Chris Hemphill (00:00):
When we started this series, we began with the conversation on health equity. We spoke about disparities facing minorities, women, and veterans. However, what was missing from that conversation? The disparities facing sex and gender minorities or SGM. SGM includes, but isn’t limited to lesbian, gay, bisexual, transgender, queer, intersex, and asexual individuals. They face a whole host of healthcare disparities based on a lack of understanding or even outright discrimination.
Chris Hemphill (00:33):
To help discuss these disparities we spoke with Dr. Kavita Mishra. Dr. Mishra obtained a fellowship in transgender surgery and in medicine from the Cleveland Clinic, and currently serves as a clinical assistant professor at the Stanford University of Medicine. Our conversation with her after the break.
Chris Hemphill (00:52):
Consumer experiences, major disruptors, and AI tech are shaping healthcare for years to come. On, Hello Healthcare, we dive deep on these issues with leaders who are driving change. I’m Chris Hemphill, VP of Applied AI at Actium Health, and we hope that these stories will help you to create or demand a better future in healthcare.
Chris Hemphill (01:16):
So when it comes to this particular topic, the reason that we are excited to have you on board as we were working directly in this field, and it was really awesome talking to you about your career and motivations on taking this particular path down medicine. Really just excited to start digging in and just taking in context that there’s a lot of people in leadership or operational or patient engagement positions here.
Chris Hemphill (01:40):
And a lot of what we can learn here can help identify like outreach patterns and ways that we engage our transgender and non-binary populations. So with that, would you mind sharing just a little bit on your background and what’s got you interested in the focus on transgender medicine?
Kavita Mishra (01:57):
Yeah, absolutely. I guess I’ll go back to, I did a lot of my training here in California at UCSF and then I also did residency and fellowship at Brown on the east coast. And I really, like my primary interest has always been pelvic health and I just, I love pelvic anatomy and I love, as part of that taboo topics, and reproductive health. And I got very interested, especially while I was in San Francisco with taking care of transgender individuals and really wanted that to be a part of my career in the future. But it wasn’t a straight path.
Kavita Mishra (02:32):
You have to find your own way and training actually in pelvic surgery and realized that I was starting to see more and more transgender patients and felt it was a great opportunity for me to really connect with a patient population that I’ve been wanting to take care of for a while. And so I had this opportunity to do a transgender surgery and medicine fellowship, and my primary focus is going to be doing vaginoplasty surgeries for transgender individuals, but I have some training in hormone management and a whole other host of things now.
Kavita Mishra (03:05):
So that’s what got me into the field. I really identify with people, individuals, who may have a history of trauma, and I feel like a shepherd in a way, and when I’m taking care of them. And I really appreciate having that role in people’s care.
Chris Hemphill (03:20):
That’s fantastic to hear, especially they used the word, the word taboo, which if something’s taboo, there’s just a lot of people who there’s these issues, this set of things that we could be discussing that just don’t make it to the table because it’s, for whatever reason, there’s social more’s against talking about it. I feel like that’s hurting awareness.
Chris Hemphill (03:40):
That’s hurting this conversation to where a lot of the recent research and a lot of the recent papers, especially like when I approach things, it’s going to be from a data perspective and a lot of the recent research on how to even capture information on sexual orientation and gender identity. A lot of that is from the past 10 years or the past six years.
Chris Hemphill (03:58):
Hugely thankful about that focus on those taboos. And that kind of leads me to a question, with those taboos and with the fact that there’s a lot of recent discussion, there’s a lot of people who might not be aware of the issues impacting sex and gender minorities, what are some of the key disparities that healthcare leaders should be aware of when addressing this group?
Kavita Mishra (04:20):
Oh, there’s several. And there, a lot of these facts may hurt me personally when I hear them, because I’m part of a system that is not welcoming or has not historically been welcoming. And we know that a third of transgender individuals, they don’t seek any preventative health services. A quarter report having bias experienced in prior encounters with the healthcare system. And a fifth have reported actual refusal of care in their past, which, you know, when you think about how many individuals that is, I find that very disturbing.
Kavita Mishra (04:55):
And even within OB/GYN, there is hesitance to take care of trans masculine individuals. There was a study that asked academic OB GYNs, how comfortable they are caring for trans-masculine patients. And only 30% felt comfortable. And actually 11% said that they were unwilling to perform routine pap smear tests, despite those being the guidelines with trans-masculine individual individuals.
Kavita Mishra (05:20):
And I see all, all of that information and I think, “Wow, we are lacking in education sorely.” Where does comfort start from? Well, it comes from being exposed to and taught. It comes from self-direction as well. And so we need this combination within healthcare of educating ourselves personally, but then also making sure that we educate those around us. We really need to keep in mind. And of course like the higher rate of violence, victimization, physical and sexual assault, harassment, bullying, hate crimes, inter partner violence. Unfortunately these numbers are painful to hear about. And I think that these are the things that, yes, they get some attention, but within healthcare, I think we need to be much more directed and focused about addressing these.
Chris Hemphill (06:10):
Thank you. And I think that addressing it from a healthcare perspective, with the backing of the healthcare system, with a lot of the things that you’re doing at Stanford, and in terms of education about these topics, that’s a, a beautiful place to get started and hopefully start wearing down those taboos. Are there significant geographic differences when you’re looking at where these disparities exist? Do you see significant differences in location?
Kavita Mishra (06:35):
I don’t know if we have the evidence necessarily to say that specifically. I think anecdotally and from expert experience, yes, that is true. I think you’re going to get better care where people have educated themselves and are marketing themselves as taking care of sexual and gender minorities. So I think in that sense, having preventative health services and those experiences, I think, logically would be different, but I don’t know if we can say that with the data.
Chris Hemphill (07:01):
Okay. And curious about the data too. You had told me about a project, one big issue, one big challenge with the taboos and the mores around this is that there’s not in, a lot of cases, there’s not a huge amount of data out there, but you had told me of a friend.?
Kavita Mishra (07:17):
Yeah, Obedin-Maliver, she’s very well known in the field of studying sexual and gender minorities. She and Mitch, who are, they’re two physicians at Stanford who have a very large NIH back study where it’s a national study of sexual and gender minorities and their experiences in different topics. So it’s a very large survey based study, but it’s been now around for several years. The information they’re publishing from it is tremendous.
Kavita Mishra (07:46):
I feel like you could go to the NIH website, look up their study, which is the Pride Study, and you’ll see like incredible number of citations because they are starting to ask the questions of the population. What are you experiencing? What is it looking like? And what is your experience in healthcare? What are the health outcomes? These are questions that for the first time, I feel like are being addressed in a very large, expansive manner.
Chris Hemphill (08:13):
As we focus on care for transgender individuals, what’s included in that, does that include things like the call center experience or other avenues where using correct names and pronouns and engagement and things like that?
Kavita Mishra (08:27):
I feel like the way we do it right now is a little bit backwards. Because we start from the place where we are doing the care and then expand out to address, okay, where does the patient encounter in our… What is, who are the people and the locations that the patient faces at my clinic, for example, how do I make my environment welcoming? How do I educate my staff? And okay, I interact with this department and that department. So now let’s educate that group of people. And then okay, the patients who are interacting with that.
Kavita Mishra (08:59):
So it’s like an in to out approach. Where I think it would be very different if our approach was as if a patient was calling the main line of the hospital. And I think that’s the part we start with the advocacy to make sure that our patients who finally get to us are comfortable, but I think we’re not doing as great of a job as going top down and all around.
Kavita Mishra (09:23):
The question in particular, talked about call center teams, and we work on that for like my practice or my clinic or the group of clinics that are taking care of sexual and gender minorities, but we’re not doing that as expansively as we should. Like when someone calls the orthopedics office. I think this is definitely a weakness. There are more things in our medical record systems that are helping. There are areas to get patients sexual orientation and gender identity information. Their pronouns are listed more prominently. Their preferred name is listed more prominently. So I think that integration is there, is getting there at least on the medical records side, but the personal education and we need to work harder on
Chris Hemphill (10:09):
That is huge. And that really strikes a chord because there’s, even with the medical records issue that you brought up, I know that Epic and Cerner, they both have adjusted the fields that are available to match with some CDC guidelines around collecting information around sexual orientation and gender identity, which I find is commendable, but it’s not just the data that we have to focus on.
Chris Hemphill (10:32):
Now that those fields are available we have to make sure that we’re collecting them in the right way. And in ways that people are comfortable sharing and educating our teams, like from top to bottom at the leadership level and all the way on down. There’s a proper acknowledgement and understanding of what the implications are here.
Kavita Mishra (10:48):
And using them. Unless you’re looking for it, unless you are attuned to it, you may not notice that’s even, there’s so much information now on patient charts. So I frequently had to tell people, “Okay, you hover over here. And then this thing shows up, it’s the worksheet and you can do this, and you can actually change what’s on that.” That education, it’s almost like a new feature shows up and no one has good knowledge about it.
Chris Hemphill (11:14):
When we talk about the experiences that people have had, like having been denied care or working with people that don’t acknowledge them, or aren’t even willing to perform routine and necessary medical procedures that really wounds the relationship. And you’re talking about how a lot of people don’t even seek care because of the anticipation that they’re going to experience those disparities. It seems like the there’s a rift being created every time an incident like that happens. So what should leaders be focusing on once they learn, once there’s an understanding of these differences and disparities, how can healthcare regain that trust?
Kavita Mishra (11:53):
Gosh, we have to do better on so many fronts. These general environments that patients encounter emergency rooms, operating rooms, primary care offices have to be a lot more welcoming. The suggestions that I’ve seen out there from other experts in the field are things to have the LGBTQIA, a Bill of Rights posted, all gender bathrooms instead of gendered bathrooms. All these general things that we can do just as patients enter the space, flags, pins, badges, things in the windows. Something that kind of signals to an individual that you will be safe here, and you are welcome here.
Kavita Mishra (12:34):
So if we can do that both physically and online, I think that would be really helpful. I feel worse for patients who are older because they’ve experienced all of those hurtful things over and over again by our field. And maybe only in the last five or 10 years, have these environments actually focused on being more welcoming.
Kavita Mishra (12:55):
And so they don’t have the knowledge or experience that things are chain out there for them. And I feel terrible about how traumatized they must be from their experience over so many decades. I do think that in that sense, so that’s where our primary care providers come in more and more, not necessarily that they have to provide all the breadth of hormone management, but be really willing to ask the question, “Are there any services, particularly for transitioning, that you’d like to access that I can refer you to?” And make sure those questions are always asked at every encounter.
Kavita Mishra (13:30):
And I think we need to do a better job of reminding everyone, we take care of people. We don’t take care of young person or an African American person or whatever it is. We don’t take care of subsets of people. And so I feel like that focus needs to be really there. Like how do we remind everybody in our field that we’re having human interactions every time we talk to someone?
Chris Hemphill (13:52):
It’s a really vital path is a, especially at the individual level when delivering care, you almost can’t acknowledge anything else, but this is a person. They might fit into a particular subset and everything like that, but all the nuances and all, everything about that individual comes into play when you’re doing on an individual basis. So I think that people can fall into that trap of say patient data, for example. Patient data, it’s not a spreadsheet. It’s a collection of different things that were tracked during an encounter. But yeah, data represents an instance when somebody’s trying to better their healthcare or perhaps have their lives saved. And we have to get away from this big aggregate view and understand like these are, yeah, I love that.
Kavita Mishra (14:33):
I agree with that too.
Chris Hemphill (14:34):
What kind of topics are overlooked by audiences?
Kavita Mishra (14:37):
You know what’s really interesting that I find now? Is that there are assumptions made about gender minorities, that they’re always seeking medication or seeking surgery. And I feel like what that does is it forgets the breadth of experience that individuals have and the breadth of desires that patients have. Not everybody wants hormones. Not everybody wants surgery. Not everybody wants the service that you’ve created. They should be offered the ability to get there. But I think there’s now maybe we focus too much on what does this patient want in terms of surgery or medication?
Kavita Mishra (15:21):
I think all a patient really wants is what problem they’re coming in for to be addressed and to stay healthy. So I think we may be getting into the trap of assuming what someone wants more now. And I don’t know if that totally makes sense the way I’m describing that, but I think that’s where some of the pitfalls are now.
Chris Hemphill (15:42):
That does resonate. If there are surgeries and medications available and people are coming in, but we’re only thinking about them in context of those specific offers rather than in just their total experience. There’s another question about how care for transgender teens and tweens differs from care for transgender adults?
Kavita Mishra (16:01):
Yeah. Huge differences. Mostly because I actually think the pediatric teams have done a much better job of treating the patient and the family and the schools very holistically. So I think programs are doing a much better job of involving social workers into their care, family therapy, mental health providers, and access.
Kavita Mishra (16:24):
At least my experience at Cleveland Clinic in Stanford have been that way where there’s engagement with all the individuals that en circle, a growing teenager, tween and unfortunately we don’t do that as well on the adult side. But the reason for this is just how impactful, this is what you’re shaping an individual at a time when it’s their… With so many pathways are being created, self-confidence, self-acceptance, how they approach the world. And I think, really smartly, a lot of programs are engaging everybody that surrounds the patient. Teachers, parents, siblings, friends, and I think that advocacy there on the mama bear side and on the pediatric side is really commendable. So I think there’s an approach there that I really appreciate.
Kavita Mishra (17:13):
So that in ways that things differ. Maybe you could say that the reason why the engagement is so high for parents and everybody else around is because they need to be on board and consent. And so if you’re going to have a healthy kid, or a kid that’s making the right decisions, you’re going to need approval and consent by their guardian. That’s the ways in which things are different. It’s a much longer process, intensive process, before a child understandably gets put on puberty blockers or hormone therapy. And then definitely we don’t consider surgeries until age of majority, which is age 18.
Chris Hemphill (17:52):
You brought up an interesting point by discussing the parental involvement. I didn’t know what to expect in that answer. I wasn’t aware about some of the progress that’s been made on the pediatric side, but one key element there sounds like there’s built in advocacy for the patient, which is the parent. So that person has their back. Curious, just with what you’re seeing on the pediatric side, are there learnings that perhaps that the adult care side can take from that and start using to improve their own practices?
Kavita Mishra (18:22):
Yeah. I think we need to put our money where our mouth is. If we are trying to take care of a complete individual and then we silo them into all these specialties. Patients can either get lost or feel overwhelmed. And I think we do need more social support, social work, therapy support, all of these things. These are incredibly hard for patients to access. It hurts me that we have these standards of care and insurance goes along with them that for surgery patients require two mental health letters and to get two mental health providers, some patients are sometimes in locations where mental health access is so limited. Or mental health providers who are comfortable taking care of sexual and gender minorities, those people are limited. Or just financial access. I’ve had patients tell me, “I can’t afford to see another mental health provider right now.”
Kavita Mishra (19:19):
And it’s a requirement for insurance to get coverage for a surgery. And so we put up these barriers in some way. I understand why a standard exists and we really want to make sure that a patient is healthy, both mentally and physically, before going through a surgery like this. And they’ve got that mental health support, but then sometimes things feel like check boxes. And we’re forcing people through a system that is actually really challenging.
Kavita Mishra (19:45):
If we’re going to require that a patient needs all this mental health help then that that should be included in our insurances. Or that access should be much better. So, yeah, there’s a reason why most patients wait so many years before they get the care that they’ve been wanting.
Chris Hemphill (20:03):
Just highlighting the overall impact of a system and how a lot of, if you need all these steps, these check marks, et cetera. But the access to them is disjointed. On top of the issues that you brought up earlier, such as discrimination. It just presents these giant walls to people accessing the care that they need. So we’ve been talking about that at the system level, but I’m curious about your work, like with somebody who had felt actively discouraged from receiving care, could you talk about the type of experience or how they respond to that and how that impacts those people?
Kavita Mishra (20:37):
Yeah. Most recently I had a patient whose letter was going to expire. Before surgery we ask that the patients undergo hair removal if they want a surgery where we use skin to line the vagina. And so they have to undergo either electrolysis or laser hair removal. And that whole process usually takes about eight to 12 months. And sometimes the patients, “I’m not going to go through hair removal until I found a surgeon and I know that I’m going to get a surgery.” So we get into these crazy time loops.
Kavita Mishra (21:08):
So in order for the patient to actually see the surgeon, we ask them to make sure that they have their mental health letters ready. Basically, we want to make sure your mental and physical health is stable before you come see the surgeon. Okay. So we’re going backwards, right? I’m telling you you immediately, what a patient needs for surgery is to have that hair removal. Patient feels, “Why should I undergo this right now if I’m not going to be scheduled for surgery soon? Because I need to save up money for hair removal.” And then the surgeon says, “Well, I need your mental and physical health needs addressed before you come see me.”
Kavita Mishra (21:42):
So that means we get letters from mental health providers. Okay. But you have something like COVID or you have family things occur or you have financial access become an issue. A patient has these letters, and now it’s a year, maybe six months to eight months later, they finally see the surgeon. The surgeon says, “Okay, you’re on my schedule. I can do surgery for you in six months.” Guess what? That letter, those letters, that they initially got for mental health now are going to expire because they’re not going to be dated within one year of the actual surgery date.
Kavita Mishra (22:15):
So the patient then has to go back to these mental health providers. You’d hope that they’d been able to continue care with the mental health providers this whole time, but they haven’t because there’s financial limitations to being able to continually see a therapist or psychiatrist. So now the patient feels like in order for them to get surgery, they have to go through the check mark of seeing the mental health provider again and getting updated letters, or dates on their letters.
Kavita Mishra (22:44):
And so all of this kind of feels, “I am mentally stable. I’ve got one mental health support person who can write a letter and all this stuff. But now I have to go to that second person because of this checklist.” And so we just had a patient go through all of the craziness. And it’s not that the patient has had ever done anything wrong in the beginning. But we’re making them go through this process multiple times. And that part, I wish I could just say, “No, it doesn’t matter. We have these letters. You don’t have to pay all this money to see that second mental health provider again.”
Kavita Mishra (23:16):
No, instead my hands are tied. Insurance is requiring that these letters be within a certain amount of time of surgery and we just end up in these time loops. So I feel like for patients, it’s so frustrating, and for us as well. Because we’re literally doing check marks.
Chris Hemphill (23:34):
Yeah. What you’re presenting is a really stiff and rigid and complex system. And it’s the physician and provider side, there’s the frustration of knowing what the next steps need to be, but why they’re inaccessible. And then on the patient side, absolute and the utter confusion. I’m curious, given all those complexities, given all those challenges, if somebody’s going to have an experience within the healthcare system, if you’re talking to a patient about how they should navigate their care, what would be your advice to them?
Kavita Mishra (24:05):
Usually I always tell somebody to have someone with them, because I think the amount of information a patient receives sometimes is so much. And when you’re listening to either what is required of you or what you need to define important as a patient, these emotional things hit and you may get distracted. Like even I feel this when I’m seeing a doctor and they’re recommending something and I’m thinking in my head, “How am I going to do that?” And in that much time, I have lost some of the information that they’re continuing to say. And I know this sounds so simple, but I really do wish that pretty much every patient had another person with them. And it’s got to be the right person. It’s got to be the person who doesn’t make them anxious, doesn’t anxs up, or create extra energy in the room that can be distracting.
Kavita Mishra (24:55):
So it just, that’s probably my number one thing that I tell anybody who’s accessing the healthcare system. Have another person there with you, a second pair of ears. Or ask the physician if you can record the conversation. You have that you have that ability. I find myself comfortable with that, maybe not all physicians would, to be recorded and then have something that you can point back to at a later time.
Kavita Mishra (25:19):
But I think when we’re doing the same things over and over again, it really is probably more helpful to the patient to be able to either reference or have someone else listen to it, those kinds of things. And see how tedious that is in terms of resources for a patient.
Chris Hemphill (25:33):
No doubt. Yeah. Yeah, no doubt the first part of the answer hinged on having an advocate, having somebody there with you that has your back. And when you mentioned recording the conversation, that’s an interesting approach to it too, because I’ve heard about a lot of technologies nuanced and they got bought by Microsoft, but focused on recording and transcribing conversations for mentation purposes. But what about doing topic analysis and things like that allow patients to access recordings?
Kavita Mishra (26:03):
Yeah. I think the other thing I tell patients is use their advocacy networks to find the local community advocacy groups, to get a sense of what’s available in the community, and who might have the experience to hold your hand through the process or be a mentor for you. I think that’s also important. There are a lot of resources out there. Most cities, most communities, do have LGBTQ Centers, and so there are people on the ground already doing the work can be accessed. There are other barriers to that too, but I tell people you’re not alone on this path. Many people have forged this path before. In fact, many people in your community, like right here physically, to access those resources also.
Chris Hemphill (26:47):
Yeah. That’s hugely important for people to not feel like they’re having to struggle alone. And a lot of times people might encounter an issue or that they blame themselves for, or blamed on something completely personal and then find out just from, “Oh, I’ve experienced that too.”
Chris Hemphill (27:04):
A couple more questions just related to the fact that we were talking about a lot of the recent research around this, or a lot of the recent lifting, not lifting of taboos, but the fact that we are more willing to talk about this kind of thing right now. How would you say the quality and availability of healthcare services for sex and gender minorities has evolved over the past decade?
Kavita Mishra (27:25):
Oh, it’s evolved tremendously. It’s, thankfully, it’s on the radar and a priority for every major medical center pretty much. And I think that recognition has taken too long, but it is there. And so the fact that we have leaders who are hiring physicians to address these disparities and take care of patients from this lens, I think that has made a tremendous difference. And then people within the fields reaching out to one another, to be able to create either centers, which are, which could be networks of offices, not in the same place, but just as an organizational level, centers. I think that has really changed the game.
Kavita Mishra (28:10):
I think the marketing of these services better websites, I think that has changed things dramatically. I think patients now can really Google easily. They can search easily now hormone therapy, transgender health, my city, and see what’s around or see what’s around within four or five hours and access virtual care. Or maybe they only have to see that that physician once a year. And then the rest of all their visits can be virtual.
Kavita Mishra (28:40):
I think all of these things have changed the game a lot for patients and what they can do and how they can get care. And that’s so recent, right? Virtual health was pretty non-existent two years ago and now it is really opened doors.
Chris Hemphill (28:54):
What about virtual medicine has benefited this avenue of care?
Kavita Mishra (28:58):
Oh gosh, so many things. From the surgeon side, being able to do consultations with surgeons across the country. You can get a list of providers that your insurance will cover. You can reach out to surgeons and call their offices and find whether they take your insurance. And then you can have a virtual consult and really get a sense of what kind of rapport can you build with that physician.
Kavita Mishra (29:23):
Do you trust their system? Can you get all your questions answered? Are you the focus? I think those are, that’s been very important to patients who otherwise they would have to fly somewhere or drive long distances, get a hotel room, and then see the physician at the physician’s convenience, the surgeons like an 8:00 AM appointment. That’s an incredible barrier. So at least getting through the door and getting into the system is much easier.
Kavita Mishra (29:52):
For hormone therapy, the same thing. A lot of patients may live in small towns where they don’t have a primary care doctor who’s comfortable doing hormone therapy. But you could see somebody three or four hours away who is, go there once a year to get your physical exam, and then otherwise do labs, virtual visits to discuss symptoms, et cetera. You can then have kind of this balance of in-care and virtual care, which I think is awesome.
Kavita Mishra (30:19):
So yeah, I think virtual care has helped tremendously. Now, I wish we… One of the limitations that I feel like as a provider is you’re limited to take care of patients within your state based on what license you have. And so the consultations really are a consultations in that sense. So, yeah.
Chris Hemphill (30:38):
So the consultations are across state lines. And I I’ve seen this before where somebody finds out maybe during a virtual consult that somebody’s across state lines.
Kavita Mishra (30:48):
Chris Hemphill (30:48):
I’m really thankful that you shared background on the disparities here. What the impact is and went all the way down to the individual level. But then shared a lot on what’s happening, what are some things that we can support, and the different things that we can do or focus on or support to create a better future. And for me, it was a really good learning experience. I really appreciate that. And just as a final thought, I’m curious, there’s a reason that you came in here and talked with us. I’m curious if there’s any kind of final thought or anything that you’d like for this group to just take away?
Kavita Mishra (31:21):
Yeah. I think you can’t wait for someone else to tell you to take care of this population. You have to do it yourself. And I think that you have to be attuned to sexual and gender minority patients are the people around us and they are us. And I think we don’t do a good job of keeping people in mind when we create these systems. So I think that’s probably the main thing I would say. Talk to your colleagues about whatever you heard during this conversation that rang true to you, or that you could empathize a patient going through. Because I think we just have to keep that empathy there, as we are in this field.
Chris Hemphill (32:00):
Definitely important. Let’s focus on keeping that empathy alive. Let’s focus on that topic that you brought up way earlier is that people need to be educated. Part of the reason we’re doing this is because you’re providing education to med students and people coming into the healthcare system. With that, Dr. Kavita, again, really appreciate you joining us.
Kavita Mishra (32:18):
Awesome. Thanks, Chris.
Chris Hemphill (32:21):
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