Most physicians don't want to leave medicine. They just want the work to fit a little better. A little more control over their schedule. A little more say in how their income is structured. Let's be honest, at some point, most of us have at least looked around. Because once you realize there are physicians structuring their careers differently, it gets a lot harder to ignore the actual question. 

Is this really the only way my career is allowed to look? 

Well, hey everyone, and welcome back to another episode of the Better Physician Life Podcast. Thank you so much for being here today. So today I am very excited to be joined by Dr. Leo Damasco and Phoebe Gutierrez, the hosts of the Telemedicine Talks podcast.

Leo is a pediatric and emergency medicine physician who has spent years working in virtual care and helping physicians understand what these roles actually look like day-to-day. Phoebe works on the operational and regulatory side of things, helping build the structures that make these models function, including where the opportunities are and where the constraints show up.

Both of them spend a lot of time speaking to physicians who are trying to create more flexibility in their careers without walking away from clinical work. Phoebe and Leo, welcome to the show. It's so great to see you. 

Thanks for having us. That was an amazing intro. 

I'm a little offended that Leo doesn't introduce me like that on our podcast. So, Leo, I'm gonna need you to step up your game. Yeah, yeah. It's gonna be so hard to follow that intro. Yeah, no, thank you so much for having us. It's our pleasure. 

Absolutely, and I appreciate that. So I would love to jump right in, and I'd love to know more. So both of you help physicians start looking at options, start weighing what it might look like to create a career that looks a little bit different. Talk to me about first, how this became a focus for you, and what led to this. Phoebe, go first. You wanna start, Leo, or you want me to jump in? You can jump in. I'll go with ladies first.

So I think one of the things that's, my background is all in compliance and, regulatory affairs. Really trying to translate what those like legal rules and requirements are and how to actually operationalize them. And one of the things that I've realized in my career when I went from the public sector into telemedicine was, it was the wild west, and you had companies that really did not care about compliance or doing things the right way because nothing actually prohibits them from launching and starting, like in your hospital system or health system side.

The only people that really understood me and like felt my frustrations were the physicians, the clinicians, and the companies because it's their licenses on the line, and so. To me, I kind of just formed this really interesting bond with, physicians really kind of trying to explain and almost, I don't wanna say like combat or be completely opposite of what some of the telemedicine companies were saying, but really trying to show them the right way to do things and to kind of avoid some of the missteps that I've seen. When these telemedicine, companies say, just don't ask questions it's a passive job, or it's, you know, to me we spoke the same language. And so that's kind of the big joke of how me and Leo got connected is really trying to like teach even the physicians how to kinda operationalize some of these requirements as they're venturing into telemedicine.

I think just even taking a step back and thinking about telemedicine, I would say pre-COVID, this was not as much of a thing, right? I think most physicians didn't do a ton of telemedicine. It wasn't reimbursed. We didn't have a ton of experience with it. And during COVID, it was kind of a very fast lesson in this is how it goes.Do you notice a lot of skepticism from physicians now when it comes to telemedicine? Like what comes up as you talk about telemedicine with physicians? 

You're right, before COVID, it existed, but it was more of an afterthought, it was there, and telemedicine goes back way back, but COVID definitely gave an avenue for telemedicine to flourish, right? It had to, right? That was the only option at most places. because you didn't wanna be anywhere, six feet from people, or you were dead, right? If you wanted to see a doctor, and if a doctor wanted to see you.

You know, sometimes your only choices was via telemedicine. And it exploded, like you said, and it just ran right? It was running, and like Phoebe was saying, it was run before you walk, it was just full board before any compliance, anything. And it had to catch up. But during that time, I transitioned to mainly telemedicine.

2021. Shortly after COVID, right before the whole excitement kind of went down, and it was like Phoebe said, it was the wild west. We were practicing like crazy. And it was up to you to be very cognizant of what you were doing. And at that point in time, because it was a relatively newer kind of modality.

And people were making a lot of money, and there was some sort of connotation about it. There was often a negative connotation. Hey, you know, you're just running and gunning. You're just sending out prescriptions, so forth and so on. And it's funny, there's a story that we told, in the very beginning, when I told people, Hey, I'm doing telemedicine.

You know, there's a lot of people would look at you sideways and go, okay, I get it. You know, you're just doing this for the money and, that was a quite opposite, Yes. There were a lot of actors out there, sometimes bad actors, that were just doing exactly that.

They were raking in and they were doing really good monetary wise. And at that point, there was nothing stopping them. But there were a lot of good actors too, just like anything else. Right. That were cognizant of practicing correctly, doing good medicine, first and foremost. And really protecting their licenses.

Because as time went along and as the COVID boom kind of settled, then the regulatory processes are catching up, or like right now, and a lot of these bad actors are getting the repercussions of what they've sewn initially. Yeah. And where Phoebe and I met was, again, when I was going through, a lot of people were questioning, well, some people taught me how to navigate it.

And, you know, I started teaching other people how to navigate it. And I was learning on the fly, and when I met Phoebe, I was like, oh my gosh, there's a whole freaking landscape out there that I don't know about. And I'm like, she definitely knows what she's talking about. And really, in order to protect myself, I was like, Phoebe, I'm staying close to you. Please keep me safe. And it turns out we work really well together. So another plus, and it just kind of, what we're doing blossomed out of that. 

That brings up a really interesting question, Phoebe. When physicians are starting to think through their options and telemedicine, what do you see are some of the common pitfalls that they fall into that they notice that they experience?

Yeah, so, I'm gonna give you a really long-winded answer, but I promise you it comes full circle. So, when I was a regulator. Basically, it is a trajectory. You have to be in a certain position until you're able to promote Leo, probably very similar to how it was in the military for you, right?

You have to go through and do all the work before you get promoted to manager one, before you get promoted to manager two and manager three, and, so on and so forth, right? I reflect a lot about my time in government as much as I complained about it, and I thought, you know, some of this stuff didn't make a ton of sense.

It really trained me and prepared me for, you know, where I'm at now, where I have the full landscape of, really understanding all the different complexities. I think one of the biggest pitfalls that I see is in virtual telemedicine and, in virtual care, that doesn't exist.

So it's like, do you wanna be a rendering provider on the platform, and you're licensed? Cool, sure. Come do it. Do you wanna be our medical director because you have that license? That's also really cool. Hey, do you wanna own our practice? Could you have that medical license that we need so bad? Great.

And so one of the things that I think is the biggest pitfall is, everybody always kind of freaks out about, oh, we have to do this contract and, I wanna make sure that there's not a non-compete and I wanna make sure this, and I'm like, do you actually understand the obligations that you are signing yourself up for?

You know, if you were gonna be a practice owner, you know, you're gonna partner with like a PC-MSO friendly structure. Do you understand how to review their marketing materials? Do you understand what are the key things that you kind of need to build into your monthly workflow so that you can do it and sleep at night? 

So one of the most interesting pitfalls I have just seen is you have a population of people that are just honestly like the most risk-averse group. You know, like y'all have spent way more time and money and sleepless nights, and you have to deal with people throwing poop at you in clinic and all of that stuff, right?

So to me it's like you have this risk-averse group of people that ultimately is kind of signing a lot of that away. Thinking that telemedicine operates the same as the hospital system or the traditional care system that they were raised and trained in. And it does not operate like that, right? I can cite so many companies that are blatantly doing things that violate FTC or DEA or, different kinds of regulatory boards, and are telling their clinical teams like, "No, no, everything's good.”

We think that everything's running smoothly. And so to me, because there aren't as many checks and balances in the traditional sense, you just have physicians doing things. It's kind of like the blind leading the blind a little bit. They don't necessarily know what the role is, but the telemedicine companies that they're working with also don't know what the role is, either.

I think it's fascinating for a couple of reasons. Number one on social media in these physician groups, we're constantly seeing people popping in, saying like, Hey, I've been offered this like medical directorship, should I do it? That's number one. Right? And as you're pointing out. All medical directorships are not created equally.

And number two, as somebody who has listened to your podcast, I have also heard that a lot of these telemedicine companies don't want you to ask questions. And sometimes when you start asking questions about the setup or the advertising or where they're getting their patients from or how it's gonna work, all of a sudden the offers go away. Which to your point about being risk-averse, I think physicians looking for flexibility, looking for freedom, are sometimes thinking like, oh, this is an easy path forward, and you have to be really careful. 

Yeah, exactly. The interesting piece is that, in the hospital system, for example, you know, in traditional healthcare, let's call it before, kind of like the boom of telemedicine and cash pay, there were a lot of regulatory checks and balances.

If you're doing insurance right, there's gonna be somebody auditing what you're being billed for, and there are all these other safeguards that kind of come into place on the telemedicine side when it's cash pay. You're kind of left at the whim of the company.

Now I'm not at all saying that, like all telemedicine companies are, like crooked or doing anything crazy. I think a lot of what happens to my point earlier, you don't know what you don't know, and so there aren't too many people out there that really understand the full landscape of how to build a compliant infrastructure with some of these, PC-MSO structures, or how, really, what like a PC owner is liable for if a regulator comes knocking.

Right? Like that to me is one of the things that me and Leo really try to prepare. Fours, like at the end of the day, like we have a solid, defensible framework, and we have chosen to be very selective with the people that we partner with. We've kind of, I don't wanna say learned the hard way, but you do, you kind of take on different opportunities, and you realize after asking a bunch of questions, certain ones aren't necessarily gonna be for you because the risk is ultimately not worth the reward.

For sure. Now, Leo, how have you navigated this process? Because you've been doing this for a long time. What does that process look like for you? It's evolved over time. And it's taken a few years, but it's exactly that's what it is. You mentioned it, you don't know what you don't know in the very beginning.

And a lot of these offers, especially for a burnt out physician, especially for somebody that wants to try to work outside the box, and these offers look great on paper. And, they're very enticing, and they want you to just take it. And a lot of times these companies may know, and just kind of wanna keep it hidden, but a lot of times, I've found is that they just don't know either.

You know, in the very beginning, I was one of those docs, I was like, oh, this is awesome, this is great. And just eating up the opportunities and taking collaborations, evaluating PC ownership, so forth, and so on. And after learning and talking to Phoebe and whatnot and, you know, getting all the information there's a lot of stuff I'm not doing now that I was doing before to keep myself protected.

Right. You know, I got rid of a lot of collaborations that weren't set up as concretely as I would like, actually. Stop doing collaborations altogether until now, until I have a good framework. Knowing what I know now in the PC ownership deals, having the now, knowing the tools to go in and ask what I ask and not being afraid to do so, it's funny, like Phoebe was saying, for somebody that's so risk-averse and so used to asking questions and evaluate.

You know, when it comes to the business side, when it comes to the PC ownership side, we have almost none. Right? We don't have that class in med school. So, we kind of just take it for face value, right? And saying, oh yeah, they're gonna take care of you because, when we were getting jobs, and brick and mortar stuff, the regulations are set, and you trust that, you know it's been in place.

So when you go into a job, it's really, what are you asking? What's my pay? What's my, you know, call schedule? Do I get time off? So forth and so forth. But, you know, these are a new set of questions to ask. Hey, who's your PCO? Or, what's your review process like?

What's your procedures like? Are you sync or async? Just all these processes, and now, after years, it's still evolving, to be honest, being able to. Add more tools in my toolbox to go in and now having the confidence, no walking away, or, hey, let's evaluate this further and see where it goes.

And if there's like, you're on the fence, and the companies are like, no, we are disregarding your concern, then out you go, you know? Definitely. And you were saying, Hey, the offers go away. That's not necessarily a bad thing. When the offers go away, and they're not respecting your concerns, then great.

That's a great thing. Let the offers go away. 'Cause you don't wanna be a part of that, right? Yeah. So if you had advice or suggestions for physicians who are just interested in exploring, like where would they start? What would they do? That's a good question, 'cause information's all over the place.

I should say, other than your podcast, Telemedicine Talks. Yeah. Other than emailing Phoebe, if you find the right community to look in, there's gonna be some insights into that. And it's really that the experience.

Trying to find that. So learning from others' experiences. So, trying to find the right community and asking the right questions is the best place to go. Any specific ones? It's all over the place. It's kind of scattered. But, I don't know. Phoebe, is there anything that you can think of specifically? 

Yeah, I think that the hard thing is, and I will have like debates with people all the time, a lot of this is very operational, and so it really is, of course, there's the key sets of like what you can do and what you can't do, and kind of how to like learn about the element. But ultimately, a lot of it is like very personal and how you want to build certain things in. So to me, this is kind of what I do a lot where I work, one-on-one with different physicians, and I really try to understand, not so much, just like, do you wanna do telemedicine? And here's how you start, and here's how you go. But you know, with one of our colleagues, I always joke is like, he's been in the game, he's been doing this for 20 years. I'm like, dude, you just need to be a medical director.

Like you really need to like mentor these people and show them what to do. And if you try to do anything else and tell 'em, I think you're gonna hate it. Just like you hated the emergency department. So I think one of the key things is. Yes, money is great, and yes, you know, like, everybody kind of wants to look at how Leo's doing this or look at how other people are doing this.

But I also think that there's a really big, kind of like introspective internal question that you have to ask yourself, right? Like, some people like doing the telemedicine work where you sit behind a screen and you click the button. That seems a little boring to me. I don’t know. But, you know, maybe some doctors really enjoy that.

So I think half of it is really trying to understand, like what is it about your current role that, besides having to be brick and mortar and having to work, and kind of just being burnt out with the traditional system. what are you trying to escape? Mm-hmm. And where are you trying to find happiness?

Are you in that place of your career where you really wanna think about like the mentorship and the education? Like where Leo is at, right? I've done the work, I'm now ready to elevate it and do more of the operational stuff, right? Are you just trying to explore telemedicine and you wanna see what it's like to do virtual care?

Because deep down, maybe you wanna build your own telemedicine company. There's a lot of questions I think that you need to ask yourself internally before you just go like, what are the rules? What are the regulations? How can I do this? Because, I mean, Leo, I'll let you answer, operationally, when you start it is tough.

It is really hard. And I think one mistake I see is a physician will burn out in the emergency room and then immediately burn out in telemedicine because they didn't actually think about what they're really passionate about, and then they end up like, I'm just prescribing this thing that I really am not super interested in. You know, it's clinically needed, but it's just not igniting that fire. 

This is such an incredible point, which is that so many physicians are looking for flexibility, and in the process, rather than really understanding what are the changes that they want to make. They're running away from something, but they're not quite sure what they're running toward. To your point, Phoebe, like this is such important work to first figure out what are the parts of your current work that you're struggling with. To actually create a strategic plan for where you want to go next. 

I heard on your podcast it was, Dr. Dany Accilien. He dropped a line and Leo and I were talking about this before on your podcast, which was the problem with incentives is that they work. And so if you know you're just looking for flexibility or you're just looking for income, but you're not thinking about what does the job actually look like, what does it entail? Yeah. What am I signing up for? You fall prey to the incentive without actually understanding why you're doing it in the first place.

Yeah, I completely agree. I take a lot of like my own personal, work where I've worked at many companies. I've made more money than I would've ever, expected. And I was not happy. I didn't feel heard, I didn't feel valued. and it wasn't anything the companies were doing.

It was just like the nature of business, right? For me, I really found that, sure, I can continue to, you know, consult for large companies. But I love working with the doctors. Like I love it because I feel like I'm fulfilling, I'm paying kind of like my experience forward to people that really kind of need the work.

And I think that on the physician side, it's kind of very similar to that a lot of the clients that I've worked with, Leo included, is really trying to kind of get in and understand, like, what is it that's missing? Because if you don't identify that and you truly jump in, I think that it is, again, like a fatal flaw where you almost get like paralysis of like, how do I get up to speed in this new industry when honestly not too many physicians have been trained, even in like the digital aspect of how to do some of this virtually and to the point of, early on of our conversation is COVID forced this. 

So I think naturally, we would have gradually gotten here. When I was actually a state regulator, I was working on some of the telehealth policies for the state of California. And it was interesting 'cause I don't know, we probably had two more years to go, and then COVID hit, and it's like, all right, well, I guess the policy's out the door.

So I think, you know now because of the way that it was even introduced, there is a good sense of people that could be overwhelmed and, I don't want people to get a bad taste in their mouth because your onboarding wasn't as like, flawless as it should be, because the training doesn't necessarily exist today.

That's a good point. It's more walk, more run. Right. Or walk before you run. Right. One of the biggest pitfalls, too, is people getting in these positions. You could go to LinkedIn and be like, oh, there's a medical director position, there's a PC owner position, and taking it without actually practicing telemedicine, without actually doing the clinical work, and without actually knowing the structure, how things go, so forth and so on.

So, you know, a lot of my opportunities came when I started clinically with the company and just started learning, and the more I got deeper in the company, got administrative duties, so forth and so on. My knowledge base and just grew and I was able to understand kind of inner workings. So, you know, jumping straight to these medical director jobs.

Now there is some, similarities, you know, if you're doing admin jobs and brick and mortar. But again, there definitely are nuances that you need to understand once, once you switch to the telemedicine side. Well, I love the connection that you just made too. 'cause a lot of times physicians are critical of the people passing down the rules and the regulations from the C-suite who aren't actually kind of doing the work and doing the thing.

So, to your point, to take on a medical director role without actually understanding the nuances of what the work looks like, it can be a huge challenge. This has been amazing. I'd love to know anything that we didn't touch on that would be a takeaway for the audience, things that they should think about moving forward.

Yeah, I mean, I can say that bringing back the episode with Dany, I think that. I really wanna see more physicians leading at the forefront of the telemedicine and digital health movement. I think that it is really, really important that physicians get comfortable flexing non-clinical skills and really there's so much that you can do in the digital health space that will one, fulfill you outside of just like the clinical work. But that will also help like, make a lot of, this new era of medicine stronger. So, you know, Dany is, building AI tools and is like a mini engineer as a physician.

Like next he's gonna be a lawyer. Watch this man just never ceases to surprise me. But I think there's so many different avenues, you know, we've had people on our shows that were clinical product managers or doing sales for companies. Like to me, there's so much that you could actually learn by coming in, and you could actually see other aspects that you're naturally, good at.

Like Leo is just naturally good at sales. He could be like the sales guy for some of these companies. As much as this conversation was probably really scary for people to listen to, like, I'm never going to telemedicine.

I think like we need physicians in this space, and I would encourage physicians to really get comfortable because this is the future. And I will tell you there are so many companies that are being led and built wrong. That probably will cause patient harm because it's not super-regulated today. And I would feel a lot more comfortable, and I'd be able to sleep better at night if we had more physicians that were ready to take the leap and support some of these companies.

Yeah. I'm gonna piggyback on that. In the brick and mortar space, the docs, we've lost initiative, right? We gave up those positions, and now we're paying the price for it, right? We are. I use this term a lot, clinical monkeys, right? We are told what to do, and as long as we sing and dance, we're good.

And then, you know, and this is how the burnout happens, right? And one of the biggest pieces of burnout is just we don't have, say in what we're doing, you know, telemedicine has given us this avenue where we could take that back. But you have to do it correctly, right? You have to educate yourself, talk to people that are doing the job right now, and there's a lot of telemedicine OGs out there that you could talk to and learn how to navigate this.

And like Phoebe was saying, it'd be great to see the docs back into a position where we actually dictate what medicine is versus being told what to do. So this is the, one of the most exciting parts is that. They actually listen to us. you go in a C-suite and you say, Hey, I'm Dr. So and forth and so on. And you know the companies that you wanna stick with, they will stop and listen to you and take your input and actually run with it. So that's actually very refreshing to say. So wanna see more of that as well? 

Love everything about that. It's so important, so necessary. And for people who want to hear more from both of you. Tell the audience where they can listen to you. 

Yeah, Telemedicine Talks podcast. Thank you for that. And really any platform. We're in Spotify, iTunes, just Google us. and we're there. But yeah, telemedicinetalks.com.

Also, I will plug by popular demand. We are just seeing so many physicians that just have questions or wanna brainstorm. And so we are actually opening up a Telemedicine Talks Slack channel. It's gonna be linked on our telemedicine talks website. It's free. Join if you'd like. The biggest thing is for people that do have basic questions or are looking for some sort of support, or just, yeah, wanna see what other people are doing. Like, we wanna also be a place where people can get information, but also, feel like they're surrounded by their peers. I see some consultants also. 

You mentioned these docs going into these conversations, saying, Hey, should I take these PC ownership gigs? This is exactly the conversation we want to have and could help facilitate. So, yeah, absolutely. Sounds like a super important community if you're telemedicine curious, and you are looking for really great insight, and your podcast is excellent. And so I really appreciate both of you.

Thank you both so much for being here. Phoebe Gutierrez, Dr. Leo Damasco, thank you again to the audience. Thank you so much for listening, and I'll see you on the next episode of the Better Physician Life Podcast.