Patients can’t solve health costs, even with skin in the game

Attempting to alter the health care marketplace so provider decisions are based on patient value has shaped my career for the last 20 years.   Often use of the health care delivery system creates a learning opportunity for me as well as the poor, unsuspecting provider of care.  A recent experience was instructive.

A close encounter with a jungle rock while mountain biking sent my husband back to our cruise ship with a deep gash on his shin.  Our ship’s doctor cleaned it, stitched it and sent him to our room with antibiotic cream.  Two days later, with red streaks around the wound and swelling puffing up around his stitches, his foot and ankle looked like a balloon with toes.  A day of oral antibiotics followed by a few rounds of IV antibiotics on the ship got us to the end of the cruise and back to the states, but things still looked bad.

Landing near midnight, we headed straight for the ER for a dose of American medicine.  Efficient service quickly led to a very pleasant doctor assessing the situation.

“Yes” she said, “That’s definitely infected.  Let’s start by getting an ultrasound.”

“Why,” we asked, “Would we get an ultrasound?”

She replied that we had just taken a long plane ride and it could be a blood clot.

We said, “It looked exactly like this before we got on the plane.  We have a $5000 deductible and really would prefer not to spend $300-400 for an ultrasound if it can be avoided.”

She said, “I’m sure it would cost a lot more than that!” and agreed that we could proceed without it.

Then she said, “Well, let’s get him admitted.”  We asked why he needed to be admitted since they could clean up the wound and get him an IV antibiotic right there in the ER.  She said they would watch him overnight to make sure he was doing all right.  Having some idea of exactly how much he would be watched after midnight on a weekend, we suggested that since we lived 10 minutes away I would watch him and rush him back if things went south.  She agreed that we seemed like responsible people who could be trusted to come back if necessary.

The next step was to remove the stitches and clean the wound.  This was going to be quite painful and the doctor said they had a new pain med that works really well.  Then, finally catching on, she looked back and said, “On second thought, we can just add some morphine to his IV.  That will work and it’s a lot less expensive.”

An hour later, armed with 4 prescriptions we headed home.  We filled the oral antibiotic ($16 at a local pharmacy) but skipped the antibiotic ointment (we already had this from the boat) and the Vicodin and Naproxsyn since OTC ibuprofen was managing the pain.

The wound slowly healed and all is well with the injury, but certainly not with our health care system.  We got great customer service, but how many thousands of dollars would have spent on this one event absent a few probing questions?  How many millions of similar episodes occur every day across the country?  Even for insured, middle class families, spending thousands out of pocket on a health care episode crowds out other needs, say a down payment on a car, a sizeable chunk of college tuition, or worse, the next few month’s rent or mortgage payments.

Yet how many patients have the background and temperament to ask challenging questions, especially in the midst of a health crisis?  Certainly, for the doctor all the incentives point in the direction of more care.  A well-intentioned desire to be thorough combines with fear of malpractice and the fee for service system where erring on the side of doing more results in greater revenues for the care providers.

Patients can’t solve this, even if they are armed with “skin in the game” and a handful of quality and cost measures.  It has to be treating physicians and their teams who consider and discuss with patients the cost/value tradeoffs of their care recommendations.  I believe most doctors would be sincerely concerned about the implications their recommendations have on their patients’ financial health if they really understood what these expenditures meant to them.  Hopefully, this particular ER doc now has an altered perspective.

Ann Robinow is president, Robinow Health Care Consulting and a winner of the 2013 Costs of Care Essay Contest.

Patients can’t solve health costs, even with skin in the game

This post originally appeared on the Costs of Care Blog. Costs of Care is a 501c3 nonprofit that is transforming American health care delivery by empowering patients and their caregivers to deflate medical bills. Follow us on Twitter @costsofcare.

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  • buzzkillersmith

    It’s called asymmetry of information. Doctors know more than pts do and so pts have to trust them. The bill comes later.

    Not following doc’s orders induces anxiety in pts, as well it should in many cases, especially cases of acute and/or severe illness.

    The separation of illness from when the bill arrives also has an effect, as does the perceived cushion of health insurance.

    How to decrease HC costs? You can decrease what the HC system charges for care (good luck with that) or you can ration care and so decrease its volume.

    The problem is that pts like the former and dislike the latter, but the two are more intertwined than some think.

    • ninguem

      The PATIENT may have some asymmetry of information, but the insurance company does have that information, maybe more than the doctor, with respect to cost that is.

      If you have a high-deductible health plan, you don’t have to “shop price” for the hospital or chemotherapy or surgery, because the insurance company has already done that, it’s called a “network”.

      Most, though I suppose not all, insurance companies have a network.

    • rbthe4th2

      Actually I can run rings around several former doctors. Quite honestly, when I can find the answers before they do and show them the proof, that’s to me a major warning sign.
      Not following doc’s orders induces anxiety? Are you sure? Its saved some people’s lives. I’ve saved myself by checking Rx’s before I took them. By pushing for tests that proved I was right.
      For costs? How about we half the price of medical school and then take out facility fees, admin salary caps, then after that, you can figure out what salaries would go next.

  • Dr. Drake Ramoray

    You make only a passing mention of the fear of litigation, but if your husband did have a blood clot from the plane and throws a PE that physician is toast (the patient too perhaps). ER docs won’t order tests you don’t think you need if you surrender your right to sue them. ER docs don’t have a long trusting relationship with patients to shield themselves from litigation. That one miss is a black mark on their career.

    Also that ultrasound is a lot more expensive at the hospital. I can’t make a comparison for lower extremity Doppler but our local hospital charges about 4.5x what I can charge for a thyroid ultrasound.

    Did they charge you a facility fee on your cruise?

    Despite your talking point of under our fee for service system doctors make more money for ordering tests, that is misleading because that ER doc makes no money off any of the tests he is doing.

    And lastly, Im surprised you went home after one dose of IV antibiotics as opposed to getting admitted given the failure of previous oral therapy and several rounds of IV antibiotics on the ship. I can’t imagine your care being the correct coarse of action on a board question. That opens a whole other can of worms that goes beyond the scope of this post. (Or my lack of recent general internal medicine experience).

    • DoubtfulGuest

      A bit OT, Dr. DR, sorry…but about your statement “…if you surrender your right to sue them”…how does one go about doing that? Is this only for the ED setting or is there some process I can follow?

      • Dr. Drake Ramoray

        No there is no mechanism for that (other than working for the VA?). I’m merely pointing out that ER docs have a tough gig because they have no long term rapport with the patient and don’t see much longitudinal care.

        Take head CTs for example. Elderly female patient goes to the ER with lightheadedness after having her blood pressure medication adjusted. She most likely either is having a reaction to her BP med or she has a UTI. I guarantee you she gets a head CT. That ER doc misses one stroke or neuro event and he or she will get sued and lose.

        • DoubtfulGuest

          Darn. I was hoping there was some mechanism. I get your point about defensive medicine. I just find it very odd that patient choice and values (i.e. not to sue) have no effect whatsoever on…anything. Not even doctors’ perceptions: “…and he or she will get sued and lose…”

          Lawsuits don’t just fall out of patients like, involuntary bodily functions, you know? There’s a decision-making process, which we don’t look at closely enough, I feel. Thanks for taking the time to answer.

          • Dr. Drake Ramoray

            No lawsuits do not fall out of patients involuntarily I don’t have the link handy but some years ago I read a study how the top two factors in suing is not the egregiousness of the error, but did the patient feel like the doctor listened to them, and did they spend enough time with them.

            Surgery, Radiology, Anesthesia, and ER are the hardest specialties in this sense because the nature of the job does not provide the opportunity for the development of these relationships. Radiology and ER have a LOT of CYA medicine for this reason which was the point I was tryin to make.

          • DoubtfulGuest

            I understand. I saw that study, I think. I just meant on the individual level, which of course no one cares about. I empathize with your position. As a patient, I don’t like essentially paying for other folks’ emotional immaturity (i.e. deciding to ruin their doctor’s life or pursue a lot of money because they had a bad interpersonal experience – - the grownup thing to do is just tell the other person what you’re upset about). AND emotional immaturity of doctors who won’t explain or apologize. It’s not my place to say no one ever needs financial compensation to recover from *medical* errors, but I think there should be a much higher bar for suing doctors. My situation didn’t quite reach the bar for me, so I didn’t sue.

            The flip side of what you’re saying is that patients who are truly injured often don’t sue, but we are punished with deny and defend tactics. Re: “there’s no mechanism”, well, why not? Starts with an “L”, ends with “awyers”. It’s ridiculous that patients can’t opt out of a stupid, stupid, adversarial system.

          • rbthe4th2

            Yep, seen this in droves. There are problems with the system that need to fixed by admin. There are problems with the system that need to be fixed by a combination of doctors and patients.

          • DoubtfulGuest

            Dr. Ramoray, Sir, I always appreciate your comments and would just like to add something here. Of course, relationships are better and more secure when developed over a long time. It’s really hard for patients, though. Patients have to trust the doctor right away, and we’re supposed to immediately build rapport, no matter the situation or specialty. It’s hard knowing the doctor doesn’t trust in return, and we’re subject to whatever decisions are made because of that lack of trust. Perhaps there’s no way to fix it — I just wanted to point that out…

    • http://hautuconsulting.com/ Shane Irving

      I would agree that the primary approach seems to have had a lot to do with litigation CYA. I’ve seen more aware physicians in these types of situations offer Options A, B or C with we documented caveats but that’s not always easy (particularly if pressured by risk managers who go straight to option C (CYA))

    • goonerdoc

      Fantastic response, one in a long line of many by you, Dr. Ramoray. I would like to hear the author’s response to the above.

  • ninguem

    I’m completely confused. You headline the article with.

    “Patients can’t solve health costs, even with skin in the game”

    This headline is then followed with a lovely essay where you show one example after another, of how you saved thousands of dollars of healthcare cost, by avoiding imaging, hospitalization, opiate analgesics, topical antibiotics………and motivated to do so, precisely BECAUSE you had “skin in the game”.

    The ER doc’s suggestions, all completely reasonable, were slanted toward overtreatment, because of legitimate malpractice concerns and especially…….precisely BECAUSE patients come in EXPECTING overtreatment.

    As far as I’m concerned, you have made a perfectly strong case that healthcare costs CAN be controlled because you have “skin in the game”.

    And the more patients like you go on to reasonably question the cost and necessity of expensive medical interventions, the more doctors will consider cost in their decisions.

    I’d like to have a hundred patients like you.

    • ninguem

      And FWIW………I can see skipping the admission, but I think I’d have agreed to the ultrasound. It would make me feel a lot better about skipping the admission.

      What say the other physicians in the group?

      • Gibbon1

        The sick thing about the ultrasound is the actual cost should be about $50.

    • Dr. Drake Ramoray

      I believe the point that the author is trying to make is that she believes she is smarter than everyone else, and the average person has no hope of asking questions like her. Note her opening of her essay with her vast (non-MD) experience of 20 years and the “poor, unsuspecting” doctors who care for her.

      I actually agree that many people in the ER setting won’t ask these questions. I also think she is wrong and ill informed on just about everything else in her post.

    • JR

      The original title was “Is That Really Necessary” – articles are given new titles not written by the authors when they are posted here.

    • rbthe4th2

      With all due respect, I challenged doctors like this and got multiple labels of non compliant and accused of other mental issues, not trusting my doctors recommendations, taking up too much time for asking questions, etc.
      I personally though, have found most of the doctors on here not like that, but we need to figure out how to get everyone else to buy in on your thoughts above. I suspect that most of the HP on here are the types that would be what you’re talking about.

    • DoubtfulGuest

      rbthe4th2 has a point. Just elsewhere on this blog, another doc told me that CYA testing would continue. Even if we say “Hey, I don’t really need this, do I? At least not yet, and you can document that I declined it?” Apparently there are all these legal loopholes, patients can say they didn’t understand the importance of the test, and so on. I actually agree with your comment…but let’s admit, please, that it would take some trust and rapport-building on the physician’s end? Not just patients adjusting their expectations?

  • goonerdoc

    Dear Ann-

    I’m glad your 20 years of consulting experience have given you the gift of knowing, with 100% certainty, the exact diagnosis of a patient. I still have yet acheive this feat, even after med school and residency. I must have been absent for that lecture. Perhaps I need to do a bit more consulting, but I digress. How DARE that physician even think of a lower extremity ultrasound

    • DoubtfulGuest

      Blood clots are scary. I *almost* wanted an ultrasound just from reading the article.

    • PoliticallyIncorrectMD

      Bravo! Not only exactly what my response would be, but also very funny.

    • Deceased MD

      zing!

  • Lisa

    Last summer, while traveling, I wound up in the ER due to a case of cellulitis.

    I had cellulitis three times previously in the same ankle, so I knew exactly what was wrong. I carry ‘emergency’ antibiotics with me and took a dose when realized I was developing cellulitis. As it was spreading fairly quickly, I went to the ER, knowing I would probably require IV antibiotics. The physician on duty wanted me to have an ultrasound. I objected because I wanted to get the IV antibiotics started as soon as possible. She agreed, given my history, the ultrasound was overkill. I received IV antibiotics and was instructed to see have my ankle looked at the next day. The next day, I went to a clinic where a NP looked at my ankle and said she thought I would be okay on the oral antibiotics the ER doc prescribed. And indeed I was, the case resolved with another few days and I was able to return home without further problems.

    As my insurance covers ER visits at 100% except for a $100 co-pay, I wasn’t worried about the cost of the treatment. What I was worried about is getting the antibiotics I knew I needed quickly, so the infection wouldn’t spread. I have two artificial hips and both my pcp and orthopedic surgeon have said that I should treat cellulitis as a medical emergency. I would have been upset if the needed treatment was delayed because of the perceived need for more testing.

    “Skin in the game’ involves more than cost; it involves recognizing that every test, every treatment has consequences which need to be considered.

    • Dr. Drake Ramoray

      In situations where patients require immediate therapy in the emergency room without lengthy triage or diagnostic testing outside the norm
      it is advisable for you to have a note from your physican in your wallet or on your person that explains as such. We have a form in addition to the recommendation of a medic alert bracelet for all of our patients with adrenal insufficiency.

      They basically need IV steroids when they hit the door if there is any question in regards to the ability to take meds by mouth. This is not terribly different than your situation and it helps facilitate urgent care amongst providers not intimately familiar with your health history or the particular condition in question.

      • Lisa

        While i needed timely therapy, I didn’t need immediate therapy.

        I related my story because I suspect the ER doctor the who saw the author’s story was following a script – red swollen ankle – rule out a blood clot despite the patient’s history. The author’s skin in the game was monetary, mine was time.

  • Dr. Drake Ramoray

    I didn’t say if you miss a single diagnosis your career is over, I said it’s a black mark. (I supposed you could add the caveat that a patient decides to sue, whether they are successful or not).

    Yeah, there’s that whole patient thing. Sarcasm isn’t for everyone.

    Speaking of which, you can’t surrender your right to sue the ER (unless you are at the VA because you can’t sue the government?) nor was I seriously suggesting that.

    I would make the case that their deductible is irrelevant and the fact that the leg has not improved despite antibiotics warrants the ultrasound (if that is how I felt in the actual clinical scenario). I don’t think that it hasn’t changed over the plane ride is relevant if it “looked like a balloon with toes” as described in the article. Patients often have this notion that negative tests are bad things and a waste of money, but that’s not how making a diagnosis works. We are supposed to rule out badness. Extremeties can only look so bad and swell so much, and the author made it pretty clear this was a big deal and wasn’t getting better. Why is it ok to order the test if the patient has a low deductible but when the author protests her high deductible it’s not necessary? The patient either needs the test or they don’t. Not much in the way of alternative tests to diagnose a clot, and detecting one changes the treatment plan. I often do state what I would do if I were the patient (you seem to be making an awful lot of assumptions about me).

    I have colored you thoroughly confused. There is so much more to the cost of medicine than the tests that are done (such as why the tests cost so much in the first place) and the defensive nature of medicine. You have successfully attacked the messenger and have subsequently missed all of my points. Here is a primer on facility fees if it may add to the discussion.

    http://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care

    I don’t dismiss my patient’s wishes but if I feel the patient is putting themselves in danger and/or they put my medical license at risk I do document that they refused my medical advice and that the patient voiced understanding of the consequences of that decision. The no ultrasound may be approaching that level but I can’t say that for certain without actually being the doc evaluating the patient. It would be interesting to talk to the ER doc about this encounter. You can only glean so much about a scenario from reading about it, and we are only getting one side of the story.

  • Lisa

    I receive my insurance through my job.

  • DoubtfulGuest

    Robbie, with all due respect, your attitude contributes to a great deal of harm to patients. That is what you’re concerned about, right — patient harm? Some of us don’t want to sue and would gladly initiate the process to sign such a contract if there was any mechanism — if the law would treat us as competent to make that decision. I just don’t go to a doctor with an adversarial stance. I don’t think that way. As a patient (not a customer), I don’t want my doctors to be jumpy and scared. I want them to make decisions based on 1) science and 2) my individual needs. Because they listen to ME instead of all those other voices in their heads that tell them I might sue. I did not *knowingly* sign up for an adversarial relationship with any doctor. But that is what I get. With your attitude, you are stepping on my right to EVER get an explanation and apology for the medical errors in my care. The whole system is built around the beliefs you espouse here. I would not take away your right to get compensation if you were injured. But why can’t it be under a no-fault system? Medicine is challenging, most doctors do the best they can, and fear doesn’t help them do a good job.

  • DoubtfulGuest

    Sounds good. Can I sit and wait with you?…I have this book of Mad Libs here…to help pass the time….

    …Hey…Does my right leg look a bit puffy? Compared with the left side?

  • DoubtfulGuest

    Good luck with your demands, Robbie. We’ll see how many doctors and nurses will be left to fulfill them. That whole “customer” thing is complicated by having a third party payor. Your “providers” often wait months for any reimbursement. It sounds like you’re a proponent of fully industrialized medicine. If that’s what you want, “customers” are just widgets, to all be treated the same. Not people, not individuals. If you wanted to be treated as an individual person, you’ve got to have human relationships with your medical *professionals*. You can’t go in, in your time of need, defensive and ready for a legal battle. If you want human relationships, you recognize we all make mistakes. Occasionally people are negligent or cruel. Much more often, folks are doing their best to help. On top of that, medicine and biology are tricky — all kinds of things can go wrong in the human body that are no one’s fault. Things that no one can fix. You have to make some choices here. You don’t want to be a pushover? What are you doing to stand up to lawyers and administrators that control your interactions with your doctors from behind the scenes? Are you going to lash out at the people who sacrifice their 20s and 30s to study and learn how to take care of you? Or do you want to think harder about what’s going on with the corrupted, for-profit, money-driven system that we have? How about showing support to doctors on this blog who are trying to restore a system based on human relationships instead?

    • Robbie

      You are missing my point. The customers did not start this problem, the industry did.

      No one I know has ever sued any medical professional. On the other hand, they have been misdiagnosed with dementia when drug dosages and interactions were the cause, almost died due to simple math errors in prescribed dosage, told that a pain was nothing but which ended up being an infection that required a trip to the ER, been consistently ignored for real pain but provided endless drugs and shots to mask said pain, etc.

      I am not sure how much more people should take.

      As I said, talk to your customer. Listen to what they have to say, explain what you are doing and why, offer up options and tell them what you would do if you were in the same shoes. Is that really so difficult?

      An old doctor I had years ago said that if everyone would get a massage every week he would lose half his patients. The young doctor who bought his practice was nothing more than a human (not even convinced of that) prescription pad.

      I miss my old doctor.

      • DoubtfulGuest

        Okay, now I’m starting to agree with you…we shouldn’t take it! The problem is the industry is controlled by these other people (not doctors). Physicians on this blog have said they are partly responsible, for giving up control to legal/admin in the first place. Patients’ role in this is wanting third party payment for health care — well, that third party wants control, too. At one point I felt exactly as you do, and it’s very hard because patients are prevented from seeing all this stuff going on behind the scenes. The doctors are the only ones we can SEE to get mad at. And they are partly responsible. I’m very mad at some individual doctors. Not so much for misdiagnoses, but for the unkind way they treated me during the process and their apparent unwillingness to fix their mistakes. But legal and administrative people have a lot of control. They get more powerful every time doctors and patients turn against one another. I don’t consider myself a customer…I’m a patient, because doctors and patients historically have had a sacred trust, and doctors have a strong ethical obligation to patients. Not so much for customers. Then it’s just a business relationship. If, by “customer”, you mean that patients should be treated with respect and dignity, then we agree and are just using a different name for it. Anyway, there is no contract to sign away our right to sue. The legal system makes sure we don’t have that *choice*, which I actually wanted, and in my case would have prevented a lot of problems.

  • charles_beauchamp

    In my opinion, ALL of this scenario could have been avoided IF:there had been a proper soaking and cleaning of the wound with Hibiclens (chlorhexidine) AND thoughtful decision making had occurred about secondary closure of the wound.
    Also, if treated as was done initially, it would have been worthwhile, at that point in initiatiating chlorhexidine sosks of the sutured wound and rx with doxycycline PLUS OTC’s that minimize oxidative stress, endothelial dysfunction, microvascular dysfunction to the point that antibiotics cannot penetrate to the wound site (because of arterial microvascular vasospasm.
    Hiibiclens should cost about 7 dollars.
    OTC’s that minimize microvascular dysfunction (see the following cascade) are: Magnesium with zinc; Benfotiamine; Pycnogenol.
    infection, trauma, inflammation, hyperglycemia, drug side effects, complications of disease, age-related changes, exposures (alcohol, tobacco, cocaine, poisons…..etc) ===>> oxidative stress ===> activation of nuclear factor kappa beta ===>>>> MORE oxidative stress ===>>> Endothelial Dysfunction ===> Microvascular Dysfunction ===>>> Regional Blood Flow Abnormalities ===>>> “Downstream Pathologies” as poor wound healing, ischemic pain, potentiated infection, systemic microvascular storm (e.g., cognitive dysfunction, mood fluctuations (depression & anxiety), arthralgia, fatigue/anergia, cardiac dysfunction, renal dysfunction….etc)
    Magnesium is a cofactor of Transketolase
    Zince is a cofactor of Superoxide Dismutase
    Benfotiamine is a fat soluble derivative of vitamin B-1 (thiamine) and it facilitates the intra-cellular penetration and conversion of thiamine into thiamine pyrophosphate, a key cofactor of Transketolase.
    Pycnogenol – French Maritime Pine Bark Extract that has a positive effect on oxidative stress & endothelial dysfunction. It can also act to regenerate CoQ10 and to minimize post-infection anergia.
    Transketolase is an intracellular enzyme that acts (with adequate cofactor support) to positively modulate microvascular blood supply
    Superoxide Dismutase is an enzyme that dismutes superoxide (oxygen with an added electron – superoxide that is a “reactive oxygen species”). Superoxide reacts with nitrous oxide to create another deleterious free radical and to negate the vasodilation properties of nitrous oxide..
    Infections deplete intracellular thiamine so that a negative positive feedback loop can occur with regard to accentuation of the above cascade with negative clinical outcome results.
    The microvascular, out of sight, out of mind but so very important.
    The modern first aid kit should contain Hibiclens (get those critters before they get you), Magnesium with Zinc, Benfotiamine, Pycnogenol, CoQ10.
    ALL of the costly aspects of this scenario could have been avoided by proper application of a first aid kit as one is seeing a primary care physician and thereafter,

  • Robbie

    “A close family friend with cancer had gone to see him some years back.
    When the friend started asking questions about the treatment plan, the
    doctor had stopped him midsentence, glared at him and said, “If you ask
    one more question, I’ll refuse to treat you.”

    http://well.blogs.nytimes.com/2014/02/27/can-doctors-be-taught-how-to-talk-to-patients/

    I doubt this is just a problem of communication. Is there any other industry where a customer would pay, say, $100K or more for a service and get this kind of treatment? Then there is the myth of malpractice suits. Malpractice itself is what causes the harm, not the suits against it.

    “Even with this conservative methodology, the study found that doctors
    were injuring one out of every 25 patients—and that only 4 percent of
    these injured patients sued.”

    http://www.slate.com/articles/health_and_science/medical_examiner/2006/07/the_medical_malpractice_myth.html

  • rbthe4th2

    I’ve got and had several non American and non American trained docs. Happy with all of them. Had another who was in a foreign country for a while and think the world of them too.

  • DoubtfulGuest

    Whoa, meyati…”Sneering, he almost screamed, And just what is the A–C–S—?” This sounds eerily familiar. I’m not talking about a PCP though, so it can’t be the same doctor. But the implied tone, and the word spacing, syllable stress, whatever you want to call it. It’s the same. I’m imagining an entire med school class dutifully reciting these kinds of statements in unison. And their professor like: “Come on! Give me a snarl! You don’t want patients to say you’re ‘mild-mannered’, do you?”

    Also, LOL at “dry mouth”. :)

  • Dr. Drake Ramoray

    I have waited a long time to find the perfect article posted on kevinmd to respond to this author. I think I may have found it.

    http://www.kevinmd.com/blog/2014/03/doctors-practice-cover-ass-medicine.html

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