State of Telehealth with David McSwain, MD
Episode 30518th September 2020 • This Week Health: Conference • This Week Health
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Welcome to this Week in Health it. My name is Bill Russell Healthcare, CIO, coach and creator of this Week in Health. It. I set a podcast videos and collaboration events dedicated to developing the next generation of health leaders. This episode and every episode since we started the C Ovid 19 series has been sponsored by Sirius Healthcare.

Now we're, we've exited that series, but Sirius has stepped up to be a weekly sponsor of the show through the end of the year. Special thanks to Sirius for supporting the show's efforts to develop the next generation of health leaders. Hey, today we're joined by David McSwain, CMIO, MD, CMIO, medical University of South Carolina.

Welcome back to the show, David. How's it going? It's going great. Thanks Bill. I'm really happy to be here again, a lot's happened since the last time we talked. The, in addition to being the CMIO at MUSC, I also am one of the main PIs for the Sprout Telehealth Research Network. And so telehealth being such a, a central part of everything that's going on with the pandemic, there's just been a lot of stuff going on there and it's amazing to.

Watch around the country, the kind of progress that people have made and, and the progress that they're on the verge of making. So it's really exciting. Yeah. So you've been spending a lot of time in telehealth and we're going to, in fact, I. 10. I have 10 questions. I I always come up with a framework of questions that they're, they're all around Telehealth

So we're, we're gonna talk a lot of telehealth. What is the Sprout Network real quick? Sprout is a, it's a national telehealth research, uh, network, and it's based out of the American Academy of Pediatrics. We started that about, uh, five years ago and last year we got NIH funding to develop a, essentially a support framework to promote telehealth research.

By people all around the country. And in fact, we've supported researchers and telehealth innovators in, in Canada and Puerto Rico and Australia, and uh, really around the world. We've got over 120 institutions that are engaged and our focus is on supporting. Everyone, not just folks that are engaged in Sprouts specifically, but to really try to provide tools to promote the evidence-based focus in, in telehealth development evidence-based.

All right, so you're a pediatrician. I don't, uh, let me think. I. I'm gonna talk to another pediatrician here shortly, but, uh, I don't talk to pediatricians all that often. I like pediatricians. They're, they're wonderful people. Everybody likes pediatricians, . Exactly. They're, they're, uh, I, I don't wanna offend any other doctors, but generally pediatricians have a really good demeanor.

They have to work with kids. They're, they're easy to talk to. I, pediatric critical care doctor specifically, so I'm not the nicest pediatrician, , uh. There, there are some that are way nicer than me. Got it. But, but one of the things, we had a, a little conversation prior to this, so I, I'm gonna go on a tangent here, and it's around education, and I'm gonna tie it back into telehealth.

But, and, and specifically around, you know, research around telehealth and those kind of things. But we're facing a really interesting time with regard to education. We have all these kids potentially staying home, some going back to school, some staying home. Parents, families are making very difficult decisions that they haven't, uh, have never really been faced with before of this, what kind of conversations are you having with people?

Uh, I, I assume parents and, and kids around them going back to school at this point. Oh yeah. I've had people, I've had principals reach out to me. I've had, uh, friends from, uh, friends I grew up with reach out to me asking what they should do, uh, with their child in terms of, uh, going back to school. And I tell 'em it's a really difficult, uh, decision because it's so, it's very situational.

It depends on the circumstances of the individual, and it's not necessarily so much about the child as much as the circumstances of the family. Do they have the support? Are they working from home or not? Do they have childcare available? Is the child coming into contact with, uh, elderly grandparent or an immunosuppressed person?

And then looking on the flip side of it, when you talk about the child, do they have the. Are they able to learn in a remote environment? I think particularly special needs children may not be able to, for various reasons, may not be able to benefit from a remote learning environment and really need more of that hands-on type of educational approach.

And it's just a really difficult, uh, question to answer certainly broadly. Yeah, so it's interesting because we, we come back to that same thing we're talking about with the Sprout network, which is. It, it's having research to back things up, but we, we had this, this education model sort of thrust upon us very quickly, and teachers from grade school to high school had to figure out how to educate across the wire without really a lot of research and scholarly work done around what it takes to educate that age group.

Remotely. Now we've got a little bit more to, to look at based on the college age and beyond because we've adopted some of those remote models. But we have, we don't have a lot to really back it up and how to do it effectively with those age groups for the teachers. But on the flip side, we don't have a lot of research on how effective it is for the kids.

And we're reading a lot of these heartbreaking stories of these kids really struggling. Because for school, for them is much more than just the education. In fact, it's a lot more than the education. It's, it's recess, it's friendships, it's all that. It's not staying home with your parents all day, every day.

It's a lot of things. Um, yeah, I mean there's a lot it, the parallels are really striking actually between what's happening with schools and technology and what's happening in TE healthcare and technology. And as it relates specifically to, because people are finding themselves thrust into situations.

That they're not prepared for, and what you're seeing is a huge amount of variability in practice, a huge amount of uncertainty in what you need to do. Can you do it? A major lack of the technological capability to support a. Both at the school, but even more so in the homes. A lack of connectivity, a lack of bandwidth, a lack of devices, even just the environment.

A lack of a private space from which to participate in remote schooling. Same thing with things like telehealth and think, when you look at what we've seen as telehealth is scaled rapidly across the country, is it's uncovered some really important shortcomings similarly to the school situation. In with schools, the risk to children with disabilities is, and, and with special learning requirements is makes it much more complicated.

They do. You can't approach them the same way. And when you look at telehealth, what we've seen is issues like non-English speaking popula populations. Them being able to access telehealth platforms, people who don't have the access to technology. The expansion of telehealth has really shown a spotlight on some of the shortcomings with regards to really impacting the access to care.

That was originally the biggest focus of telehealth. When it was conceptualized, it was really gonna reach out to rural areas and disadvantaged populations, and now we're seeing that lack of access to technology. And, and the availability of interpreter service is now becoming a social determinant of health.

And that I think, is we need to focus on addressing and overcoming these really core central barriers that are preventing us from making progress in some of these areas. And we need to really focus on. Developing some standardization and understanding what is the best practice? And to your point, that requires data.

It requires research, it requires understanding of what it, what's the real value, the real impact, and what are some of these unforeseen consequences that people may not have predicted. And we really need to focus our energy on that sort of integrated approach. And getting that information Interesting.

You've given me a lot to, to go off of there. So let's start with this. There's, I've, the pandemic has shortened everything and it almost feels like telehealth has gone through the complete Gartner hype cycle in six months. So, mm-Hmm. expectations to peak, to disillusionment, uh, literally in about six months.

So people are sitting there going, this is gonna be, uh, the change, it's the tipping point. We're now at a new norm. It's gonna be amazing to, some of the things we're reading now is telehealth visits are way down and people, I, I don't think anyone thought we would sustain what we were doing at the peak.

And numbers are just staggering and, and we're amazing. But, but it hasn't turned out, some people feel like it hasn't turned out to be that tipping point and that they're disillusioned. What's the pandemic, a tipping point for telehealth? Or is was, was there just an illusion of a tipping point? I think it depends, depends on how you define the tipping point, right?

If. , if the thought is that it's a tipping point in that we're not gonna have these challenges with adoption, that the people that have been championing telehealth for years can finally take a breath and relax and that they've tried it and they love it, they're gonna love it and, and it's gonna continue to accelerate, then no.

It's, that's not how medicine and healthcare works. I think if you define the tipping point, as we have gotten engagement and understanding . On the value and the potential value of telehealth from stakeholders at both the healthcare institutional level at the, at the policymaker level, payer level from patients and population health experts, and folks genuinely see both the value and the challenges of implementing telehealth and are now aligned towards

An approach to really have, uh, really moving towards a digital transformation that integrates telehealth into the provision of care in a meaningful way so that we can support patients with chronic and complex conditions and, uh, improve the coordination of care and improve the coordination with the patient-centered medical home.

Then yeah, I think this. Could certainly be a tipping point. The key is do we change our, do we focus in on those opportunities? I think there's a huge what, what the pandemic has done has provided. It's provided us with an amazing opportunity and an amazing amount of data that we can use. To drive this transformation, but it's not just people.

I think people that talk about a tipping, tipping point, often they were talking about other people's tipping point. They were right all along and these other people that, that just weren't getting on board with telehealth, it's a tipping point for them. That's not, that's not true. It should be a tipping point for all of us.

We have to learn from this experience and. Look at the low hanging fruit of telehealth is now not so much. The on demand urgent care, minor acute condition type approach, as much as it is a really integrated approach to, um, managing these chronic complex high cost conditions and moving towards a value-based approach that can not only improve outcomes and improve quality, but.

Lower costs and really achieve these goals that telehealth has always talked about achieving. Yeah. You know, I, so I'm gonna go in two di different directions here. One is, I, I wanna talk about the barriers and the, the headwinds that we faced going into the pandemic and, and get the lay of the land of how these are impacting us today.

But the second direction I want to head and I wanna start here, is establishing the value of a telehealth program. At the peak of Covid, it was assumed that, hey, telehealth is here to stay. Look at the value. It's great people once the pandemic, or at least the perceived risk of the pandemics, uh, subsides, people go back to their normal behaviors and those kind of things.

Uh, and it's really incumbent on on C-M-I-O-C-I-O, just the team of people, CMO, even. How do you establish the value of your telehealth program? Within a system, I think it's really about the data and what we do with the data. And I also think it's about that integration component. And if the institutions that have created sustainable models of telehealth during the pandemic are the ones that had already devoted significant time resources to integrating telehealth into their care model, the integration of virtual care.

Workflows and technologies and remote patient monitoring into the electronic health record is incredibly important. Integration with remote patient monitoring applications, taking into account a potential for predictive analytics and how that could play into triggers of, uh, virtual video visit, having that well-rounded, integrated approach.

Is the way that you move this forward towards value and I think from our standpoint, we've been, I, we really can't understate the value of research. I think healthcare prov one of the key misunderstandings on the part of folks that maybe focus on the technology aspect is. That at the end of the day, healthcare providers are always driven by evidence.

We've had that drilled into us from a very early stage in our careers that you don't change practice based on anecdotal evidence. And I've heard people say regarding telehealth, if they just try it, then that'll be it. That'll be the tipping point. But that is literally saying that you're relying on an anecdotal evidence.

Your adoption, the anecdote being, I tried it, I liked it, therefore I'm gonna change my practice. And that's simply not. Practice change In healthcare works, you have to have the research and the key thing. And what Sprout really focuses on is providing the tools and the frameworks to have some standardization, some standard data definitions, some frameworks.

We actually just published in pediatrics, our STEM framework, which is the Sprout Telehealth Evaluation Measurement Framework. It's a first of multiple tools that we're developing, but that's really key. Wow. I, it's, and there's, again, as you're talking there, it's, I just did a podcast, actually, I don't even think it's aired yet, but I just did.

By the time this airs, it will have, and we talked about scientific method because this healthcare startup, CEO, was a scientist before she was a doctor, so she. She, she practiced science and then became a medical doctor. And I asked her, which of those really lends itself to being an entrepreneur? And she said, the scientist.

And she said, because so much of what we do is the scientific method. It's making a hypothesis. It's proving or disproving that hypothesis, learning from it, adjusting and doing the next experiment. She goes, we're constantly experimenting. And the same thing's true here with telehealth, isn't it? It's, we don't just throw up our hands and say, this worked.

This didn't work. We say, okay, what did we learn? What can we do different? Because telehealth is here to stay. As a mechanism. No, I think it's important to, to take the big picture view, and I, to be clear, I'm not what anyone who's a hardcore researcher would consider a hardcore researcher. I'm a hardcore pragmatist.

I, from my standpoint, you don't. I'm not anymore in favor of doing research just for research sake than I am for doing telehealth, just for telehealth sake. You do it with. Uh, as a means to an end, as a way to approach this larger goal of establishing value in healthcare. And I've heard people say many times over the past decade that I've been having these discussions that research is too slow.

d to go because. I've been in:

We're still talking about the same challenges in many cases, which if we had focused on the research. Five years ago, 10 years ago, to actually answer these key questions, to have the data that this, the decision makers in the legislature and in at state medical boards need. If we had done that back when we initially had this opportunity to devote some resources to really getting data and developing evidence, we would be so much further along.

And that I think is . Where we really need to look critically at what the approach has been because we're always chasing that carrot of we wanna get this done in in three months, and research is too slow. We've been chasing that carrot for a decade. So let's look at what's the realistic, pragmatic approach to getting this stuff done.

All right. Let's talk about headwinds facing telehealth. So you have money, behavior, both, uh, on the clinician side and on the patient side. You have regulatory, uh, scale technology or some, some of the headwinds, some more than others. But let's start with money. I've heard people saying that the funding uncertainty is holding them back from, you know, really making the investments that they.

Want to make as a health system across the board? What are your thoughts with regard to money? Its current funding? Is it sufficient? Uh, should we be worried about where the funding's gonna go from CMS and others? Or how are you, how are you thinking about this? I think about it in terms of you should be paying for care and, and more so than paying for a particular approach to care.

And if you focus on how do you provide the best quality service. Regardless of whether that's in person or remote or using remote patient monitoring, then that's an overarching principle to take and getting more, getting a little bit more down in the weeds. I've heard a lot of people talking about telehealth could be reimbursed, but at a lower, a discounted rate because you don't have to pay for, you don't have to cover the cost of a brick and mortar location.

But that's actually counter to a truly integrated model that leverages telehealth to improve overall value because ideally, the same providers that are providing in-person services have the capability to provide virtual services as needed, depending on the circumstances. There actually does need to be, in my view, in most cases, to provide a truly coordinated model.

There needs to be a brick and mortar location and. So that you can provide the ser whatever type of service in whatever location is best suited to that circumstance. And if you're gonna take that approach, then you have to think about the total costs of ca of providing care in that integrated way, in that flexible way, rather than what's the cost of providing telehealth versus what's the cost of providing in-person care.

And so my, I am a believer in . We need parity for telehealth services. We need broad parody for telehealth services, but I think it needs to be true parody and not, yeah, we'll pay for it, but we're gonna pay for it at 50% or 75%, and that will then drive the broader adoption, a more integrated model, because you're not forcing clinicians to decide not only between what's most appropriate and.

Or not, you're also forcing them to decide, do I want to get paid full price or 50%, uh, when they're making that decision and they shouldn't be having to make that decision. They should be deciding in-person versus virtual care based on what's best for the patient at that time. Yeah. I actually, that last phrase I think really summarized it so well of, you know, it, it, it really should be what makes the most sense.

The financials should be. Baked in either at the system level or at the payer level that people have thought it through and, and they're giving the person who's sitting across from that patient the ability to do what's best in the best interest of the patient, if that makes. So much sense. Let's talk about behavior though.

Uh, behavior is interesting to me 'cause I remember the pushback we got from physicians when we were rolling out our telehealth program. And, uh, you know, and to be honest with you, we saw some of that on the patient side too. The patients, some of the patients were like, no, I'm coming into the office. I, I look forward to that visit to the office.

I, what, what have you seen? We have new stats, new numbers. We've had a ton more experience. What, what have you seen? I've seen it really across the board. I've seen folks that were very anti telehealth who are now true devotees of telehealth and, and realized that it was, there was value there that they never, they never realized.

I've seen folks that have experienced it and are just saying never again because they didn't think it provided that value. I think the true, the truth of the matter is people are really thinking about it in terms of. What allows them to provide the best quality care, and I think patients are looking at at it in terms of what allows them to maintain that connection with their providers, with their care teams, to have some control over their health information and their care plan to feel like they're really connected and engaged with their care.

And if you have a model, if you have workflows that. Allow that kind of facilitate the physician or the respiratory therapist or the dietician or whomever, members of those care teams, they, if you have workflows that allow them to feel like they are truly providing high quality care and doing so in a way that fits within their workflows, then.

They're gonna be, they're gonna be champions of telehealth. If you have patients that feel like it allows them to have a better connection with their providers and their care team on top of being more convenient, then they're gonna want to see that continued. So, based on what you're saying. If I went out and did like a class has the EHR survey, which is a handful of questions.

Mm-Hmm. , it gives people's happy or or satisfaction with their EHR and those kind of things. But if we had a similar survey for telehealth or that was like the class survey for telehealth. What, what I would find is those systems that have truly thought through and baked in the experience, into the clinical workflow, done the proper education and training, given them a tool that's, that's, you know, easy to use that doesn't, doesn't require a lot of.

There's not a lot of complexity to it. It doesn't really change their workflow all that much. And on the patient side, it's again, easy to schedule, easy to see the physician. It maintains that contact in, in a good way. If we saw those kinds of things, those are the kinds of systems that would probably rank high and the ones that would rank low really probably didn't have it well thought out ahead of time and just piece things together to try to handle the covid surge.

Is is, yeah. Do you think that would hold true? Absolutely. I'm actually, I'm a really big fan of the Class Arch Collaborative. We're in the, at MUSC. We're in the midst of completing our arch collaborative survey. Your conversation with Taylor Davis from the Arch Collaborative back, uh, year or two ago, I think I actually saved it and listened to it occasionally.

It's, that's the kind of approach that we really need to take. It's not so much about the technology itself. About how you work it into your system and how well integrated it is with your educational approaches. Everything that you said, I think that's entirely accurate. Well, here's, uh, so I, I'm gonna hit some, uh, little different points here.

It's just some of the stuff I'm picking up. From other interviews and, and from social media and stuff, some health systems and health system leaders are calling for changes to the state rules around practicing across state lines. This specifically impacts telehealth prior to the. What are we calling them?

The, whatever, the relaxation of the rules. Mm-Hmm. that were instituted a physician would have to get certified in multiple states to practice telehealth across those state lines. Well, some are saying, Hey, look, let's just, these allowances that have been made, let's just make 'em permanent. Let's, if somebody's certified in South Carolina, they should be able to practice in North Carolina.

They should be able to practice in Florida, and we'll be able to do telehealth across those state lines. Yeah. What. What's your view of that? What, how do you, how do you view that suggestion? I think there's absolutely value to relaxing those restrictions. I think looking at it, again, I'm a ragus, looking at it from a practical standpoint, the stakeholders that were opposed to relaxing those regulations prior to the pandemic.

I, I'm not sure that they are going to completely change their tune now, but I think that there's absolutely value to trying to continue to push that forward. I think the thing we need to also keep in mind though is there are, there is downside and there is risk that goes beyond just state medical boards lose their power.

I think there is risk because. The people, the, the institutions that are really focused on relaxing state LI licensure requirements are big box telehealth providers, large institutions that are looking to expand their reach across multiple states and such. Those sorts of relaxed regulations advantages those institutions.

And it really can disadvantage the community provider, the primary care pediatrician, to take it straight to the folks that I know that don't have the resources or even the, they don't necessarily want to have a A three state footprint. They wanna provide care to their patients and their communities.

And I think there is certainly a way to do this that could facilitate that and lower those barriers. To allow, what I would love to see is, is a relaxation of regulations so that providers can follow their established patients across state lines when they go to college, when they go on vacation, when they go somewhere for work, right?

If you have a, a CF patient that you've been following for years and they go to college outta state, you should continue to be able to see that patient. If you are following a complex, uh, a patient with a chronic disease. Or you have a care team, a coordinated care team that's really helping to manage a patient that has a lot of medical issues and they should be able to go on vacation in a different state and still be connected with their care team.

And I think if we look at it from that standpoint, then we can institute some really smart policies and regulations that will protect that medical home and protect that relationship with your providers and still facilitate the . Expansion of quality telehealth services. I'm, I'm gonna steal a whole bunch of that.

I've been trying to say what you just said right there on the Newsday show over the last, uh, six months or so in, in that this is a highly nuanced. Yeah, thing, it is not just a all states rights versus, you know, the federal sort of coming in and, and whatever. There is a competition aspect of it. It does, it does favor the funded institutions, the large academic medical centers, the, uh, the national telehealth players.

It favors them. I think some people aren't taking that into account. I love the, uh, aspect of, you know, a long-term care relationship. Being extended, uh, to, to somebody who, who's going, you know, to another location. The, the medical record stays with you. The relationship stays with you. They don't have to find, as they go to college, they don't have to find another physician.

Obviously, that's not a, a good example if somebody literally moves away, but if somebody's gonna go to co, if it's a temporary situation. Uh, it makes way too much sense. Uh, yeah. There's really no reason why we shouldn't be able to figure out how to do that. I think that the challenge is a lot of people wouldn't be happy with just that and, but it's something that would be great to see happen and I think it would be relatively, if we could get everyone aligned towards that sort of approach, it would be a fantastic thing to see as an out, even if that's one of the major outcomes of.

Regulatory environment around the pandemic, allowing people to care for their own patients no matter where they are. I'm gonna have to skip some of these questions 'cause I've, I, we, and I love the conversation so far. Talk to me about quality. Do we have any numbers on quality? Has quality, how would we measure it?

What are we seeing around the effectiveness of the care that's being delivered through telehealth? I think it's, it's quite variable. And again, it gets back to there's not a lot of established standards of how you measure that. That's a lot of the work that we've done in Sprout has attempted to address that.

And we're not trying to do that on our own, but we're working, we're collaborating with institutions around the country that have more of a focus on quality. And collaborating with academic institutions and community providers to really look at how can we support that? And I think there is one of the biggest challenges is the lack of resources that are truly devoted to evaluating this and that lack of standardization.

We did a survey, one of the, the first studies that we did in Sprout was back in 20 16, 20 17. And it was looking at the infrastructure for pediatric telehealth across the country, and it's published in pediatrics. You can look it up. The, we looked at what at telehealth programs, most of these were in academic centers, but where did they devote their resources, uh, in terms of developing telehealth, supporting telehealth and sustaining telehealth?

And everyone had technical resources. Everyone had administrative resources. People had billing and compliance resources, but the two things that were least often supported, um, amongst all the institutions that we surveyed were quality improvement and research. And I think there's such a push to expand telehealth rapidly that the quality improvement and research aspect kind of takes a back seat while you're trying to get this, these efforts rolled out quickly and because of the.

Huge variation in state regulations around the country. Telehealth programs have evolved in such a different way. In different states. There's such a huge amount of variability that defining what quality looks like for a particular telehealth program becomes very difficult. So another one of the things that we've seen, I think as a result of the pandemic is

This relaxing of a lot of regulations has leveled the playing field in a lot of states. And interestingly, it's resulted in a lot more or a lot less variability in practice. People are doing a lot of the same types of things because they're all dealing with the same types of regulations, at least during this period.

And so this provides us with an opportunity to look at in this environment, what does quality look like? How can we measure it? How can we collaboratively report on it and established some best practices and standardizations and really push, move the needle on that aspect? Hey, let's, so let's close on this question 'cause that's probably the notice for your next meeting that just popped up.

So let's talk telehealth leadership. And this is a hard one too, right? So I've seen CIOs lead it. I've seen CMIOs lead it. I saw a social media post about a chief telehealth officer. I've seen a lot of different things, and it's hard, right? Because if you're talking rural healthcare, it's probably the CIO.

If you're talking academic medical center, it could be a chief telehealth officer if you're talking, you know, it, it, it really could be all over the board. Just talk about what is your structure? How do you guys manage telehealth today? We have a, at MUSC, we have a, a great center for telehealth. And we've got some really, some really, I'm sorry.

Carolina legislature back in:

And so there's, we've been in a very fortunate situation, I think relative to a lot of institutions in a lot of states, to be, uh, well-funded and to have the ability to really focus in on the development of telehealth services at our institution. I think that it does take a, a large amount of funding to be able to support that level of dedication to telehealth innovation.

And if you look at how do you do it when you don't have ? Millions of dollars of of funding. It's really about getting the engagement of the leaders at your institution, whether it's the CIO or the CEO or the COO and driving it forward with a focus on what are the strategic priorities of the institution, what are the opportunities?

How does telehealth and virtual care fit in with ? The other initiatives that are happening on campus and the priorities of the institution, and really move it forward in, in that way. Because the, the question of telehealth for telehealth sake, I think it gets almost, I've heard similar sorts of questions about should there be a telehealth fellowship?

Should there be a special telehealth certification? I don't really think it should be. I think what you wanna see is . Uh, telehealth integrated within your approach to healthcare So that telehealth care is just healthcare and it's a way of providing it. And people under people learn about telehealth the same way that they learn about using a stethoscope.

That it's an option that you can use in the practice of caring for your patients. And I really think it's important not to have a siloed approach, but to support telehealth as an institutional effort. David, as always, I love our, our conversations. I learn something every time. I learn a ton today, but I've learned something every time we talk.

Uh, if, if people wanna follow you or get more information on some of the work or the Sprout network, how, how would they do that? I have, I'm pretty active on LinkedIn and you can search David McSwain and I should pop up, if you look closely, it's actually a picture of me and the tuxedo from my wedding from a couple of years ago.

So you can confirm that I'm also on Twitter at d McSwain MD and um, yeah, I'd love to get some connections. So did you buy the tux? Do you own the tux? That's just, I'm curious. I used to own a tux back when I was in college, and I sang in an acapella group. Um, I rapidly outgrew that tux once I left college , and so now I'm aware I wear tux, uh, tuxedos infrequently enough, um, that I cannot count on my, I cannot count on myself to be able to fit into any given tux in any given year.

This is, this is the podcast that won't end, but I'm, I'm sorry. Are you still in an acapella group or is that just a, a college thing? No, and I'm not. I am not in a acapella group. Unfortunately, those are a little hard to come by. Once you hit 40 plus. We did, and this opens a whole new can of worms, but we did have a karaoke wedding reception that was unique.

Next time I have you on the show, you're gonna have to be prepared to sing something. I don't know what it is. We'll figure out. Maybe, maybe we'll sing together and, and no, we don't wanna do that. People would not be happy with, maybe we'll have my wife on with me and we can do, we can do a duet. That would, that would be great.

David, thanks again for, uh, being on the show. I really always appreciate our time together. I enjoyed it, bill. Thank you. That's all for this week. Don't forget to sign up for clip notes. Send an email to CliffNotes at this week in health Special thanks to our sponsors, our channel sponsors VMware, Starbridge Advisors, Galen Healthcare Health lyrics, serious Healthcare Pro talent advisors, and HealthNEXT for choosing to invest in developing the next generation of health leaders.

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