Episode 5: Highlights and Insights, Part 1

A deeper dive into the first four episodes reveals new insights about the changing mindsets in healthcare. Join Scott, Michael, and Jared as they share additional articles and resources related to themes from their conversations with Dr. Kirschenbaum, Dr. Greene, and Robin Kingham. Highlights reflect themes of trust, empowerment, the new patient/physician relationship, and more.

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Show Resources

Bedside Manner and Patient Satisfaction

1. Compassion, patience, and bedside manner improve patient satisfaction


A study from Healthgrades and Medical Group Management Association (MGMA) analyzed seven million patient reviews and comments about health care providers. This Patient Sentiment Report found that over 52% of patients stated that they wanted their doctor to have at least one of the following qualities: compassion, comfort, patience, personality and bedside manner.

2. Can bedside manner affect malpractice cases?


According to a study published by the University of California, a patient’s satisfaction with medical care, their compliance with treatment regimens, and the outcome of treatment tend to be substantially related to their physicians’ ability to satisfy their socio-emotional needs in the healthcare encounter. To put it simply, when doctors are nice and likable, their patients are more likely to do as they say and trust them.

3. Physicians’ bedside manner affects patients’ health


The review found that relationship-focused training had a small but statistically significant effect on the specific health outcomes in patients with obesity, diabetes, asthma, or osteoarthritis. Among other things, it could affect weight loss, blood pressure, blood sugar and lipid levels, and pain. In fact, the researchers noted that the impact was greater than the reported effects of low-dose aspirin or cholesterol-lowering statins for preventing heart attack.

Treating Patients in Poorer Neighborhoods

1. Hospitals, doctors moving out of poor city neighborhoods to more affluent areas


A Pittsburgh Post-Gazette/Milwaukee Journal Sentinel analysis of data from the largest U.S. metropolitan areas shows that people in poor neighborhoods are less healthy than their more affluent neighbors, but more likely to live in areas with physician shortages and closed hospitals. At a time when research shows that being poor is highly correlated with poor health, hospitals and doctors are following privately insured patients to more affluent areas rather than remaining anchored in communities with the greatest health care needs.

2. Listening to low-income patients: Obstacles to the care we need, when we need it


The article lists off many reasons that low-income patients struggle. One of the issues cited was in trust of the providers. The interviews revealed that many of these low-income patients have had poor experiences with care in the past and do not trust providers or traditional medicine to help them, leading them to forgo needed care.

Empowered Patient Communities

1. Patient communities list from e-Patient Dave

“e-Patient Dave” deBronkart keeps a running list of online patient communities.

2. Patient education information vetted by physicians

Health Tap provides patient information vetted by physicians.

3. Perspectives from the advocacy community 


Many value frameworks simply reflect the clinically focused values held by health‐care professionals rather than outcomes that also matter to patients. Frameworks should attempt to incorporate the broader range of outcomes that patients may regard as more relevant.

Full Transcript

Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone, and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans. And many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together. And here are some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to the “Paradigm Shift of Healthcare,” and thank you for listening. I’m Michael Roberts with my co-hosts Jared Johnson and Scott Zeitzer.

This week, we’re gonna dive further into the shifts that we’ve discussed with our guests in the first few episodes. So in our first three interviews that we’ve had, we spoke with two orthopedic surgeons and an education manager for a large patient advocacy and research community. We covered very different topics and so I really enjoyed the types of discussions we’ve had, but I wanted to make sure that we take a break and go back and tie their stories into the larger trends that are actually happening around healthcare. This isn’t just the fact that Dr. Greene is such a nice guy, that Dr. Kirschenbaum is working really hard in his community, that Robin’s really connected with patients. There are larger trends, there are larger stories that are happening not only in these communities where they’re located but really across the nation.

So we’ve got the three of us here. I wanted to go back and bring up some details. I’m going to talk about Dr. Greene in particular and we’ll kind of bounce the discussion around, but I wanted to tie this in, like I said, to what it is that each person’s doing and how it’s affecting the larger whole. So let’s jump in with Dr. Greene.

Dr. Greene: I really view the doctor-patient relationship as just that, it’s a relationship. They’re entrusting me with something that’s very valuable. I don’t take that lightly. And so, you know, one of the things I tell people if they come to me for a surgery, I say, “Look, this is kind of our first date, all right? So, we’ll just get to know each other.” So, we do have this relationship and that’s important because I think trust is so important.

Michael: Dr. Greene, in Episode 3, we spoke about the details of his patient appointments. When he gets in there, there’s a specific spot that he sits in the room, there’s a specific way that he interacts with his patients, and it’s all very calculated, and it’s all…and that can sound kind of cold to say that it’s calculated, but it’s calculated in a way to bring more connection, more warmth to other people, to have that relationship more solidified.

There’s the quick benefits that you think of. So one of the big things that everybody has to think about now, if you’re a provider of any sort, is what kind of reviews you’re getting online. So as we’re going through these notes and as we’re talking about each of these different guests that we’ve had on here, we’ve prepared a number of links that we’ll be including in the show notes, we’ll also be including in the blog post that you can find at paradigmshift.health, and we can really explore these concepts a lot further.

But in this first article that I’ve found to go along with what Dr. Greene was talking about, there’s a study from Healthgrades and the Medical Group Management Association, the MGMA, and they analyzed something like 7 million reviews and comments about healthcare providers. Over half of those reviews, that’s over 52% of patients said that they really wanted to have one of the following qualities from their provider: compassion, comfort, patience, personality, and bedside manner.

So right off the bat, we can easily link that story, right? Dr. Greene is a nice guy, patients say that they want to have those kinds of reviews. I think that that’s a pretty obvious connection, but it’s more of the other articles that I’m pulling together here, one where a guy named Dr. Edward Mallory talked about how much of a difference when it comes to malpractice cases bedside manner actually makes.

So you think about…there’s obviously a very high percentage of providers have to deal with malpractice cases at some point in their career, and here’s a way that you can reduce that. Again, reviews are good, you’re reducing the number of malpractice cases, hopefully, just by being a nice person, and these discussions, so you’ve got point one and two, that makes a lot of sense.

And then the last article that I pulled here from the site advisory.com, that actually bedside manner actually affects patients’ health as well. So it’s not just, “Hey, I’m causing less problems for myself and I’m getting these reviews,” but there’s actually outcomes that are affected, and they go in to say that researches noticed that the impact was greater than the reported effects of low-dose aspirin or cholesterol-lowering statins for preventing heart attacks. So it’s not that it, like, completely revolutionized everybody’s care, but it had a measurable difference for patients.

Scott: Yeah, that’s frankly a big part of the way that Dr. Greene is wired is that he is just empathetic in nature, he’s also a science guy. And so as he started to realize that, “Hey, this is helping my patients.” And I know, I’ve spoken to Dr. Greene many, many times, and it’s critical to him that he tries to do well with his patients. He knows that he gets better results. It wasn’t a study that you’re talking about. It was more just seeing, like, better outcomes with people that trusted him more.

And you can kinda get a feel for that, all of us, as we think about our doctor-patient relationships that had that kind of conversation in their head of that trust is built with someone and so when they offer suggestion, you want to try to do it, you want to try to comply. I know I’ve had many conversations with family members when they don’t like the doctor. It’s the exact opposite, right? “Oh, that guy wants me to do X, but I don’t trust him.” It’s like whoa, what happened there? And just the exact opposite, that, “My doctor really cares about me. It’s important that I take my medicine on time. I feel so much better, you know, when I spoke to my doctor about X.”

I have a personal story where I had a hernia surgery. It’s a very simple surgery, probably one of the most simple general surgery operations that you can receive, but I was very nervous about it. And here I am, right, the biomedical engineer, a person who works with surgeons and doctors all the time, and I’m nervous. I’ve had my surgery, and I’m kinda nervous about doing any kind of exercise afterwards and I knew the surgeon and he had built trust with me, and he looked at me. And he said something along the lines of, “Scott, your surgery went great. And I’m telling you, you can lift the house today and it’s not gonna affect your surgery.” And I’m telling you, guys, I just felt better. I was done. I felt better. That’s it. I started to work out, I wasn’t nervous. So I can see how all that can come into play.

Michael: For sure. Jared, you worked in a couple different settings with healthcare. I know that you worked with hospitals in the past, that sort of thing. Can you tell us a little bit about… I guess, did you have any sort of…ever have to deal with patient reviews, that sort of thing, in those kinds of settings, and see where certain doctors kinda got it more than others.

Jared: Absolutely. One of my responsibilities at one point was to look at every review that came in, in very different formats and channels, on Yelp, on Google, on Facebook, to start off with, so mostly publicly available online reviews and not ones that are being solicited at all versus our HCAHPS or whatever press they need, you know, actual patient surveys. So I would look at all of those, and sometimes, I would read every single one, and other times, it was just a recap report.

But whenever I pored through them, the trend was consistent across the board that the things that people cared about, or at least enough to write about them in a review, were nearly always, I mean, it was always 90-something percent of those reviews either have to do with one or two things. One was the billing experience, how terrible it was, and the other thing was bedside manner. In fact, some of the times, quite a few times, you know, quite a few of those were not even having to do with the doctor. It was a PA. It was front office staff. It was the nurse, the nurse practitioner. It was someone else other than the physician who was being mentioned in a review, and you know, that led to at 1-star review versus something else.

And it was like, “Oh, by the way, I got treated great. You know, I’m fixed now, but this one person seemed impatient with me or they seemed like they had a little attitude or bedside manner stopped” or whatever it was. And those trends were consistent month after month after month after month. So that just led me to really understand the importance of it on a patient’s perception of the overall experience. They could have been completely healed from whatever caused them to come in in the first place, and that was only part of the reason why they were happy or sad at the of the day. I mean, at one point, it was so mind-boggling that I kinda had to sit back and think, you know, if I’m a doctor, how do I deal with that?

I think the biggest part for me is bringing that up with more and more of the doctors along the way, when we’ve mentioned that, because they got more aware and more conscious of those types of reviews that were being left for them. They wanted to know exactly what was their average star rating and things. You know, some were a lot more aware than others. And so we have these conversations, and they’d be like, “So, what do I do?” And sometimes, it wasn’t just an easy answer. It was like, “Well, you know, read these. Read the actual reviews.” And if you’re willing to understand where that perception comes from, you can see that they’re happy with their care, but…

Scott: That’s an interesting point you bring up, Jared. I know that Dr. Greene actually works with his team as a whole, and he talks to the entire team in the office and tells that team how important it is to take great care of the patient. And he walks them through that. And I can’t tell you how many surgeons I’ve spoken to over the years who had a similar issue with, “Why? As far as I can tell, the surgery went great.” And I had to kinda look at them and go, “I’m sure it did. But did you show enough time to the patient? Did you talk with them long enough?” If you keep getting poor reviews about billing, well, perhaps it’s time to go talk to the billing people about what’s happening? Why is this occurring?

I spoke to a friend of mine who had a LASIK surgery done. And they said, “It went great but I wrote him a poor review.” Okay. I’m curious. Why did that happen? And he goes, basically, it was, “I can’t believe that they made me pay in cash.” I said, “I don’t understand. Why did they make you pay in cash?” He was starting go on the lines of you had to pay extra if you didn’t want to pay with a credit card, they didn’t like the way they were spoken to, etc., etc., and I’m thinking, “Wow, here’s this poor review that came in with a person with excellent results and it is about the bigger picture.”

Getting back to the core of the conversation with Dr. Greene, he makes it so that the whole team works together, not just him. And I think that’s part of his success. But I know that in the future, and look out for this, we are gonna be interviewing other people and one is an office manager in an orthopedic practice that I’ve known for a long time, and that balance between the time to see a patient, to take care of a patient, to process the patient, and frankly, make a profit is a very difficult set of operations and calculations to make. And that’s what you’re talking about here.

Michael: That’s actually a good segue into Dr. Kirschenbaum. Here’s a guy that not only came in to improve care in a particular place, but also really tackle the entire system around that.

Dr. Kirschenbaum: I tell them, “You give me four years and I will give you a career. There is a unique opportunity to get busy right away, get tremendous oversight in the beginning of your training, be brought along properly as a surgeon, hone your skills extremely well.”

No one’s coming here to practice. These are top surgeons to begin with, and they understand that the opportunity is two-fold. One is they have patients who are extraordinarily appreciative of the effort and the time that they’re spending and have very advanced disease with multiple comorbidities. So the people I attract want to treat people who need extremely high-level surgical skill. So high-level surgical skill surgeons are attracted to a place that has challenging cases.

And the second reason is there is a lot of camaraderie in the department. There’s a lot of opportunity for research, for innovation. We have interesting arrangements on how surgeons can invent things and do intellectual property and benefit from that themselves. So I have a model of innovation built in to the recruitment. And also, once you build a reputation that people have been happy here, you know, over 5, 10 years, then word gets around.”

Scott: Yeah, you know, Kirschenbaum, a good friend of mine that I’ve known for a very long time, he actually has worked in most every area that a professional surgeon can work in. He’s, of course, gone to residency, but he worked for Kaiser for a while. He worked in private practice for a while. He’s won a…ended up at a hospital system in, I think, the poorest congressional system in the United states. He’s worked for a large practice as well. So took a lot of that experience with him in terms of measuring and trying to come up with systems that make sense.

You know, you mentioned that Dr. Greene got very science-based about how to be most empathetic, and it wasn’t something fake. It was more like, “Wow, this is very important to me, I need to come up with a way to structure these conversations so that I can be most empathetic.” It wasn’t like he was trying to fake it. He just thought about it from a systematic approach, a medical doctor who probably did very well in science over the years, and that’s just how his mind thinks.

Same thing with Dr. Kirschenbaum, the say he sets up his clinics and the way that he works with his team to make sure that all of the carers, again, it’s not just Dr. Ira Kirschenbaum and that surgery, like Jared was talking about earlier. It was, “How did his team work with the patient? How did the entire workflow go?” He has lighting set up with different color codes in his clinic so that everybody knows when to go in and when not to go in. It’s amazing. And he processes a lot of people quickly and efficiently and gets a lot of hugs at the end of the day. So it’s a pretty good set-up.

I know that we’ve got quite a few articles that we can refer and we’ll have it up there. One is a 2014 article. It must have been some sort of joint effort between the Pittsburgh Post-Gazette and the Milwaukee Journal, and essentially, they are finding that the analysis shows that the largest U.S. metropolitan areas shows that people in poor neighborhoods are less healthy than their more affluent neighbors. And that’s kind of a gut feeling that we’d all would get without that, but here they are proving that sentiment, and it doesn’t surprise anybody.

And here’s Kirschenbaum again, going against that whole trend, that’s why he did do what he did. There’s a lot of research that shows that being poor is highly correlated with poor health. Hospitals and doctors are following privately insured patients to more affluent areas rather than remaining anchored in communities with the greatest health care needs. It’s just a plain fact, and that’s what I found so interesting about what Dr. Kirschenbaum did. He not only went to a poor neighborhood, not like as if he’s falling on the sword, excuse me. It was more about, “Hey, I can come up with a way to solve this with what’s out there now.” And he did. It took a lot of lifting, but it did. He did. He was very successful about it.

Michael: I think that’s one of the interesting things as we were preparing for the show is we were talking about what is the government need to get in and solve, what does a large healthcare organization need to get in and solve, and versus what can somebody do right now, with the tools that they have available. And I love how Dr. Kirschenbaum was able to get in there and make change happen without having to wait for the government or for a large healthcare system, or for policy to shift or for all of these other things that could happen eventually. He was able to step up in the immediate…

Scott: Yeah, there are a lot of podcasts out there where you can listen about policy and arguments about healthcare policy, and we’re much more focused on hey, this is what we have now, and how do you deal with it? And that being said, I do like that he came up with some solutions about that, at a time when a lot of faith-based nonprofits which moved in to “solve it all” and some have been successful, some have failed, and we don’t know what all the solutions could be today, he has one good solution. But I really do think, the one thing about Dr. Greene, and the one thing about Dr. Kirschenbaum, from our conversations, was how important both of them felt it was to build trust with their patient. Dr. Greene works in a fairly affluent area, in Baton Rouge, he takes care of everybody, that I know for a fact, but he takes care of a lot more private patients than Dr. Kirschenbaum certainly does, but they both care about building trust with their patients, through themselves, as well through their teams as a whole in a very structured way.

Jared: I think that’s really fascinating, Scott, because I think it kind of points us to the fact that one size doesn’t fit all with doctors either, in terms of what motivates them and what their understanding is of the patient, because there are clearly those who are more focused on building trust with their patients than others. And when anyone comes in, whether it is the next government mandate or whether it is someone else in the their practice that the business implication, those who hold the keys to how prosperous they’re gonna end up being, there are a lot of different things that motivate physicians in different ways.

And you have heard great examples from Dr. Greene and Dr. Kirschenbaum of different motivations and what that tells me is just the way that Dr. Kirschenbaum built his clinic, the way that he has…not even the clinic but the whole team at the hospital now, like you said, from all the different settings he has been in, he has found ways to build teams around him to all be successful together and he’s used those motivations and that understanding of what drives physicians in different ways, he’s used that to his advantage. I remember him speaking about bringing other…recruiting, about recruiting to the hospital once he started there, and how he would explain, you know, this is not just, “Hey, do you wanna accept a challenge,” you know. It’s like, “Do you get what I’m doing here? Do you want to be a part of this?”

Scott: Exactly.

Jared: “And if so, then what will it take to bring you here?” And wasn’t manipulative at all. It was like, “Look, if you get what I’m doing here and you want to do it, come be a part of it.”

Scott: Yeah, it is something that I’d read all too many articles about when trust isn’t built, how it fails, especially in a low income setting where some people feel the answer is, “Well, just be quick. Get him in, get him out. And then we’ll make it up in volume.” I think that that’s actually a red flag, quite frankly. Because if you don’t build trust up, you’re not really listening to your patients. I know that I’ve read reviews about, “Hey, this doctor was more of a pill pusher. This doctor didn’t really care about me.” And those are red flags.

And I think, you know, you get back to that whole how important reviews are. I’m not certainly suggesting that every doctor should go online and change everything that they do, that’s just plain silly, but I do think, since most doctors probably have a more of a science background and I’m glad that we’re finding more with the arts background, I think that’ll even things out in terms of overall care, but I do think that having an open mind and if you do see patterns where you’re not getting the kind of results. I mean, I speak to some surgeons, they’ll talk to 30 or 40 patients in an afternoon. And they’re trying very hard, desperately hard to sit and take the time to be with all of them and be late at the end of the day. But they don’t know what happens to that patient when they walk out the door. You know, Michael, they don’t know that they went to the billing person. They don’t know what kind of information they’re reading after they talk to them, which is so critical to get good information to the patient.

It’s not just… A lot of these doctors and surgeons have so little time to build that trust and empathy, and then it’s about that follow-up, especially for long-term care people. When we talk to orthopedic surgeon, generally, they come in and they “get fixed.” Yay! But with people like, say, with diabetes, heart issues, etc., these are long-term care issues, and in some ways, that’s good, because you can build trust over time, and I’m talking about for the doctor-patient relationship. In some ways, it’s like…I think the joke that Robin had made about if you don’t have good information out there, you can search online and make sure that even if it’s bad information, that you’ll get somebody on the internet to tell you that that’s correct.

Robin: Having someone who actually knows what you’re going through, has experienced it, it really makes a difference in your mental health and your ability to get through the day. So through Take Steps, it’s building that community. It’s introducing families like yours to other families with small children that are, you know, going through the same thing.

Golly. Just yesterday, I was on the phone with a mom of a patient who had questions and needed support and we were on the phone for over an hour, probably an hour and a half. And I’m kind of like tearing up a little bit just thinking about it. It’s being able to provide hope for people in a situation where they’re confused and they don’t understand and, “What do you mean now I have a chronic illness that there is no cure for?” So, it’s letting people know that there is a new normal and giving them hope for a normal life. A normal, long, full life.

Jared: That’s a great way, Scott, to really just focus on Robin’s topic for a few moments here too, in terms of really her focus and her world that she lives in. I loved diving into this world personally, because when we are all patients, it’s almost like we are so focused on understanding everything. It’s like we’ve all been just shoved into the deep end of a pool and we’re all just trying to catch up with everything. To know in advance about patient communities and about what it means to be empowered as a patient in advance, I think, is so telling. And that’s why I think just thinking of this as just a shift unto itself. A lot of the resources and things that Robin mentioned were just things that I don’t think we can overemphasize and overcommunicate out there because everyone’s gonna need to be a part of some of these efforts one day, or we need it right now and we just don’t realize it, or we don’t know where to find it.

So Robin spoke a lot about empowered patients and patient advocacy and communities out there. And one of the most well-known, I guess, empowered patients out there these days is e-Patient Dave, Dave deBronkart, who has just, for years, been battling this battle of how to really change, like completely turn around the patient-physician relationship into something that makes sense for both sides. He wrote a book about it at one point. He has a lot of communities available on his website. His website’s epatientdave.com. He has a Communities page that just lists a ton of these that are disease-specific and that will help, if anyone just wants a starting point for, “Hey, is there a community for such-and-such type of patients?” He has a starter list there on his website, which is a great resource.

There are other types of services that focus on involving physicians as well. There’s one called Health Tap, that some of you listening probably know about, but it’s basically a community out there that helps consumers have free access to more accurate online health information. And they make the point that the information that they provide is sourced directly from doctors. So, Michael, I know that’s something that you’ve mentioned before that is interesting, especially on your family’s journey that having accurate information, that’s from a validated source, you know, from a doctor, has bee helpful. So I was curious how that part has gone for you, how helpful that has been or that has not been for you.

Michael: It’s made a world of difference. We, as parents, when we first found out about our daughter’s condition, having Crohn’s, you know, we go online and we start talking to people about, “This is the experience we’re facing,” and this is even before we’ve diagnosed it, what’s actually happening, just our daughter having all these health problems. Everyone has a solution for you, right? “Oh, you need to try this diet. You need to try this supplement. You need to try this…” And there’s a list that just goes on and on and on.

And people, if you’re a parent out there and you’ve ever had this conversation with somebody, people have opinions, and they push very, very strongly on those opinions, and it even gets to a point where people can almost…and depending on your relationship and your friendship, but we’re definitely had some conversations where, you know, people said, “How dare you not take care of your daughter by doing what I tell you to do,” essentially. And it’s the most self-righteous, frustrating conversation you can have, because just its implication of, “Well, you don’t really care about your kid.”

Scott: Yeah, that’s what I like about what Robin brought to the table and what groups like what Robin does is that it’s empowering patients with good information that’s been vetted. And anybody, any patients that’s listening right now, that’s the key thing – properly vetted good information is critical.

The other thing that I thought Robin talked about which was so helpful was just making you feel like you’re part of the community of others that have the same problems.

I can’t tell you how many times I’ve spoken, especially to younger residents, I remember talking to a resident once, and the resident said, “Wow…” I’ll never forget this. This is, like, 25 years ago, it’s like yesterday, maybe 30 years, at my age. I’m getting older. And then the resident said something like, “Wow, I can’t believe that that patient is so scared of a simple sports medicine procedure.” It was a simple sculpt. And I looked at him and I said, “Well, how many times have you been operated on?” And he looked at…big, strong guy, he goes, “I’ve never been operated on.” I said, “Well, maybe next time, when you’re gonna get operated on, you might have a different perspective and…” He called me up, actually, we talked to each other many years later, it was probably a decade later, I think I was doing some work with him, some online marketing, and he said, “You know, I still remember how stupid I was that day.”

But, guys, the takeaway for me from all this is you need to find a physician, a surgeon with whom you‘ve built a good relationship, where there is trust. On the other side of the coin, the surgeons and doctors, they’re trying to figure it out too, and they’re trying to figure out how to build that empathy, how to build that trust. I’ve never ever met or spoken to a doctor in the last 30 years who basically said, “I don’t care about my patients. Whatever, man.” Like that has never the case. I mean, Jared, you’ve been in this business a long time. Have you ever heard that?

Jared: Never, never.

Scott: Yeah. I can promise you that everybody’s just trying to figure it out. But I do think some of those takeaways are…and this is on both sides of the coin, take the time to build trust with one another, with good people. Get good, well-vetted information. And I think that’s something that kinda came out from these three, you know, conversations we had.

Michael: Thank you, guys, both. “Paradigm Shift of Healthcare” is brought to you by P3 Inbound. You can find our full archive of episodes at https://www.p3inbound.com/resources/podcast.php and recommend a guest or topic on Twitter, @p3Inbound.

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