NYT Today: "Nurses are Not Doctors"

[Gifted Hands]

http://nyti.ms/1mVUgVi

The comments are particularly interesting

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[postbacpremed87]

http://nyti.ms/1mVUgVi

The comments are particularly interesting

It's sad really. I say let them practice independently..........................

After they pass the REAL versions of USMLE Step1,2,3....not a watered down version that over 50% failed.

Edit: And they took a watered down Step 3....not Step 1 or both parts of Step 2. I could be wrong, but I think it is believed that Step 3 is the easiest of the steps....they took an even easier version...and had a failure rate of over 50%.

Folks we have nothing to fear in the long run.

 

[BobbyB]

is new york the worst state to practice as a doctor now?

your professional license is considered marital property and NPs can independently practice

 

[postbacpremed87]

is new york the worst state to practice as a doctor now?

your professional license is considered marital property and NPs can independently practice

No Oregon is up there too now judging by a comment that one poster made...
"It is even worse than Dr. Jauhar knows. Oregon passed HB 2902 last year which mandates that physicians practicing primary care or psychiatry may not be reimbursed more than nurse practitioners or physician assistants for their services. This applies to all commercial health plans in the state. Given the fact that NPs were already granted the same scope of practice as physicians in these specialties, the state appears to have determined that the additional 5-7 years of physician training and hundreds of thousands of dollars of additional debt do not matter. In other words, education doesn't matter. It is truly astonishing. I can't imagine that any rationale person will choose to go to medical school with the plan of practicing internal medicine, family practice, pediatrics or psychiatry in the state of Oregon."

 

[BobbyB]

No Oregon is up there too now judging by a comment that one poster made...
"It is even worse than Dr. Jauhar knows. Oregon passed HB 2902 last year which mandates that physicians practicing primary care or psychiatry may not be reimbursed more than nurse practitioners or physician assistants for their services. This applies to all commercial health plans in the state. Given the fact that NPs were already granted the same scope of practice as physicians in these specialties, the state appears to have determined that the additional 5-7 years of physician training and hundreds of thousands of dollars of additional debt do not matter. In other words, education doesn't matter. It is truly astonishing. I can't imagine that any rationale person will choose to go to medical school with the plan of practicing internal medicine, family practice, pediatrics or psychiatry in the state of Oregon."

ya i read an article about that

it is like they actively want to remove doctors from their state

 

[postbacpremed87]

ya i hear about that

it is like they actively want to remove doctors from their state

This process will accelerate and ultimately come to a head 10-15 years down the road when there are too many bad outcomes. It's sad that it will take bad outcomes to put physicians back into control of healthcare.

I contend that the pay disparity isn't as pressing as the issue of job security. Who in their right mind would go into primary care when it is clear that state boards deem you equivalent to nurses? Posters talk about doctors in their ivory tower - doctors are in the "ivory tower" because of the education they received. They could have chosen to go to medical school, but they didn't. There is a systematic campaign against people who work hard and achieve in America. There is a lot of resentment.

 

[NickNaylor]

ya i heard about that

it is like they actively want to remove doctors from their state

Or you just stop taking insurance. This is less feasible with FM, peds, IM, and OBGYN, but with psych this will simply give a field that can easily survive without third party payers (at the expense of failing to provide care to those who need it) even more incentive to move to cash only.


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[DermViser]

http://nyti.ms/1mVUgVi

The comments are particularly interesting

New York Times commenters are some of the most elitist, deluded idiots I've ever read in print. You can bet many of them who advocate NPs practicing on the unwashed masses would never THEMSELVES seek one for their care or their own family members.

Edit:
One of my favorite quotes:
The author states that we must find ways to pay primary-care physicians more instead having nurse practitioners provide primary care. I find it interesting that the author is a cardiologist, one of the highest paid specialties, often earning between $500,000 and $1,000,000 per year. The solution is simple. We should finds ways to pay cardiologists less, then there will be more money to pay primary-care physicians more. Then there will be more primary-care physicians. There will also be less need for cardiologists because fewer people would be getting heart disease. Everyone wins except the cardiologists.

Yup that's exactly how we fight heart disease. Pay those ****ers less. Those atheromas will start disappearing in no time.

How many likes did that comment get? 454. Like I said, NY Times commenters are some of the most deluded idiots. It's scary that some of them actually vote.

 

[postbacpremed87]

New York Times commenters are some of the most elitist, deluded idiots I've ever read in print. You can bet many of them who advocate NPs practicing on the unwashed masses would never THEMSELVES see one for their care.

Well done.

 

[Slack3r]

Sigh, it'd almost be funny if it wasn't so sad.

 

[NickNaylor]

Contrary to my initial inclination, I made the mistake of reading the comments. Some people seem to understand the subtlety of the issue. Most clearly don't (eg, "the AMA limits physician supply to make big bucks," "nurses have years of bedside nursing experience that makes up for residency training," "nurses can be doctors now that they can get a doctorate" (holy ****), and a whole bunch of other nonsense). It goes to show you how the average person simply doesn't understand how medical training works and has no understanding of what providing basic medical care actually involves. The fact that someone thinks an RN practices any degree of clinical decision making is laughable. That's not a jab at nurses. That's just the reality of the situation. You can see this when you talk to nurses and get a sense of their understanding of what's going on with a patient and their suggestions for a plan based on what they see. Oftentimes they're reasonable, but sometimes they're so off-base that I wonder what they learn in nursing school.

I say let NPs practice if they want to practice. As multiple people brought up in the comments, the proof will be in the pudding. If NPs begin getting sued for malpractice and they begin to realize that perhaps those years of bedside training aren't adequate, things will swing the other way. On the other hand, if they end up having competency and outcomes similar to MDs... well, then perhaps we should reconsider our role.


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[Gifted Hands]

I just can't rationalize how MDs and NPs can practice equally when they don't have the same licensing requirements, take the same exams. If NPs want to practice like primary care doctors, hold them to the same standards - or lower the standards for primary care docs so we can practice earlier too. It makes no sense.

I'm going into peds but you bet I'm going to specialize. It's insulting to stay in primary care and be told my 4+3 yrs of training are equivalent to an online masters degree.

 

[Arkangeloid]

You guys are tempting me, but I'm not going to read the comments this time. I would rather preserve what neurons I have left.

 

[postbacpremed87]

You guys are tempting me, but I'm not going to read the comments this time. I would rather preserve what neurons I have left.

 

[Prodromo]

I just can't rationalize how MDs and NPs can practice equally when they don't have the same licensing requirements, take the same exams. If NPs want to practice like primary care doctors, hold them to the same standards - or lower the standards for primary care docs so we can practice earlier too. It makes no sense.

I'm going into peds but you bet I'm going to specialize. It's insulting to stay in primary care and be told my 4+3 yrs of training are equivalent to an online masters degree.

I'm going to have to agree with lowering the standards of primary care if NPs can practice independently. Once I'm done with intern year I'll take my boards and open up an urgent care. After all I've done way more than the 600 hours of clinical training NPs get right?

 

[DermViser]

I just can't rationalize how MDs and NPs can practice equally when they don't have the same licensing requirements, take the same exams. If NPs want to practice like primary care doctors, hold them to the same standards - or lower the standards for primary care docs so we can practice earlier too. It makes no sense.

I'm going into peds but you bet I'm going to specialize. It's insulting to stay in primary care and be told my 4+3 yrs of training are equivalent to an online masters degree.

That's because practice scope is defined by state governments, not by the degree you have. If tomorrow, the state said that all you need is a Masters in Biology to practice Medicine, there is nothing that could stop it. MDs are under the Board of Medicine and NPs are under the Board of Nursing.

 

[postbacpremed87]

I'm going to have to agree with lowering the standards of primary care if NPs can practice independently. Once I'm done with intern year I'll take my boards and open up an urgent care. After all I've done way more than the 600 hours of clinical training NPs get right?

America....raise the freaking bar

 

[DermViser]

http://nyti.ms/1mVUgVi

The comments are particularly interesting

I'll go one up on you, I believe that optometrists and pharmacists can do primary care: http://medcitynews.com/2013/02/cali...sts-eye-docs-diagnose-and-treat-diabetes-hbp/

 

[circulus vitios]

Whatever, let them have it. I won't be paying the price if this social experiment backfires.

 

[Kaputt]

Those comments are scorching my retinas.

 

[DermViser]

Those comments are scorching my retinas.

Careful, you'll need them in the dark. j.k.

 

[deleted500612]

Found this gem of a comment... had the most likes (47) of any comment I saw. lol.

"As an Advanced Practice Nursing student at the University of California-San Francisco and future primary care provider, I am disappointed by Sandeep Jauhar’s limited inquiry into advanced practice nursing and his assumption that nurses want to be confused with medical doctors (clarification: many nurses ARE doctors, having attained Doctorates of Nursing Practice or PhDs). Jauhar’s acceptance of APNs as being more “sensitive to patients’ psychological and social concerns” coupled with his rejection of nurses as competent clinicians suggests an outdated understanding of nursing science, one in which nurses only meet the spiritual/emotional needs of patients. A systematic review of APN practice from 1990-2008 concludes APNs have comparable patient outcomes with MDs (Newhouse, 2008). The 15 yo study Jauhar cites does not, as he asserts, prove NPs “compensate for a lack of training” by ordering excessive diagnostic tests. Rather, the researchers “found a trend toward increased utilization… but for most of these [measures] our study lacked sufficient power to show statistical significance” (Hemani, 1999). The anecdote about a MD diagnosing goiter based simply on a patient’s hoarse voice is quite remarkable considering that an actual diagnosis of goiter would require, at minimum, a physical exam and labs confirming abnormal thyroid hormone levels. Perhaps as long as residents believe primary care requires near mystical powers they will choose specialization over family medicine."



Strong awareness of the difference between a PhD and an MD

 

[NickNaylor]

Found this gem of a comment... had the most likes (47) of any comment I saw. lol.

"As an Advanced Practice Nursing student at the University of California-San Francisco and future primary care provider, I am disappointed by Sandeep Jauhar’s limited inquiry into advanced practice nursing and his assumption that nurses want to be confused with medical doctors (clarification: many nurses ARE doctors, having attained Doctorates of Nursing Practice or PhDs). Jauhar’s acceptance of APNs as being more “sensitive to patients’ psychological and social concerns” coupled with his rejection of nurses as competent clinicians suggests an outdated understanding of nursing science, one in which nurses only meet the spiritual/emotional needs of patients. A systematic review of APN practice from 1990-2008 concludes APNs have comparable patient outcomes with MDs (Newhouse, 2008). The 15 yo study Jauhar cites does not, as he asserts, prove NPs “compensate for a lack of training” by ordering excessive diagnostic tests. Rather, the researchers “found a trend toward increased utilization… but for most of these [measures] our study lacked sufficient power to show statistical significance” (Hemani, 1999). The anecdote about a MD diagnosing goiter based simply on a patient’s hoarse voice is quite remarkable considering that an actual diagnosis of goiter would require, at minimum, a physical exam and labs confirming abnormal thyroid hormone levels. Perhaps as long as residents believe primary care requires near mystical powers they will choose specialization over family medicine."



Strong awareness of the difference between a PhD and an MD

Yeah, that was also the one that made me go nuclear and close the browser tab. The ignorance is so substantial that you really can't even have a productive discussion about the problem.

The reality is that the scope of practice for mid levels will only continue to increase unless convincing data suggesting poor care is discovered. Rather than fighting the inevitable, I think physicians would be better served to position themselves as managers and consultants for more difficult cases. You already see this in many community practices. And I'm sure there will always be space for physicians who really want to do clinical care to position themselves to do that.

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[SouthernSurgeon]

Yeah, that was also the one that made me go nuclear and close the browser tab. The ignorance is so substantial that you really can't even have a productive discussion about the problem.

It's not ignorance. It's propaganda.

 

[postbacpremed87]

Yeah, that was also the one that made me go nuclear and close the browser tab. The ignorance is so substantial that you really can't even have a productive discussion about the problem.


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It's high time we go on offense

 

[NontradCA]

Found this gem of a comment... had the most likes (47) of any comment I saw. lol.

"As an Advanced Practice Nursing student at the University of California-San Francisco and future primary care provider, I am disappointed by Sandeep Jauhar’s limited inquiry into advanced practice nursing and his assumption that nurses want to be confused with medical doctors (clarification: many nurses ARE doctors, having attained Doctorates of Nursing Practice or PhDs). Jauhar’s acceptance of APNs as being more “sensitive to patients’ psychological and social concerns” coupled with his rejection of nurses as competent clinicians suggests an outdated understanding of nursing science, one in which nurses only meet the spiritual/emotional needs of patients. A systematic review of APN practice from 1990-2008 concludes APNs have comparable patient outcomes with MDs (Newhouse, 2008). The 15 yo study Jauhar cites does not, as he asserts, prove NPs “compensate for a lack of training” by ordering excessive diagnostic tests. Rather, the researchers “found a trend toward increased utilization… but for most of these [measures] our study lacked sufficient power to show statistical significance” (Hemani, 1999). The anecdote about a MD diagnosing goiter based simply on a patient’s hoarse voice is quite remarkable considering that an actual diagnosis of goiter would require, at minimum, a physical exam and labs confirming abnormal thyroid hormone levels. Perhaps as long as residents believe primary care requires near mystical powers they will choose specialization over family medicine."



Strong awareness of the difference between a PhD and an MD

 

[NontradCA]

I'm willing to bet that most nurses themselves would rather see a physician than an NP, if they were sick.

 

[DermViser]

Found this gem of a comment... had the most likes (47) of any comment I saw. lol.

"As an Advanced Practice Nursing student at the University of California-San Francisco and future primary care provider, I am disappointed by Sandeep Jauhar’s limited inquiry into advanced practice nursing and his assumption that nurses want to be confused with medical doctors (clarification: many nurses ARE doctors, having attained Doctorates of Nursing Practice or PhDs). Jauhar’s acceptance of APNs as being more “sensitive to patients’ psychological and social concerns” coupled with his rejection of nurses as competent clinicians suggests an outdated understanding of nursing science, one in which nurses only meet the spiritual/emotional needs of patients. A systematic review of APN practice from 1990-2008 concludes APNs have comparable patient outcomes with MDs (Newhouse, 2008). The 15 yo study Jauhar cites does not, as he asserts, prove NPs “compensate for a lack of training” by ordering excessive diagnostic tests. Rather, the researchers “found a trend toward increased utilization… but for most of these [measures] our study lacked sufficient power to show statistical significance” (Hemani, 1999). The anecdote about a MD diagnosing goiter based simply on a patient’s hoarse voice is quite remarkable considering that an actual diagnosis of goiter would require, at minimum, a physical exam and labs confirming abnormal thyroid hormone levels. Perhaps as long as residents believe primary care requires near mystical powers they will choose specialization over family medicine."



Strong awareness of the difference between a PhD and an MD

Yes, I deliberately skipped that one, bc it was raising my blood pressure. Notice she said, "Doctorate" which is an academic degree, not a clinical credential. Right now nearly all NPs are all at the masters level. The "doctorate" is nothing more than added academic/theory coursework, NOT actual increased clinical contact. It's degree creep at it's finest. Physical Therapists did it, Pharmacists did it, etc. This is nothing more than a blatant attempt to jack up tuition.

 

[Arkangeloid]

Goddamn it, I read them. I just died a little inside.

If I fail Monday's exam, it's your fault.

 

[JP2740]

Goddamn it, I read them. I just died a little inside.

If I fail Monday's exam, it's your fault.

Thanks obama

 

[deleted480308]

best decision I made all year was to stop the NHSC application.....Oregon, what the hell are you thinking? banning insurance from paying doctors more than nurses? Not even just setting medicare rules, but banning private business from setting pay schedules?

looks like I'm a surgeon, at least that's the last place they'll let the nurses take over

 

[NickNaylor]

Thanks obama

In this case the meme is actually applicable. At least moreso in this case than others.


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[circulus vitios]

Yeah, that was also the one that made me go nuclear and close the browser tab. The ignorance is so substantial that you really can't even have a productive discussion about the problem.

The reality is that the scope of practice for mid levels will only continue to increase unless convincing data suggesting poor care is discovered. Rather than fighting the inevitable, I think physicians would be better served to position themselves as managers and consultants for more difficult cases. You already see this in many community practices. And I'm sure there will always be space for physicians who really want to do clinical care to position themselves to do that.

Sent from my iPhone using Tapatalk

That would be pretty sweet. Open shop in a state that requires supervised practice and bring on a good mix of experienced and newbie NPs. Collect a percentage of what the experienced NPs bill. Work the newbies to the bone with a flat, far below market salary under the guise of 'gaining valuable experience.'

 

[Davida]

Yeah, that was also the one that made me go nuclear and close the browser tab. The ignorance is so substantial that you really can't even have a productive discussion about the problem.

The reality is that the scope of practice for mid levels will only continue to increase unless convincing data suggesting poor care is discovered. Rather than fighting the inevitable, I think physicians would be better served to position themselves as managers and consultants for more difficult cases. You already see this in many community practices. And I'm sure there will always be space for physicians who really want to do clinical care to position themselves to do that.

Sent from my iPhone using Tapatalk

I worked at a primary care clinic that existed to provide care for children with chronic and complex conditions. It was essentially "specialized" primary care for a niche population that needed more expertise. I always wondered if this would be the direction that PC physicians would end up going in the future, if midlevels ended up taking on the bulk of the "bread and butter" primary care.

Then again, I also swear I read somewhere (can't find the citation, sorry - I might be making this up) that NPs and other midlevels are increasingly choosing to go into specialties rather than primary care, so midlevels may not be the ultimate solution to the PC shortage anyway.

 

[evilbooyaa]

Another one of these... surprise surprise.

That would be pretty sweet. Open shop in a state that requires supervised practice and bring on a good mix of experienced and newbie NPs. Collect a percentage of what the experienced NPs bill. Work the newbies to the bone with a flat, far below market salary under the guise of 'gaining valuable experience.'

The issue is that NPs are fighting for independent practice without physician oversight, straight out of school. You aren't going to be the consultant on anything.

What you're proposing is how it currently works. NPs see patients and go to the MD for supervision and with any issues they have. MDs that trust their NPs give them slightly more leeway and just to periodic chart review.

 

[postbacpremed87]

Goddamn it, I read them. I just died a little inside.

If I fail Monday's exam, it's your fault.

The hate is swellllllling in you now. Use it. They are defenseless.

 

[circulus vitios]

Another one of these... surprise surprise.



The issue is that NPs are fighting for independent practice without physician oversight, straight out of school. You aren't going to be the consultant on anything.

What you're proposing is how it currently works. NPs see patients and go to the MD for supervision and with any issues they have. MDs that trust their NPs give them slightly more leeway and just to periodic chart review.

Legality doesn't always go along with reality. Physicians can legally practice medicine after their intern year. Getting malpractice insurance and getting insurance companies to reimburse you is a different story.

 

[Instatewaiter]

I say let NPs practice if they want to practice. As multiple people brought up in the comments, the proof will be in the pudding. If NPs begin getting sued for malpractice and they begin to realize that perhaps those years of bedside training aren't adequate, things will swing the other way. On the other hand, if they end up having competency and outcomes similar to MDs... well, then perhaps we should reconsider our role.

Malpractice suits are tied to patient satisfaction. If a patient likes you, they are very unlikely to sue you, even if you commit the most attrocoius malpractice. NPs tend to spend 2-3 times as much time with the patients as doctors and the patients love them for it. Just because more tests will be ordered and worse care will be delivered, does not mean the malpractice suits will go up. I would not be suprised if they had lower malpractice suits.

There is another study out there that compares patient satisfaction to mortality. The more satisfied the higher the mortality... this is not to say that a satisfied patient is doomed but rather to highlight what a worthless metric patient satisfaction is.

 

[Instatewaiter]

New York Times commenters are some of the most elitist, deluded idiots I've ever read in print. You can bet many of them who advocate NPs practicing on the unwashed masses would never THEMSELVES see one for their care.

One of my favorite quotes:
The author states that we must find ways to pay primary-care physicians more instead having nurse practitioners provide primary care. I find it interesting that the author is a cardiologist, one of the highest paid specialties, often earning between $500,000 and $1,000,000 per year. The solution is simple. We should finds ways to pay cardiologists less, then there will be more money to pay primary-care physicians more. Then there will be more primary-care physicians. There will also be less need for cardiologists because fewer people would be getting heart disease. Everyone wins except the cardiologists.


Yup that's exactly how we fight heart disease. Pay those ******* less. Those atheromas will start disappearing in no time.

I call this ostrich syndrome. If your head is in the sand and you never look for it, you never find it.

 

[BurghStudent]

I'm glad someone has the spine to say it like it is in as public a forum as the New York Times. Take to the papers, let our voices be heard.

 

[evilbooyaa]

Malpractice suits are tied to patient satisfaction. If a patient likes you, they are very unlikely to sue you, even if you commit the most attrocoius malpractice. NPs tend to spend 2-3 times as much time with the patients as doctors and the patients love them for it. Just because more tests will be ordered and worse care will be delivered, does not mean the malpractice suits will go up. I would not be suprised if they had lower malpractice suits.

There is another study out there that compares patient satisfaction to mortality. The more satisfied the higher the mortality... this is not to say that a satisfied patient is doomed but rather to highlight what a worthless metric patient satisfaction is.

I believe that study was regarding ED patients only. I believe that an average ED patient is significantly different than an average PCP patient.

 

[Instatewaiter]

That would be pretty sweet. Open shop in a state that requires supervised practice and bring on a good mix of experienced and newbie NPs. Collect a percentage of what the experienced NPs bill. Work the newbies to the bone with a flat, far below market salary under the guise of 'gaining valuable experience.'

I think we call that residency...

 

[SouthernSurgeon]

Malpractice suits are tied to patient satisfaction. If a patient likes you, they are very unlikely to sue you, even if you commit the most attrocoius malpractice. NPs tend to spend 2-3 times as much time with the patients as doctors and the patients love them for it. Just because more tests will be ordered and worse care will be delivered, does not mean the malpractice suits will go up. I would not be suprised if they had lower malpractice suits.

Patients also love tests, to be honest. Even if they are not indicated. It makes them feel secure.

Vague abdominal pain --> Let's get a CT scan

Chronic back pain --> Let's get some x-rays, or better yet an MRI!

 

[Instatewaiter]

I believe that study was regarding ED patients only. I believe that an average ED patient is significantly different than an average PCP patient.

True, but still representative of what a worthless metric patient satisfaction is.

I'd much rather someone be an dingus and save my life than hold my hand and kill me with their incompetence.

 

[Instatewaiter]

Patients also love tests, to be honest. Even if they are not indicated. It makes them feel secure.

Vague abdominal pain --> Let's get a CT scan

Chronic back pain --> Let's get some x-rays, or better yet an MRI!

Patients want to feel like you are doing something for them, even if you don't need to. That's why people want antibiotics for colds and CT scans for BS complaints.

You go to the doctor not necesarily because you need a doctor; many times a nurse practicioner would probably do. But you go to the doctor because he/she has the knowledge and background to catch the stuff you're really worried about. You don't go to the doctor because you have some sinus pain... unless in the back of your mind you think it might be brain cancer. NPs just don't have the training to catch the rare/worrisome things but Joe Public just doesn't know the difference between the training modalities.

 

[NontradCA]

True, but still representative of what a worthless metric patient satisfaction is.

I'd much rather someone be an dingus and save my life than hold my hand and kill me with their incompetence.

Why wouldn't someone be satisfied with someone saving their life?

 

[Instatewaiter]

Because it's that black and white.

The latter is more common than you think.

 

[NontradCA]

The latter is more common than you think.

I edited to ask a question instead.

 

[NickNaylor]

Patients also love tests, to be honest. Even if they are not indicated. It makes them feel secure.

Vague abdominal pain --> Let's get a CT scan

Chronic back pain --> Let's get some x-rays, or better yet an MRI!

Dat radiation exposure, enjoy that NP-induced cancer brah

In all seriousness I found that cited study regarding medical utilization very interesting. In a time when utilization is a huge concern - throughout my medical school experience there has been a strong focus on having a reason for ordering tests rather than going for the shotgun approach - it's pretty interesting that that data exists. I'd be curious to know whether there's any difference today.


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[DermViser]

Thanks obama

To be fair, in this case the "Thanks Obama" meme applies, bc Obama and Dr. Emmanuel have been advocating for NPs and PAs to be taking over much of what is current scope of practice for primary care.

Mary Mundinger, a Dean of Columbia's Nursing School, who has the ear of Obama and other elites, has been advocating the take over of primary care by NPs for decades: http://observer.com/2009/12/the-nursecrusader-goes-to-washington/

For her part, Ms. Mundinger readily concedes that there are some things nurses are not educationally equipped to do: oncology, surgery, things that call for medical specialists. But she argues that, if anything, primary care physicians are overeducated. “I spoke to the Federation of State Medical Boards, the people who run all board certifications, and a primary care physician stood up and said, ‘Are you saying I wasted my time going to medical school?’” recalled Ms. Mundinger. “I wanted to say, yeah.”

I swear, I truly believe for those who go into primary care, no good deed goes unpunished.