It Could Happen Here - The USA's Impending Telemedicine Cliff

Episode Date: March 5, 2025

James is joined by Venktesh Ramnath and Kaveh Hoda to discuss the potential for an end to Medicare funding for Telemedicine and challenges for healthcare under Trump.See omnystudio.com/listener for privacy information.

Hello and welcome to the podcast. It's me, James, today. And we have a very special episode in which everyone is a doctor. I will be leading discussion, of course, as Doctor of Modern European History, but I'm joined today by Venkatesh Ramnath, who is a practicing pulmonologist, a professor at UC San Diego Health, a medical director of several ITUs in rural and urban settings, and also the author of the sub stack, Be a Health Architect.

Welcome to the show, Vinktesh. Thanks for joining us. Great to be here. I'm also joined by Dr. Kavihoda, a gastroenterologist and the host of our favorite medical podcast, The House of Pod. Of the many you listen to, I'm sure. Yeah, and what they might call a super user in the medical podcast space.

You listen to more than me. Most importantly, Carvey is, of course, our friend. That's right. Our resident doctor with a useful doctorate. So what we want to talk about today is Medicare and specifically some of the cuts to Medicare, more broadly, the, I don't know really how to put this, challenges in, for people working in healthcare in the Trump administration, right?

We addressed specifically gender affirming care in a previous episode, but it doesn't start and end there, right? That might be the thing that sort of the cultural wars have been focusing on recently, but I want to talk more broadly about the challenges facing healthcare. So first of all, would one of you care to explain Medicare for people who are not familiar? Some listeners might not be living in the United States, or they might just not have encountered this yet in their life. So could one of you explain what this particular type of health insurance is and how it's maybe

more vulnerable than other types to federal government changes? I could take a stab at it. I'm not a health policy wonk, but I am a physician that has to deal with Medicare all the time. So Medicare in sort of general terms is a type of health insurance that is provided by the federal government. It is almost exclusively for individuals above the age of 65, as it dates back to the 1960s with Lyndon Johnson's Great Society program. And so since that time, there has been this blanket coverage for any individuals above that age such that

all their medical services or products you know whatever they need for their health care is actually covered by the government this is the federal government now the interesting thing about Medicare is that there are different parts to it there's part a which is primarily for some essential services and includes hospital care there's part A, which is primarily for some essential services and includes hospital care. There's part B, which includes whatever physicians fees go into that healthcare. And then there's part D, which relates to pharmaceutical prices, so your drug costs. It's not comprehensive in the sense that there's always something more that individuals need, but Medicare, for all intents and purposes,

is the sort of standard and it should cover most of an individual's needs. Now that said, the commercial payers, that is the other insurance companies that are not federally government sponsored, take their lead from Medicare. So a lot of the different payment rates or coverages and services, they all look to what the centers of Medicare and Medicaid services dictate as far as what is an acceptable reimbursement rate, what are the rules around, what should be covered and what should not. So that's why Medicare is such an important entity for the United States. Yep. I'll add to that. They set the lead of importance here too, because if we're talking about telemedicine, telehealth, how important that is to Medicare patients, to everyone in the country at this point, then if they are to cut it, if that happens, as I think we're probably going to discuss if that goes away

Then the other private insurance companies are going to follow. That's right It could be across the board changes led by these changes in Medicare Yeah, so let's talk about those changes and as you mentioned right? There's this telemedicine. It's a waiver right that has allowed Telemedicine to be funded through this for the last five years, I suppose. It's going to expire by the end of this month, which is March 2025, if you're listening later. Explain, like, why telemedicine has been such a positive step, like, in healthcare, if you could, since 2020, and then what we're facing if it's no longer funded federally? May I start this one, but Venkatesh,

definitely want you to weigh in on it as well. Just to give a little background, over the past five years, it's grown quite a bit and it's gone from being kind of this emergency stop gap to a real cornerstone of what we consider modern health care. And now it's exceedingly common, like over 75% of hospitals in the US connect at a distance via video conference or some technology to patients. And it's been popular on both sides.

It's been popular on both sides of the aisle. When it first was done, as you mentioned, during COVID, when they said, okay, we're going to peel back some of the restrictions on Medicare coverage for these telehealth things. It was considered like a victory, like one of the few good things to come out of COVID. Both sides liked it. It was popular amongst patients. It was popular amongst patients.

It was popular amongst medical providers. It was good for Republicans and Democrats alike. And as you mentioned, it's been kept going through being put in some bill or another since it was initially put in, I think as they called it in 2020. And it's been put in one bill or another to go with the funding.

But then came this last December when Congress was going through their spending, it was only given this three month reprieve, which is going to be up, as you mentioned, at the end of this month. And if it goes away, there's a lot of factors will go into a lot of them. But there's a lot of people, older patients, immunocompromised patients who don't want to come into office, people with disabilities, people who can't get around that well, people in rural areas, which is really how it started, people who are gonna be hurt all across this country.

And at this point, the majority of people have had at least one experience or more in a year with telemedicine. It's become a part of a lot of people's lives. And if it goes away, you know, there's still going to be health care as it is. I mean, it doesn't mean health care is going away, but it is going to put a tremendous burden on patients and hospitals, for that matter, across the country. Yeah, let me let me add to that. So, you know, telemedicine has been around for a very long

time, at least technically speaking, right? I mean, you can go back to the 1970s, even when you talk about the intensive care unit, which is where the sickest people in the hospital are. There are studies that come out of the 1970s. However, ever since people have had iPhones and been on Airbnb and everything else since 2007, that inflection point actually had a wave of opportunity that washed right into medicine.

And as Cave is saying, you know, we have such a fragmented healthcare system that has, you know, folks living in rural areas, suburban areas, and urban areas, all of whom are at the mercy of what specialists may be there contracted at any given time for any given specialty. Now telemedicine, as it's gotten more and more popular, has kind of leveled the playing field. I mean, you can be in a rural place like where I'm sitting right now on the US-Mexico border, or you can be in New York City, you know, one of the densest populations,

but you may not have access to specialty expertise without telemedicine. With telemedicine, you can now have access. And I've seen patients love it. You can deal with the sickest of the sick, like I said, intensive care units, but you can also have outpatient experiences. We've seen a number of different, you of different commercial opportunities that have leveraged that.

But the point is that as we're hearing on this, it's become sort of a standard operating procedure for how we deliver healthcare. And if you just pull the rug out from that, there can be some unintended consequences to that that are not insignificant. Yeah. And it makes a lot of sense for a lot of people, right? Like, if I think about my own experience with it, I was traveling recently and got COVID like a couple of months ago. And there was no need for me to go to a clinic and be around other people, right?

I just needed to contact my doctor and get some prescriptions and check in. And like, it was so much better that I could do it in my pajamas from the bed rather than like having to get out. And I'm, I'm lucky I have access to a car. I can drive to the doctor's surgery. It's not that far away. I have a job that accommodates my schedule, but there are a million reasons why it might be very beneficial to people. So let's talk about, you mentioned this before, but we have commercial

insurers and like people might think that this is limited to older folks or it doesn't affect them or it's something that only impacts people who have Medicare. But as you said, Medicare kind of sets the standard for what is covered and what isn't covered, right? So can you explain how this might end up resulting in it in a just a massive, like a cliff? I've seen it described as a telehealth cliff. Yeah, so basically the convoluted way that we pay for services is it looks to one standard, even though some may argue how did that standard come about. But regardless of that, Medicare is the central authority that basically tells everyone, this is what we should be doing

and this is how much we should be paying for it. Now, the commercial insurers can decide to exceed that if they wish, if they say have an employer whose employees they want to have a special contract with, that's fine, that's not restricted, but the bottom of what is considered a reimbursable amount is really set by Medicare. And so they move the bottom. And so if you drop the bottom, you can pretty much well assure it in this, you know, in a capitalist, you know, sort of mentality that the cost should go down,

right? I mean, why should you pay more for something that you don't need to, right? And we see that, we see that every year. Okay every year There's new technology, but the slightly older technology which is again covered by Medicare They move those reimbursements down. So whether it's a sleep study You know for someone with obstructive sleep apnea or difficulty sleeping at night or it's some Ophthalmology technology or it's some ultrasound machine. It doesn't really matter what it is. Medicare is always trying to minimize costs,

which is understandable. They wanna make it cost effective, but they are setting the lead. So everyone will follow what they do. That's kind of the way that our system is sort of set up. Yeah. You know, I might just add to that, that aside from all the things we mentioned about it,

how, you know, it helps people in rural areas, people with difficulty getting places, or just really busy schedules, it also, you know, helps free up hospital beds, it helps prevent emergency rooms from being overwhelmed, it leads to faster testing, it leads to a higher number of people that we can see. And in terms of its quality, we know it works well. And about

90% of cases of telemedicine to get the same outcomes if the patient was there in clinic. And that 10% that's not, it's not clear that they're getting inferior care in most of those cases. So it's an effective treatment. And you could make an argument that it is cost effective in some ways too. It's particularly clearly for like things like dermatology, pediatrics, these are things where it's clearly cost effective to have it. But even beyond that, it's not even necessarily, I think, a strong argument that we'll be losing money from it and that cutting it would help us in the long run. I feel like we're being smart about how to manage American healthcare system and how to keep it afloat. Telemedicine is

gonna be an important part of that going forward. I do want to I do want to add something here and I do want to be careful about the term because it telemedicine and telehealth are not only sort of a catch-all, but they're sort of used interchangeably, right? And just like anything, you have to be specific about the term. So I think what we're talking about on this podcast is telemedicine in terms of a two-way audio-visual interface, where you can have a direct face-to-face consultation or interaction with a practicing practitioner. Usually that's going to be a physician but it

may be a nurse practitioner or other physician extender we call them. But just to be clear, telemedicine also extends to other types of devices like wearables. Those things that they're either you know trackers that you can wear as your Fitbit or a sleep device, you know, that you can wear around. Those kinds of things are kind of put into the telemedicine bucket. And it's not clear to me, at least, how that is going to change. I think April 1st is when the face-to-face coverage from a professional fee standpoint, that is slated to end because they did liberalize it during the COVID pandemic. And it's been extended, I think, another year around that.

And that will definitely change the dynamic here. But it's not clear how much of it extends to other types of remote physiologic monitoring services and products. Right, yeah, so something like a glucose monitor or like some other, yeah, which could be catastrophic for people, right, if they don't get those funded. Right. We're going to take a little break for advertisements here. Maybe you'll get an advertisement for a glucose monitor or even insulin.

Only hope. Yeah, yeah, yeah. I'm glad they're taking some of that money that they've made me bleed out of my wallet over the years and returning it to me in the form of podcast advertisements. All right, we're back. Let's talk more broadly about, I guess, the changes in the legislative environment for healthcare might be a good way to put it. Think, if you were an excellent op-ed recently where you discussed you were one of the many recipients of the TomBee5 useful things you did at work this week email. I thought you wrote like a really good piece about the varied and critical work that you do.

Can you talk about like what is the feeling among healthcare professionals, physicians, whoever you'd sort of like to speak as going into four years of possibly vastly reduced government spending and a sort of bizarre and haphazard cutting of the federal bureaucracy that we're seeing. Yeah, it's a tough time, certainly, and coming out of the pandemic, this is not what really anybody expected. But you know, the stresses have been mounting for quite a while, right? Healthcare professionals are seeing and feeling more stress at work, whether it's, you know, the demands of the job, meaning that there are fewer resources to spend on a heightened number of patients with, you know, increasingly

complex diseases, or even just the questions that we are getting from patients. A lot of patients now are asking me really financial questions. I mean, literally the other day, I had a woman who was unfortunately having septic shock and was faced with having to amputate her leg. And I was speaking with her husband because she was becoming more and more delirious and he was just asking me about well I'm gonna have to sell my house in order to Fund what might come down the pike as far as being at home with services And I was trying to I was trying to kind of get an understanding of how he viewed

His wife actually going through the thing that we're watching in the moment, but it's a preoccupation that has taken up a lot of space in the room. And it's now coming onto physicians to sort of navigate at least some questions and answer those questions around it. So that's a long way of saying that, you know, physicians and nurses and other healthcare professionals are feeling more and more stress in a system that's just buckling, right? And the last thing anybody needs is to be having to do more without really a clear understanding of the purpose around it, right? And we are all for cost-effectiveness. We want that

to work. We also want to provide care irrespective of someone's religious, political, or other beliefs. And yet, you know, we have to work within a system that we kind of are not really understanding how they're approaching this issue. Are they with us or against us or somewhere in between? It's sort of a, it's a moving target. And so I think that's what's kind of sandwiched a lot of healthcare professionals.

And we don't really know where to turn for some of the answers that we ourselves are looking for. I would add also you know we're seeing this active dismantling of the US healthcare infrastructure and our friends in the academic world in particular it's a very stressful time for them who knows if their studies are going to go through, who knows if they're going to get their funding, who knows what's going to stay, what's going to go in the next couple of years. There's a lot of concern over that, obviously, but even in the medical world outside of the academic centers, I know a lot of doctors right

now are concerned and they're concerned about what's going to happen to the state of our scientific community that helps us with new advancements in medical technology in the coming years. And it seems like as Venkatesh was alluding to, we're dismantling all our ability to follow, to study, to really closely track infectious disease in a time that is exceedingly dangerous across the world with rising disease, tuberculosis in this country, measles in this country, in Uganda, there's Ebola again, there's threats all over the world and this is one of the worst times I could think of to be in this like moment of austerity and particularly because so much of it seems unclear to us why why these things are being done you know is is it all because of this ridiculous gender ideology

do they actually think they're saving money with some of these things it's a very unclear time and of course there are a lot of people in the medical world doctors included that are conservative or republican voters getting into conversations with them about this is sort of a tough thing to do. Because like Vintes mentioned, they, like a lot of us want to make sure we're doing this in a cost effective manner. Something we talk about and we have been talking about in medicine for a long time, particularly academic medicine, interestingly enough, which is really on the cutting board. It's academic medicine that usually talks about, you know, trying to be cost effective.

What tests are we going to order? What labs do we need to get? How are we doing this in the most cost effective way? These are important things that are discussed. And across the political spectrum in medicine, I think there is some concern, even amongst some of the more right leaning doctors. But again, it's hard because they've gone this far down the road. It's hard to know, you know, when they're going to pull back, what's the line in

the sand for them about what is maybe too far for this administration? Yeah. And certainly like an area where we're seeing that right now is in like, like public health, right? We don't really know, like, I'm going to Texas next week, where there's currently a measles outbreak. Yeah. Things that we didn't think that we might be seeing in this country again, we're seeing again. And like, as you say, it's coming at a time when like, not just funding is unstable, but also like, the, I guess, like the basics of science have been somewhat politicized

to a degree. And like people, I don't know if that's something you see in your practice, but like, certainly like I was talking to a doctor friend who said half their clients are now like declining vaccinations as I was there to get, you know, every disease that I could get. I have a lot of travel vaccinations, so I'm always getting new and exciting vaccinations, but I'm making up for some of the gap, I guess. But it's a really challenging time, right, from that perspective as well, the culture around it. Yeah, that's right. I mean, even here in the San Francisco Bay Area, you know, I've seen more vaccine hesitation than I remember ever seeing before in the past. It's sort of a vaccine question because I think some of this is, let's be clear, some of this is on our messaging, you know, as healthcare professionals. I mean, there are more and more

articles, in fact, there was a Wall Street Journal piece a couple weeks ago that was saying how patients, you know, are increasingly not trusting their doctors. And there are data to say that we don't communicate very well. So there is that and that's on us. And another op-ed piece in the Boston Globe by Ashish Jha did a mea culpa around some of the things that public health, we did wrong. We got it wrong in COVID where we didn't, you know, deal with some of the doubts and lack of evidentiary base for masking and some of these other things

that basically hurt us in the end. So there's definitely that. However, you know, restoring the trust in healthcare professionals is sort of like a basic step to anyone getting their healthcare. I mean, I think people still go to their doctors. Most people still trust their doctor to some degree. And I think that that's at least a bright spot

in where we are because when we've lost that, I think we're really in trouble. I mean, that's slipping, but I think that there is a way to restore that trust, but it just starts with a conversation. If someone has a vaccine hesitancy or they don't understand what's going on, that's the opportunity to open the doors to a dialogue.

And I think maybe that's the starting point for any of this. We all want cost effectiveness. We all want, you know, transparency. We also want to have choices that make sense to us, but let's not make it an adversarial confrontation. And I think that that goes for both sides. I would add though, I agree with you

on pretty much all of that. I agree that we need to have those conversations, you know, if they're difficult, we need to be able to look back objectively about things that worked and didn't work. But a lot of these sort of mea culpa's that have come out about like, you know, this is what we went wrong and why we lost trust. If I'm being honest, including that one from Ashish Jha, it has a lot of, in my opinion, pick me energy. A lot of people who are trying to appeal to the incoming administration and be like,

hey, look, I'm cool too. I'm not always about vaccines. And to me, that's just as bad too. And I do think we need to have an honest conversation. And I do think we need to be clear about how we do science. Something we need to be able to explain, and you're absolutely right, which we didn't do very well, is look,

we are working with information we have at hand. We're doing everything we can. This information may change. When it changes, our recommendations are going to change too. And that is tough. That is a tough message to get across because people don't like nuance like that. People don't like the uncertainty of that. People want wanna know yes or no, absolutely. And sometimes it's hard. It's hard to find good communicators in science to do that. But that you're exactly right, it is incumbent upon us as doctors who have a substack like yours,

have a podcast like mine, who are academics who have a reach to students and beyond to communicate these things. And even though it would be awesome if for the next four years, my podcast was just about farts and poop, I know I have to do a lot of this stuff because I know how important this is now more than ever. So I totally agree. It's going to start with conversations.

I think there's a big difference between, this is the information we have available and we're doing our best with it, and when we get new information, we'll do something different, if that's what that information points to, and these people are acting out of malice to deprive you of your rights, which is sometimes what's been suggested by some people. And I think a good way to defeat that, as you say, is communicating around it. It is very sad that like, when I was doing the research

for my PhD dissertation, I wrote about, first I wrote about violence in the anarchist builders union for my masters, and then I wrote about public health and popular sport in the 1930s in Barcelona. A lot of what you saw anarchists doing in Barcelona in the 1930s was talking to people about tuberculosis, educating people about tuberculosis and explaining what tuberculosis was and where it came from.

And like that was in 1931. How far we've come baby. Wow. Yeah, it's great. There were some other things from the 1930s, which have also made an unwelcome return. Duberg says this is not the only one. There's also the Nazi salute in large public gatherings in the United States. Holy shit. Which, yeah, I don't know. Anikis had answers for them both in the 1930s, and they're the same answers that apply now. I think people will be distressed by this, right?

Like a lot of people of my age and younger, I guess it's folks a bit younger than me for the larger part, like the pandemic was a life-defining event for a lot of younger folks, right? And it was a scary thing, it still is a scary thing. Like getting COVID still really sucks. And I know people who have long COVID and the thought of that is petrifying to me. People will be genuinely anxious now, right, at this potential dismantling of the public health apparatus, like a rise in vaccine hesitancy, less funding for research such that if we enter another pandemic with some novel infectious disease, we won't be able

to respond as fast. The response to COVID, for the criticisms of it, like the speed with which we had vaccines was amazing. So that came from like, Venkatesh's college at UCSD actually, or at Solk, I guess, which is next door, with free parking, which is nice. So like, what would you say to people, because this is a thing I see more and more among folks who, you know, who are friends of mine, right, is like real worry about infectious disease, real concern about new variants of COVID or about, you know, the bird flu is one, right, these

other infectious diseases. I saw 50 people have died of it as yet unexplained disease in Congo recently. What would you say to those people? Because their concerns are somewhat legitimate, right? Like if we go into another pandemic, we're not going to be anywhere near as effective as we were in 2020, because of all these combination of reasons we've discussed. That's a hard question to answer. I would say, let me back up. I think that the COVID pandemic, yes, there are a lot of things that went well.

The vaccine development was phenomenal. I mean, that was revolutionary. Who would have expected that to happen? However, it also just revealed how shattered our public health system really is in terms of messaging, even detection, spreading information, even the vaccine distribution was completely chaotic, right? So I don't wanna say that the public health response

during COVID was some sort of paragon to be emulated or replicated, right? So that said though, absolutely. I mean, you know, how are we going to handle a new era of this what if, you know, scenario where we don't know what virus is coming next? I mean, I'm seeing these days, I'm even seeing viruses that never caused the kind of respiratory failure in the past. They're doing it now, whether it's RSV, the respiratory syncytial virus, or even non-COVID coronavirus, which should just give you a cold,

and the sniffles, and yet it's causing devastating, you know, pneumonias. So we're in a new era, and you know, antibiotic resistance is not getting any less, you know, problematic. So what do we do in this era? Well, I think awareness is the first thing, okay? Awareness around, yes, I mean,

these diseases are transmitted from person to person. We all know somebody who doesn't wanna take a vaccine. I mean, I don't think that's a surprise to say. We know of somebody or directly, or maybe one degree of separation, right? And I think you need to have those community conversations. You need to have one-on-one conversations. Yes, it's going to be uncomfortable, but we got to talk about it and talk to your health care provider about it.

I mean, yes, you can look up stuff on TikTok. Yes, you can look up stuff on Google or you name your online resource, but you want to have a person that can actually understand from years of living and breathing this stuff, and also who listens to you as a human being in the same community or somewhere nearabouts, right? To put together what the science says in some sort of meaningful way to you and not some anonymous resource that may or may not have all the data at their fingertips. So I guess it still goes back to how does anyone find reliable information? Where do you go when you've got questions? Most people want a human being who's lived and breathed with

experience to help them navigate. I certainly see that not just as a doctor, but as a friend, as a family member. I'm a consolate, you know, they're asking me these things. And I would suggest that, you know, your audience may have connections, both personally, but also professionally to those folks that can help them navigate. You know, and to answer your question from my perspective is a challenge. Because I think people should be concerned. In fact, I just did two-parter with one of the world's best virologists talking about the, you know, possible bird flu pandemic that could arise and all the threats that

are out there. And so I do think there are some really significant serious risks to be worried about. However, I'm never gonna say there's nothing that can be done about it. There's plenty that can still be done about it. I still maintain hope in the medical community for what we're able to do

and what we're able to accomplish. And to echo what I think both of you guys have said or would at least agree with, there's a lot of changes that we can make locally amongst our small sphere of influence and then growing out from there in terms of getting vaccinated, in terms of wearing masks when needed,

or at least looking at the data with an open mind and sharing good resources. Because one thing that the younger population is good about and what some of these people you're mentioning, James, is they're good at detecting bullshit online. And that's a skill that needs to be honed for medical literacy as well. And I'm hopeful that that's gonna continue to improve. Maybe stupid optimism,

but I do believe the younger generation is gonna continue to be better at that than the older generation. And I think that will help battle a lot of the misinformation that's out there. But there are things that they can do. In fact, for getting back to the telehealth thing, for example, talking about telemedicine slash telehealth, as Ventech sort of broke down, in terms of it being cut at the end of the month, there are people that are really pushing against that, including Ro Khanna, who's here, a legislator here in California, who's proposed a new bill. I haven't been able to see any of the details of it, but there are a lot,

including Amazon, by the way. Amazon is one of like 350 companies that have written a letter to 150 companies that have written a letter to the to Congress to help push for this funding So if you can call a congressperson if you can do that if you can keep bothering them telling them how important it is I think those are things that can help so I think that's a good place to start Mm-hmm. Yeah, that's a really good piece of advice if I could add to just follow up with that I think part of what will help With the support for some of these programs is to take You know take us take a few minutes to think about what the other side is worried about right? I mean we all know about the excesses of certain online bad actors who are telemedic they use

telemedicine to promote you know ADHD medications or other types of psychotropic medications which was not it was not supported and it actually caused harm right so so there are things out there that are excesses and somewhat harmful and if we could as a community sort of help frame the approach to Dealing with some of those things that preventing some of those problems Then I think some of the support will kind of sort of show itself I think the worry is if you open up the floodgates too wide, you know human nature being what it is

It's going to encourage bad behavior not that that anybody wants that. But there is something to be said about some scrutiny, right? So if we're the ones, and I completely support the use of telemedicine, but I also want to be careful about how to promote its thoughtful and safe use, and wed that in the proposal, and not just leave it for others to figure out that that I think would potentially change the conversation around, well, you just want this and we're not gonna give it to you.

Like the standoff will subside when you try to work it, work a partnership out as opposed to a give it to me or else kind of scenario. I don't disagree with that, but I also think you're giving Doge more credit than I would, which is to say that they actually really, they really would focus or listen to. I think what they've just done is literally, you know, take a chainsaw and cut away at major

federal funding and then kind of seeing what was really bad about that and what wasn't and being like, oh, okay, maybe we do need people in charge of nuclear security. Oh, maybe this is popular. We'll put it back. You know, I kind of, I kind of think that they're not taking as much attention or care, but I also do agree that the point is, is valid. I mean, sure there's, is there fraud in some telemedicine? Yeah, I'm sure probably small, very small percentage, but if we can specify its use, if we can be better about that, I agree, I'm all for it. Yeah, especially right now, just thinking as you were talking about, like how important is people accessing reproductive health care and being able to access reproductive health care wherever they are? And like how much more difficult that would be if people didn't have telemedicine appointments, something we've spoken about before on the show. But yeah, I'm sure there are some small cases.

I'm sure there are a bunch of cis gender guys getting gender affirming hormonal care through telemedicine, who probably could go without and be okay. Guys, I'd like to wrap up there, but I want to give you a chance both to, you talked a lot about like science communication, so where can people find you online, where can they see you communicating your medical knowledge? Okay, well so I, thanks James, I have a sub stack, it's called be a health architect, you can look me up at at be a

health architect, and you know I have a conversation there around an issue that certainly affects me and those around me, which is physician burnout, but in the larger sphere of healthcare professionals, it really touches everybody in healthcare. So that's where I'm posting actively. I'm also sharing that through various other avenues such as X and Blue Sky and other places. So you can find me there. Look forward to seeing you there. Yeah, I would also recommend Venkatesh's Substack if you're in the medical field in particular,

I think you'll appreciate it. A focus on burnout is as important as it's ever been, if not much, much more. I mean, we were talking about burnout and moral injury in doctors before COVID and now, you know, down a couple of years down the road, it's only worse. So I think it's really important. And I do recommend it or, you know, check out his latest article in the Los Angeles

Times as you mentioned before. As for me, find me on Blue Sky at Cave MD. But more importantly, just listen to the podcast, the House of Pod. If you are a fan of this show, I think you're gonna like The House of Pod if you haven't already given it a try. It's a lot of the same people that you hear on this show on The House of Pod, James included.

He's gonna be coming back to talk about the measles and with an author of a new book down there about the measles outbreak. And, you know, we take a look at grifters, medical grifters, we take a look at some people that would be considered medical contrarians. We take a look at some of the quackery in medicine as well. So I think you'll appreciate this show if you like the whole behind the bastards verse,

I think you'll get into the house of pod too. So check us out wherever you get your podcasts. Yeah, great. Thank you so much for joining us, guys. Really appreciate it. Thanks. Thank you. It Could Happen Here is a production of Cool Zone Media. For more podcasts from Cool Zone Media, visit our website, coolzonemedia.com, or check us out on the iHeart Radio app, Apple

Podcasts, or wherever you listen to podcasts. You can now find sources for It Could Happen here listed directly in episode descriptions. Thanks for listening!