we're very much pro pharmacy. I am a pharmacist myself by I I training right by pharm D degree.

00:21:34:03 - 00:21:57:16

I am a registered pharmacist and this is always a big point where although I don't practice on the front lines myself in my my career now, when I still explain or talk to people about what a pharmacist actually does, aside from discounting the pills right. Pretty much everyone that you that you talk to acknowledges and recognizes that, yes, the pharmacist are an essential member of the team and you are not talking to talk to enough people about it.

00:21:57:16 - 00:22:20:04

Dorich

They're going to have their own stories about how a pharmacist caught a missed dosing or an incorrect dosing. And it's never a question from the public on, well, it was my clinical pharmacist that did this. Right. Any pharmacist can identify what that item is, and that's our specialty on the health care team. So, Dave, going back to another part, we're all part of the health care team and how we're connected.

00:22:20:10 - 00:22:42:24

Dorich

So lots great opportunity and we as the pharmacy profession have an opportunity to just embrace what we are. We're all pharmacists. There doesn't need to be a definition for clinical pharmacist necessarily and move forward for the better of our profession. So again, really appreciate you spelling this out in a and as you said, there is a, you know, an editorial response.

00:22:42:24 - 00:23:02:17

Dorich

There's going to be folks that have different opinions. That's that's okay. We welcome that. All right. Well, Dave, before we close, we've got a couple of questions for you that are not really not related to pharmacy or what is or is not a clinical pharmacist. These are just some fun questions for us to kind of loosen things up before we close at the show.

00:23:02:19 - 00:23:26:08

Dorich

Are you you're ready for these? Let's do it. First question. Are you a morning person or a night owl and 100% a morning person? 

Dixon

I'm generally starting my day 530, maybe six a even on the weekends. And wasn't all that always that way. But I definitely do my best work in the morning. So I get up and get started.

00:23:26:10 - 00:23:45:01

Dorich

Excellent. Does that usually require caffeinated beverages? Are you just ready to go with some straight H2O water at that time? 

Dixon

So I will hit the glass of water first and then I'm immediately going to grind the coffee and get the coffee pot going. 

Dorich

Excellent. I think I do that in the reverse order, or maybe don't have as much water as I should.

00:23:45:02 - 00:24:12:03

It sounds like better morning start than I have. Next question for you. Do you prefer to read the book or watch the movie? And if you have any examples, we'd love to hear that. 

Dixon

Yeah, I probably say read the book because it's almost always better than the movie. I mean, there are rare exceptions to that and you know, one of my favorite books as a kid was Ender's Game, which is a science fiction novel, and they made it to this movie.

00:24:12:03 - 00:24:36:21

Dixon

And Harrison Ford was starring in it and I was all pumped up to go see it. And it was just terrible. And it almost ruined the book for me, to be honest. And so I'm definitely more into the book as a preference. 

Dorich

And I'm realizing as I ask that question, I may need to rephrase the question Is the book watch read the book or watch the movie or TV series, since that is also very prominent now.

00:24:36:21 - 00:25:05:20

Dorich

So future note for myself. Next question is, is health care related but doesn't have to be pharmacy specific? What is your recommendation for living a healthy life 

Dixon

Sleep. I denied it for years like a lot of us do and you can always make an excuse to not sleep or to stay up and really during the pandemic, it was one of those things that I got in a better routine with.

00:25:05:23 - 00:25:31:05

Dixon

And, you know, I get 8 hours of sleep. I make it a huge priority. I have noticed tremendous improvements in just overall well-being, being able to function throughout the day. So for me, I think it all begins with sleep. 

Dorich

I cosign that answer very strongly, something that were and to me it's a it's a part of you catching up with like sleeping 12 hours a day on a weekend.

00:25:31:07 - 00:25:58:22

Dorich

Not the same as getting your consistent sleep. Dave, our last question here in the segment for you. What is one goal, personal or professional that you are currently working towards? 

Dixon

Yes. So I would say becoming a black belt and tie condo, I started taekwondo with my son about a year ago, somewhat reluctantly, and certainly didn't think I would be doing martial arts in my early forties.

00:25:58:22 - 00:26:16:14

Dixon

However, it's really been a lot of fun. We're purple belts right now, so about halfway there and it's a great way to spend time with my son as well. 

Dorich

When you start out with saying black Belt as being professional, I assumed that that was going to be a black belt in like Six Sigma or something like that. Right?

00:26:16:19 - 00:26:44:13

So you caught me off guard. Dave So kudos for that. Yeah. All right, Dave, what we appreciate having you on the show that that concludes our fun, fun segment for the show. But folks may want to hear from you either about your work at VSU or follow up as it relates to the editorial. So before we go, one, where can people contact you and then anything else you would like to add that we did not cover about the editorial and and folks that may have been involved with that?

00:26:44:15 - 00:27:09:03

Dixon

Yeah. I think in terms of the editorial, you know, check it out read it, read the other a companion editorial from the editor in chief as well. Have conversations at your place of employment or with your colleagues, have conversations with organizations you're involved in. And let's see where we can go with this. You know, I think that's kind of the starting point or my my call to action, so to speak, in terms of getting in touch with me.

00:27:09:03 - 00:27:35:08

Dixon

So certainly, you know, reach me on on email. D.L. Dixon at VCU Dot Edu. If you Google my name in VCU, you can find my office phone number or email. They're also active on Twitter at VCU. Deep past share. I know it's a bit of a mouthful and look forward to the conversation. And thanks again for having me.

00:27:35:10 - 00:28:01:15

Dorich

Yeah, our pleasure, Dave. So that part's here. We certainly welcome this conversation. Glad to have you here on the show. But for folks that does wrap up this episode of the show, definitely read Dave's editorial when you get a chance to reach out to him with any questions or thoughts you want to share. Dave, apologies in advance if your email and or your Twitter timeline or LinkedIn get flooded here with activity, But that's somewhat the point of the episode as well is to talk about this conversation.

00:28:01:15 - 00:28:14:00

Dorich

So, Dave, we thank you again and for our listening audience that's going to wrap up today's show. So we thank you for listening to the Quality Corner Show. Before we go, we have one final message from the trustee.

00:28:14:02 - 00:28:35:15

Outro

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