politics and my salary

[Boyder]

With the election coming up my thoughts have been drawn to the impact the new president will have on my, well, salary as a psychiatrist. I'm don't follow politics so what are YOUR thoughts?

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[BabyPsychDoc]

With the election coming up my thoughts have been drawn to the impact the new president will have on my, well, salary as a psychiatrist. I'm don't follow politics so what are YOUR thoughts?

My thought is that we all should ideally follow politics, since this is a democracy and if you do not want to partake in it, somebody else will on your behalf.

Besides, politics is an extremely "charged" area. I can tell you that GOP will make you better off, and OPD will tell you that Obama is better for your patients. But really, we may both be mistaken, so you need to figure it out for yourself.

In reality, you will be able to make comfortable living no matter what candidate ends up in the office. Saying anything beyond that is extremely risky at this point, since this is the time of unprecedented uncertainty.

 

[Boyder]

Obama being better for my patients translates into what decrease in income for psychiatry? Essentially I'm not familar with the prevailing single-payer proposals of the moment.

I am typically leary of the word "comfortable" when looking at $200K+ in student loans.

BPD are you actually English?

 

[OldPsychDoc]

Obama being better for my patients translates into what decrease in income for psychiatry? Essentially I'm not familar with the prevailing single-payer proposals of the moment.

I am typically leary of the word "comfortable" when looking at $200K+ in student loans.

BPD are you actually English?

Look--no one has any real idea what, if any, actual change in income will come from either candidate's health plan. If Obama is successful in decreasing the numbers of uninsured, that plus the passage of parity may well INcrease demand for our services, and may put upward pressure on what our services are worth. However, since actual reimbursements are controlled by third party payors, I'm skeptical that it will change our individual bottom lines by much. Here's a quick article summarizing the gist of their plans, and criticising both equally. One needs to keep in mind that a high proportion of our clientele comes from the uninsured and underinsured. I don't see McCain's plan changing that, and in general, I don't see Republican policies caring much about these folks. So that's where my bleeding heart liberal bias lies.

I'm confident that, barring a total economic collapse--which scarily seems less impossible this week than it did a month ago, and which is equally out of the control of either party--you will be easily making enough as a psychiatrist to pay back your loans, and live a nicer, more secure lifestyle than 90+% of your patients. I try to make my decisions based on what I think might be the best direction for the country, not necessarily for my bottom line, but I do not believe that I will ever be put in the position of bartering prozac prescriptions for chickens.

 

[BabyPsychDoc]

A good, detailed review of each candidate's platform on healthcare is here:

http://www.economist.com/displaystory.cfm?story_id=12321573

Agree with OPD that nobody can "foresee" who is going make you better off - and chances are, neither candidate will actually make you better off. My point is that you cannot rely on 2nd hand information in this issue - you need to read the original sources and make up your mind for yourself.

And no, I am not "actually English".

 

[BabyPsychDoc]

I do not believe that I will ever be put in the position of bartering prozac prescriptions for chickens.

I dunno - these days I think we may actually end up bartering our services for food. The world seems to be going to ****, bail out or not...

 

[OldPsychDoc]

A good, detailed review of each candidate's platform on healthcare is here:

http://www.economist.com/displaystory.cfm?story_id=12321573

Agree with OPD that nobody can "foresee" who is going make you better off - and chances are, neither candidate will actually make you better off. My point is that you cannot rely on 2nd hand information in this issue - you need to read the original sources and make up your mind for yourself.

And no, I am not "actually English".

Nicely evaded...you might be as good a candidate as Sarah Palin!

Ahh thank you , The Economist. Nice article, reasonably impartial. So good sometimes to get our view on US policy from outside our shores.
(I would take one issue with the article, however. It implies that the Clinton administration instituted "managed care" as an attempt to slash costs after "Hillary Care" failed. Truthfully, managed care was already being put into practice by various insurance companies well before Clinton was elected, and was already seen as acting to restricting patients’ choices at the time the Clintons attempted to enact reform.)

Here's the bottom line (for those in too much of a hurry to digest the article(emphases mine): "In the end, both plans have their virtues. With Mr Obama’s, the big unknown is how much it will really cost to reach near-universal coverage, while the uncertainty about Mr McCain’s strategy to tackle costs is whether it will do much to expand coverage. Given the growing ranks of the underinsured and an increasingly common view that this is a scandal for a country as rich as America—never mind the 46m with no health insurance at all—voters may prefer the plan that promises to cover everyone quickly, and let future voters worry about the cost."

Now THAT's the American Way!

 

[Anasazi23]

I feel that universal coverage for all Americans will collapse the system. It's already taking on water big-time. The costs will be astronomical, both to the system, and in new taxes. It pretty much has to. Those trillions aren't going to come from "cutting spending."

 

[OldPsychDoc]

I feel that universal coverage for all Americans will collapse the system. It's already taking on water big-time. The costs will be astronomical, both to the system, and in new taxes. It pretty much has to. Those trillions aren't going to come from "cutting spending."

This is one place where I am not so sure about the Obama proposal. I think that universal coverage under the system we now have is likely to collapse the system. However, I think that part of our problem is that consumers do not see that the costs are ALREADY astronomical--that employer-based coverage costs workers big bucks in lost wages, costs employers big bucks in premiums, costs consumers big bucks in higher prices that they pay so that producers can buy insurance for their employees, costs government big bucks in tax subsidies to employers to provide the insurance to their employees, etc... I really think that once the employer contributions to insurance premiums, employer and employee withholding for FICA, etc. were removed, the NET increase in taxes would be minimal. Politicians could even call it a "tax cut". Corporate profits would increase, tax revenue on those profits could increase, etc.

As I've said before, I am intrigued by Ezekiel Emanuel's non-single-payer universal coverage model wherein a national value-added tax pays for 100% of Americans to receive a voucher to enroll in a health plan of their choice, with the guaranteed benefits of the much touted "member of Congress" plan, and the option to purchase a higher level of benefit on their own. Again, I'm not going to recap the book--but it's a cheap paperback and an easy read.
Still , you know--if we really got going on this, and did it right, and didn't wait (as we have with the banking system) until the system is already in free-fall... Oh well, I can dream.

 

[Anasazi23]

This is one place where I am not so sure about the Obama proposal. I think that universal coverage under the system we now have is likely to collapse the system. However, I think that part of our problem is that consumers do not see that the costs are ALREADY astronomical--that employer-based coverage costs workers big bucks in lost wages, costs employers big bucks in premiums, costs consumers big bucks in higher prices that they pay so that producers can buy insurance for their employees, costs government big bucks in tax subsidies to employers to provide the insurance to their employees, etc... I really think that once the employer contributions to insurance premiums, employer and employee withholding for FICA, etc. were removed, the NET increase in taxes would be minimal. Politicians could even call it a "tax cut". Corporate profits would increase, tax revenue on those profits could increase, etc.

I'm not quite sure how to say this without getting crucified...Hmm..lemme see.

Good points about proposing to businesses that this will lower their employer contributions. But, this still doesn't address the sheer massive number of people that will seek out services under this plan. Cutting employer costs won't double the healthcare workforce, or increase hospital revenue, which is in absolute crisis nationwide. This destruction will occur 10-fold in inner cities at a much higher rate. How do we address this? Flood the system with mid-levels and non-physician docs? That could be disastrous.

As I've said before, I am intrigued by Ezekiel Emanuel's non-single-payer universal coverage model wherein a national value-added tax pays for 100% of Americans to receive a voucher to enroll in a health plan of their choice, with the guaranteed benefits of the much touted "member of Congress" plan, and the option to purchase a higher level of benefit on their own. Again, I'm not going to recap the book--but it's a cheap paperback and an easy read.
Still , you know--if we really got going on this, and did it right, and didn't wait (as we have with the banking system) until the system is already in free-fall... Oh well, I can dream.

It is interesting, and sounds like the HMOs could continue to exist, and to charge even more outrageous premiums to those that demand those services. Otherwise, their lobby group may nix this before it gets off the ground.

 

[masterofmonkeys]

random comments until I have the time/energy to post a more thought-out piece:

1) Just read a paper that stated that roughly 1/3 of psychiatrist income is derived from medicare/medicaid. Unfortunately I couldn't find a breakdown of managed care and self-pay as well.

Considering how poorly both medicare and medicaid pay (with medicaid being far more awful), that's a pretty significant number. Given that medicare's ranks will swell along with medicaid's, it gives me reason to worry. Not merely from a reimbursement perspective but also one of freedom to practice. I will not be a med-checker, except for people under the care of a PhD/PsyD therapist. I am unaware of just how unwilling medicaid/medicare are to pay for psychotherapy but I know that it's a pretty dismal situation. I also expect that as enrollment swells and funding shrinks, this reluctance will only grow.

Also worth mentioning is the fact that even when you can get reimbursed for psychotherapy, you take a hit relative to doing med-checks for the same amount of time. Not a big fan of that myself.

2) Obama's plan as I understand it may involve increased enrollment into state-sponsored plans like medicare/medicaid. Which means that a greater proportion of our patients will come from a pool that yields lower reimbursement and less freedom to choose the more efficacious/expensive medications as well as to practice as we see fit. "Oh you're husband died a year ago and you can't get over it? Well you're 5/9 on SIGECAPS so here's some prozac and call me in 6 weeks." Umm no.

I can't see how Obama's plan WON'T result in a hit to our bottom lines and our consciences/freedom. But that's just me.

3) As for McCain, I'm not sure whether it'd help or hurt. I have long been a proponent of eliminating the employer-insurance tie for several reasons: 1) it hides true income (you don't make 50,000 plus health insurance, you make 57,000 from which your employer takes 7,000 and spends on the heath insurance). Same reason I think that the whole concept of an 'employer contribution' to FICA is stupid. It conceals from us the true tax burden. 2) it increases market flexibility. Call me a raging capitalist, but i truly do believe that open and efficient markets result in the best value. Note that that requires both openness and efficiencey, which we have never had in the health insurance market. And given that it requires perfect rationality and information, is something of a pipe dream given the public's myopic view and uninformed nature. 3) It puts the right actor's motivations in control. When you buy your own health insurance (with perfect rationality mind you), you are interested in receiving the most VALUE to yourself in terms of healthcare cost control. For me that's a very high deductible/catastrophic plan. For hypochondriacs, the risk-averse, worry warts, and those with children, it might be what we think of as traditional low copay comprehensive health insurance. However when we place the employer in control their motivation is to buy the cheapest possible insurance that satisfies the legal requirements of comprehensive health insurance. Which is not in either side of the spectrum's best interest.

4) Mental Health Parity.

I believe this is the most easily forecasted and that it should boost our incomes fairly significantly. Parity means that comprehesive insurers can no longer restrict access so heavily to doctoral level therapists. It also means that given how high coverage typically is for other issues (ex 1: just think of the cost of a low back pain case that goes through conservative treatment, pain intervention, and finally back surgery. ex 2: The cost of treating someone with diabetes with just one or two of the newer agents is easily in the thousands of dollars per year), this means that long-term psychotherapy will be a more tenable treatment option. This latter prospect will be boosted by the sheer amount of evidence coming out on the high relapse rates for mood disorders treated with medication vs. the much much lower rates for those under either long or short term therapy.

The one major variable in parity is the little loophole allowing insurers to opt entirely out of covering mental health. It's hard to say how many people/plans will opt for this approach. OB coverage is already something that people can and often do opt out of. I have no idea what the numbers are like for this. Given that mental health issues affect such a large proportion of the population, I would like to think that people would opt in. But at the same time, we are tight-fisted penny-pinching bastards at heart.

And now, off to get ready for rotations. yay me.

 

[OldPsychDoc]

I'm not quite sure how to say this without getting crucified...Hmm..lemme see.

Good points about proposing to businesses that this will lower their employer contributions. But, this still doesn't address the sheer massive number of people that will seek out services under this plan. Cutting employer costs won't double the healthcare workforce, or increase hospital revenue, which is in absolute crisis nationwide. This destruction will occur 10-fold in inner cities at a much higher rate. How do we address this? Flood the system with mid-levels and non-physician docs? That could be disastrous.
.

Actually, I think that having some sort of universal coverage will help these situations. Right now "the sheer massive numbers" of uninsured get their care by showing up with severely advanced conditions in expensive EDs, instead of having more economical, cost-effective primary & preventative care. As things are now, these folks also bust hospital revenues because hospitals have to eat the costs of caring for them as charity care, instead of receiving even the pittance that Medicare/caid reimburses for the covered. If they have insurance, they might go to their primary, stay on their blood pressure meds and not have the stroke, the ICU stay, the 12 consults, and the unpaid six-figure hospital bill.

We've got to do something different...

 

[Anasazi23]

Actually, I think that having some sort of universal coverage will help these situations. Right now "the sheer massive numbers" of uninsured get their care by showing up with severely advanced conditions in expensive EDs, instead of having more economical, cost-effective primary & preventative care. As things are now, these folks also bust hospital revenues because hospitals have to eat the costs of caring for them as charity care, instead of receiving even the pittance that Medicare/caid reimburses for the covered. If they have insurance, they might go to their primary, stay on their blood pressure meds and not have the stroke, the ICU stay, the 12 consults, and the unpaid six-figure hospital bill.

We've got to do something different...

I hear ya. But still...there are lots of people that are sitting at home, or going to free clinics to get care. If you open the floodgates, and the workforce can't handle it, what do we do? Family practice is in absolute crisis. Nobody's going into it anymore. What do we do?
I'm probably jaded from having spent the last 5 years in a city program, but there just won't be any beds for anyone. They'll be filled with hospitals looking to boost census and recoup some of the cash they've lost over the last 15 years. I agree that it would be good for the next generation, but that generation won't mature for 10 or 20 years. The system wouldn't last that long to care for them when they did mature.

Seems like we're damned if we do, and damned if we don't.

 

[OldPsychDoc]

Seems like we're damned if we do, and damned if we don't.

You know, the only certainty in this is that we are damned if we don't. The trends are pretty clear. It has to be better to try doing...

 

[BabyPsychDoc]

Nicely evaded...you might be as good a candidate as Sarah Palin!

I am hurt...:cry::cry: What did I do to deserve such an insult?

 

[BabyPsychDoc]

Actually, I think that having some sort of universal coverage will help these situations. Right now "the sheer massive numbers" of uninsured get their care by showing up with severely advanced conditions in expensive EDs, instead of having more economical, cost-effective primary & preventative care. As things are now, these folks also bust hospital revenues because hospitals have to eat the costs of caring for them as charity care, instead of receiving even the pittance that Medicare/caid reimburses for the covered. If they have insurance, they might go to their primary, stay on their blood pressure meds and not have the stroke, the ICU stay, the 12 consults, and the unpaid six-figure hospital bill.

We've got to do something different...

MIGHT is the key word there. Because if they do not, the proposed savings simply will not work out. Is there any evidence to suggest that universal healthcare increases patients' involvement in preventative care and improves patients' compliance with secondary preventative measures? Honestly, I do not know. Anecdotally, I can tell you that I have no shortage of patients on my list that have not refilled their antihypertensives prescriptions for the last 6 months - and you would think, there is nothing stopping them from doing that in the NHS...

Also, what proportion of uninsured actually CANNOT afford insurance as opposed to CHOOSING not buy one? (Honestly, I do not know.)

 

[BabyPsychDoc]

You know, the only certainty in this is that we are damned if we don't. The trends are pretty clear. It has to be better to try doing...

I agree, but...
1) You can't just try various options in the hope that one will work - there should be a good solid plan to start with (and so far I am not convinced either candidate has conceived one) and
2) There must be money available to finance such a plan (OK, this now looks more and more unlikely for the next few years).

 

[whopper]

Right now "the sheer massive numbers" of uninsured get their care by showing up with severely advanced conditions in expensive EDs, instead of having more economical, cost-effective primary & preventative care.

Correct, but there's also a population out there that smokes despite me reccomending them not to smoke. Then when they finally get a heart attack & at a cost of 6 or 7 figures to the system for all the lab workup & the hospital stay, then they finally want to quit.

Universal coverage IMHO may cause as many, possibly more problems as it solves. It all depends in the way its implented. Not every country with socialized medicine does it the same exact way. Some countries handle it more effectively than others. Compare Canada vs the UK for example. There are significantly differing numbers on satisfaction from the provider & the patients.

 

[OldPsychDoc]

I am hurt...:cry::cry: What did I do to deserve such an insult?

You just deftly evaded the question of being "actually English".
I meant no harm...

Actually, I'm quite certain that you have more foreign policy experience!

 

[billypilgrim37]

Actually, I'm quite certain that you have more foreign policy experience!

Because she can see England from her house?

 

[OldPsychDoc]

http://punditkitchen.com/2008/10/12/political-pictures-vladimir-putin-sarah-come-back-alaska-live-sigh/

Because she can see England from her house?

That's probably a fair assumption.

BPD--I promise you, I would choose you as my running mate!

 

[bashir]

Masterofmonkeys, I realize this wasn't the main point of your post, but I was intrigued by your comment that you "will not be a med-checker" for anyone not under the care of a PhD/PsyD therapist. I can understand such a stance for patients with personality or mood disorders, but do you actually mean universally? As in you've never met a schizophrenic patient who you didn't think needed therapy? I'm not trying to nitpick; I'm genuinely curious as to whether I'm understanding you correctly.

 

[masterofmonkeys]

Masterofmonkeys, I realize this wasn't the main point of your post, but I was intrigued by your comment that you "will not be a med-checker" for anyone not under the care of a PhD/PsyD therapist. I can understand such a stance for patients with personality or mood disorders, but do you actually mean universally? As in you've never met a schizophrenic patient who you didn't think needed therapy? I'm not trying to nitpick; I'm genuinely curious as to whether I'm understanding you correctly.

Most schizophrenics can benefit from supportive therapy at the very least, and many could benefit from psychodynamic therapy as well to strengthen their support structures and social relationships--which are often the first thing to deteriorate in the natural history of schizophrenia. But no, obviously, mainstay of treatment would be an antipsychotic. Just as I wouldn't dream of treating a bipolar I patient without a mood stabilizer of some sort. And I wouldn't hesitate to try something like clomipramine to improve symptoms for someone with OCD.

I also have a great respect for MSWs, MFTs, and others who are practicing psychotherapists. I probably should have mentioned them as well.

But my main interests are mood, eating, ADHD/ODD, personality disorders, and adjustment disorders (the latter particularly in the setting of physical impairment/illness).

My point was merely that I am uncomfortable with the idea of purely symptomatic treatment of the above disorders, which medications are for the vast majority of these people. While there are people out there with bonafide organic, intractable underlying causes for these psychiatric disturbances, I believe that psychotherapy is the best way of getting to the root of the problem for most. This doesn't mean I think everyone can successfully cope with mood disorders without medication, but the more mentally healthy they are before the medication the better. Same as maximizing lifestyle management in diabetes.

I'm no Thomas Szasz and believe psychotropic medications play an important part in psychiatry. I just believe that--for the majority of the patient population I am interested in--they do not provide a complete solution in psychiatric care.

 

[plainfacts]

Primary care specialties will benefit greatly by universal health care. The reason they currently lose out to other specialties is because their patients can't afford the costs.

Universal Health Care will greatly increase demand for primary care and force patients to see their primary care provider before going to the specialist. Also the government can afford the costs increasing demand. When they will be by law be obliged to make sure PCP's exist in every corner of the country, underserved areas will see great wage increases to attract PCP's. I expect psychiatry to be the best imbursed specialty for moon-lighting jobs due to supply. Expect moonlighting jobs with $10000 a week salary for a board-certified psychiatrist in alaska.

Basically, politicians will be forced to open their wallets to staff the psychiatry ward.

The losers will be dermatologists, plastic surgeons and other subspecialties. Universal health care allows for no malpractice law suits, and PCP's will take care of 90% of pimplepopping. Gensurg will take care of basic plastic surgery and cosmetics. CT surgeons will blow interventional cardiologists into oblivion.

Hopefully, borders will be opened so attendings from lower income countries can moonlight in the US to fill gaps and push subspecialty salaries even lower.

 

[bashir]

Fair enough, masterofmonkeys. I recently finished a stint as a community support worker working primarily with clients with bipolar disorder or schizophrenia. There were plenty on my caseload who could have benefited from therapy, but there were others who in my judgment didn't seem to need it, psychodynamic or otherwise. My confidence in my ability to make this determination at this point is minimal, as I started this job straight out of college and only stayed with it for a year before deciding to pursue medical school, but my boss (M.S.W, L.I.M.H.P., in the field for 50 years) agreed.

I suppose some people would consider my job (mostly life skills training, relapse prevention planning, and support network building) therapy of sorts, but I wouldn't, particularly as I am not licensed in any way. So my views on the subject arise from my admittedly modest experience. The way I see it there are people suffering from mental illness who do need medication but do not particularly need therapy, though some type of support service is likely to be helpful.

Thanks for your perspective, masterofmonkeys. I apologize to all for hijacking the thread!

 

[Anasazi23]

Primary care specialties will benefit greatly by universal health care. The reason they currently lose out to other specialties is because their patients can't afford the costs.

Universal Health Care will greatly increase demand for primary care and force patients to see their primary care provider before going to the specialist. Also the government can afford the costs increasing demand. When they will be by law be obliged to make sure PCP's exist in every corner of the country, underserved areas will see great wage increases to attract PCP's. I expect psychiatry to be the best imbursed specialty for moon-lighting jobs due to supply. Expect moonlighting jobs with $10000 a week salary for a board-certified psychiatrist in alaska.

Basically, politicians will be forced to open their wallets to staff the psychiatry ward.

The losers will be dermatologists, plastic surgeons and other subspecialties. Universal health care allows for no malpractice law suits, and PCP's will take care of 90% of pimplepopping. Gensurg will take care of basic plastic surgery and cosmetics. CT surgeons will blow interventional cardiologists into oblivion.

Hopefully, borders will be opened so attendings from lower income countries can moonlight in the US to fill gaps and push subspecialty salaries even lower.

Where the heck are you getting this information?

 

[BabyPsychDoc]

Where the heck are you getting this information?

Blue dreams.

 

[BabyPsychDoc]

http://punditkitchen.com/2008/10/12...dimir-putin-sarah-come-back-alaska-live-sigh/
That's probably a fair assumption.

BPD--I promise you, I would choose you as my running mate!

No problem - I am sure we would make a great team. We will just undermine each other's pet projects and save the country lots of money.

The only problem is that the closest a foreign-born American ever got to the office was a Secretary of State (4th in line) - Henry Kissinger and Madeleine Albright were both naturalised. But, I could always rule the country through my children

 

[OldPsychDoc]

But, I could always rule the country through my children

Baby Psych Doc, Queen Mother.

 

[OldPsychDoc]

No problem - I am sure we would make a great team. We will just undermine each other's pet projects and save the country lots of money.

The only problem is that the closest a foreign-born American ever got to the office was a Secretary of State (4th in line) - Henry Kissinger and Madeleine Albright were both naturalised. But, I could always rule the country through my children

BTW, in showing that you can name TWO previous secretaries of State, you probably show more foreign policy acumen than 50% of the American populace, let alone the current GOP Veep nominee...

 

[whopper]

Where the heck are you getting this information?

Exactly.

If Universal Coverage were adopted, there's several different ways it can still be implemented, several of which wouldn't follow the suggested infrastructure. Besides managed care has already made the PCP the gatekeeper & drastically changed practice. Trust me, I know. Several specialists used to have primary practices & their practices were blown out of the water in the 80s when managed care changed things.

 

[Faebinder]

I think plainfacts needs get in touch with reality a little. Enough of reading psychology theories. The mobs of average people will not put up with the sudden lack of cardiology support due to lower reimburisements if they are made equivilant to PCPs.

In universal healthcare we all lose, psychiatrists will just lose a lot less than cardiologists.

 

[BabyPsychDoc]

Baby Psych Doc, Queen Mother.

nah... I will just do the parental version of Hilary...

 

[BabyPsychDoc]

BTW, in showing that you can name TWO previous secretaries of State, you probably show more foreign policy acumen than 50% of the American populace, let alone the current GOP Veep nominee...

So, if I add Colin Powell and Condoleeza Rice, will that put me in the top 1 per cent ?

Interestingly, very few Americans actually know that Madeleine Albright was a first generation immigrant...

 

[OldPsychDoc]

So, if I add Colin Powell and Condoleeza Rice, will that put me in the top 1 per cent ?

Interestingly, very few Americans actually know that Madeleine Albright was a first generation immigrant...

Or that her father was Condie Rice's mentor!
http://www.npr.org/templates/story/story.php?storyId=5516648

 

[OldPsychDoc]

nah... I will just do the parental version of Hilary...

Or Barbara Bush...

(I was kind of disappointed that Hilary isn't going to be president, as I had hoped for a few more years of Clinton, possibly followed by a term for Jeb Bush, and then---CHELSEA vs JENNA in 2020! )

 

[plainfacts]

Jenna will be 46 by 2020... I'm afraid her appeal will be lost by then.

 

[OldPsychDoc]

Jenna will be 46 by 2020... I'm afraid her appeal will be lost by then.

Ageist...