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How To Be A Bad Gastroenterologist

I am a regular reader of patient blogs, and I find myself frequently gasping at the mistreatment they experience at the hands of my peers. Yesterday I had the “pleasure” of being a patient myself, and found that my professional ties did not protect me from outrageously poor bedside manners. I suppose I’m writing this partly to vent, but also to remind healthcare professionals what not to do to patients waking up from anesthesia. I also think my experience may serve as a reminder that it’s ok to fire your doctor when conditions warrant.

I chose my gastroenterologist based on his credentials and the quality of training and experience listed on Healthgrades.com I had no personal recommendations to rely upon – so I used what I thought was a reasonable method for finding a good local doctor. When I met him for our initial office consultation he seemed rushed and distracted, without genuine curiosity about my complaints, complicated history, or how to help me find the correct diagnosis. I brushed my instincts aside, presuming he was just having a “bad day” and hoping for more time to discuss things fully once a battery of blood tests had been completed.

Sadly, I didn’t have the chance to review the results with him – instead he instructed his nurse to read me the results over the phone and to schedule me for a colonoscopy. I wanted to discuss the pros and cons of the procedure and what he thought he might be able to rule out with the test. He did not provide me with basic informed consent information, nor was he able to articulate medical necessity for the scope. I decided not to have the test, and I didn’t hear another word from him or his office.

Months later my symptoms had worsened and so I decided that a colonoscopy might help to further elucidate the potential cause. I was not able to get through to my doctor via phone, so I scheduled the test via his nursing staff. I planned to be the first patient of the day, so that we would have time to discuss my symptoms and concerns.

On the day of the procedure my physician stormed into my surgical bay and began reading my medical history to me from the computer screen, without exchanging basic niceties or introducing himself to my husband. I confirmed the information and tried to offer some nuance since our last office meeting. He cut me off, and made me feel as if my observations were completely unhelpful and were getting in the way of our scope time. He left in a rush before I felt that he had any clear sense of what we were trying to accomplish or rule out with the procedure.

A jovial anesthesiologist then entered my curtained cubicle, and made genuine human contact with me. He inquired about the reasons for the procedure and expressed appropriate glee regarding my Mallampati grade I airway. I asked him if he would be so kind as to not position me directly on my left shoulder during the procedure as it was exquisitely tender from a recent orthopedic injury. He promised to do his best to protect the injury while I was sedated.

Cut to the endoscopy suite where the gastroenterologist enters with a grumble as the techs bustle around the scope equipment and the anesthesiologist explains the slightly altered positioning for my comfort. As the propofol anesthetic goes into my vein I feel the gastroenterologist push me fully onto my injury as I lose the ability to protest.

After the procedure I’m back in my bay with my husband, groggy but with more pain in my shoulder than anywhere else. The curtain is drawn back with a yank and in marches the GI doc, relaying the unanticipated abnormal findings. I ask (in a slightly slurred tone) for more information, to which he responds in a loud voice, “You’re not going to remember any of this so just be quiet and listen!”

I persist in my attempts to understand the details to which he shouts “Shut up and listen” with increasing decibels. When I say that the findings still don’t explain my symptoms and that I remain perplexed he says that I should “try probiotics.”  Finally he leaves the room, not offering any reassurance about the possibility of bowel perforation and stating that we’ll “Just have to wait for the pathology report, and it will take a while because of the July 4th weekend.”

I was dumbfounded, and not just because of my post-anesthetic stupor, but because of the open hostility showed to me by one of my peers. I asked my husband if I was out of line in my questioning and he said that I sounded “like a drunk person” but that the doctor was definitely being “an a**hole.”

As the nurses untangled me from the IV and EKG stickers and rushed me into a wheelchair and out to my husband’s waiting vehicle, all I could say was “Wow, my gastroenterologist was really mean to me.”

The nurses just nodded and suggested that I wasn’t the first to notice that.

As I recover from the whirlwind interaction with the healthcare system, I feel relief and anger. I’m relieved that my GI doc didn’t perforate my bowel and that we accidentally caught some very bad stuff early on, but I’m angry about how I was treated and feel no closer to an explanation for my symptoms than when I started investigating a year ago. My experience was probably fairly typical for many patients dealing with physicians who have lost empathy and compassion. I am sad that there are so many like that out there and I promise to do my best not to follow suit.

My bottom line on gastroenterologists (sorry for the horrible pun): Go with your gut. If your doctor displays jerk-like tendencies during your office visit, rest assured that they can bloom in time. Have the courage to find another doctor before you put your life in their hands and/or they get the chance to verbally abuse you in a post-anesthetic stupor. I am firing my doctor a little bit on the late side, but doing it nonetheless. I just hope that my orthopedist is a good egg (like my anesthesiologist) – because I’ve got one heck of a sore shoulder coming his way!

All You Need To Know About Dr. Oz And The Dietary Supplement Scandal

Comedian John Oliver did an excellent job explaining everything that’s wrong with the Dr. Oz show and the dietary supplement industry. Please watch this video for a good laugh:

I’ve been warning folks about Dr. Oz for many years – and I hope that John reaches more people with his message.

To be fair, there are reputable companies who manufacture safe and effective vitamins and supplements too, as I have noted here.

Mystery Solved: Which Patients Are Good Candidates For Acute Inpatient Rehabilitation?

Occupational Therapy Environment, Saint Luke's Hospital, WA

For most physicians who practice inpatient medicine, acute inpatient rehabilitation facilities are mysterious places with inscrutable admissions criteria. This is partly because physical medicine and rehabilitation (PM&R) has done the poorest job of public relations of any single medical specialty (Does anyone know what we do?), and also because rehab units have been in the cross hairs of federal funding cuts for decades. The restrictive CMS criteria for inpatient rehabilitation have resulted in contortionist attempts to practice our craft in an environment where clinical judgment has been sidelined by meticulous ICD-9 coding.

But I will not bore you with the reasons behind our seemingly capricious admissions criteria. Instead I will simply tell you what they are in the simplest way possible. After much consideration, I thought it would be easiest to start with the contraindications to acute rehab – I call these “red lights.” If your patients have any of these, then they will not qualify for transfer to the acute inpatient rehab unit. I followed the absolute contraindications with relative contraindications (you guessed it, “yellow lights”) – these patients require some clinical and administrative judgment. And finally, I’ve listed the official green lights – the diagnosis codes and medical necessity rules for the ideal inpatient rehab candidate.

I hope that these rules demystify the process – and can help discharge planners, rehab admissions coordinators, and acute care attending physicians alike help to get the right patients to acute inpatient rehab.

RED LIGHT (Patient does not meet criteria, admission is not currently indicated):

  1. Inability to Participate: Patient cannot tolerate 3 hours of therapy per day.
  2. Unwillingness to participate: The patient does not wish to participate in PT/OT/speech therapies and/or shows no evidence of motivation in previous attempts to perform therapy
  3. Poor rehabilitation potential: The patient’s functional status is currently no different than their usual baseline. (Confirmed by previous history, medical records, or reliable source.)
  4. Dementia: The patient has a chronic brain deficiency that is not expected to improve and makes carryover of training unlikely or impossible.
  5. Doesn’t need help from at least 2 different rehab disciplines: The patient must demonstrate likely benefit from working with at least 2 of these: PT, OT, Speech.
  6. Acute illness or condition: The patient has an acute illness/condition requiring medical intervention prior to transfer to an acute rehab facility – these include:
    • septicemia (infection with fever and elevated white count)
    • delirium (medication effect, dehydration, infectious, toxic-metabolic)
    • unstable vital signs (severe hyper or hypotension, severe tachy or brady arrhythmia, hypoxia despite oxygen supplementation)
    • acute psychotic episode (including active hallucinations or delusions)
    • uncontrolled pain (the patient’s pain is not sufficiently controlled to allow participation in therapy)
    • severe anemia
    • extreme fatigue or lethargy due to medical condition
  7. Procedure or workup pending: The patient is in the middle of a work up for DVT, cardiac disorder, stroke, infection, anemia, chest pain, bleeding, etc. or is about to undergo a procedure (surgery, imaging study, interventional or lab test) that could alter the immediate course of his/her medical/surgical management.

YELLOW LIGHT (The patient may not be a good rehab candidate, clinical/administrative judgment required regarding admission):

  1. Possible poor rehabilitation potential: The patient’s prior level of function (PLOF) is likely low or similar to current level, however there is no clear documentation of the patient’s PLOF. It is unclear if aggressive rehabilitation will substantially improve the patient’s functional independence.
  2. Unclear benefit of ARU versus SNF: The patient is unlikely to avoid future placement at a skilled nursing facility. Would it be in the patient’s best interest to transfer there directly?
  3. Mild dementia or chronic cognitive impairment: The patient has carryover challenges but is able to participate and follow directions. There may be family members who could benefit from PT/OT/Speech training so they can take the patient home and be his/her caregiver(s).
  4. Unclear safe discharge plan:  The patient lives alone or has no family support or has no financial means to improve their living conditions or their home is unfit for living/safe discharge or patient refusing SNF but qualifies otherwise.
  5. Insurance denial: The patient’s insurer declines their inpatient rehab stay. Physiatrist may attempt to overturn decision or facility may wish to take patient on a pro bono status.  Uninsured patients may be candidates for emergency Medicaid. Facility must decide if they will lobby for it.
  6. Severe behavioral disorders (unrelated to acute TBI): Verbally abusive, violent, inappropriate or disruptive to other patients.
  7. The patient meets medical necessity criteria for acute inpatient rehab but their impairment is not represented by one of the 13 impairment categories approved by CMS. (E.g. medical debility, cardiac impairment, pulmonary disease, cancers, or orthopedic injury without required comorbidities). Admission may depend upon individual facility’s case mix and its current annual compliance rate with 60% rule.

GREEN LIGHT (The patient is a good candidate for acute inpatient rehab if they have no red or yellow lights, meet criteria for medical necessity AND meet the impairment categories listed below):

MEDICAL NECESSITY DEFINITION:

Acute inpatient rehabilitation services are medically necessary when all of the following are present:

  • Individual has a new (acute) medical condition or an acute exacerbation of a chronic condition that has resulted in a significant decrease in functional ability such that they cannot adequately recover in a less intensive setting; AND
  • Individual’s overall medical condition and medical needs either identify a risk for medical instability or a requirement for physician and other personnel involvement generally not available outside the hospital inpatient setting; AND
  • Individual requires an intensive inter-disciplinary, coordinated rehabilitation program (as defined in the description of service) with a minimum of three (3) hours active participation daily; AND
  • Individual is medically stable enough to no longer require the services of a medical/surgical inpatient setting; AND
  • The individual is capable of actively participating in a rehabilitation program, as evidenced by a mental status demonstrating responsiveness to verbal, visual, and/or tactile stimuli and ability to follow simple commands.  For additional information regarding cognitive status, please refer to the Rancho Los Amigos Cognitive Scale (Appendix B); AND
  • Individual’s mental and physical condition prior to the illness or injury indicates there is significant potential for improvement; (See Note below) AND
  • Individual is expected to show measurable functional improvement within a maximum of seven (7) to fourteen (14) days (depending on the underlying diagnosis/medical condition) of admission to the inpatient rehabilitation program; AND
  • The necessary rehabilitation services will be prescribed by a physician, and require close medical supervision and skilled nursing care with the 24-hour availability of a nurse and physician who are skilled in the area of rehabilitation medicine; AND
  • Therapy includes discharge plan.

13 Diagnosis Codes Approved by CMS for Acute Inpatient Rehab

1. Stroke

2. Spinal cord injury

3. Congenital deformity

4. Amputation

5. Major multiple trauma

6. Fracture of femur (hip fracture)

7. Brain injury

8. Neurological disorders, including:

• Multiple sclerosis

• Motor neuron diseases (Guillain Barre, ALS)

• Polyneuropathy

• Muscular dystrophy

• Parkinson’s disease

9. Burns

10. Arthritis: Active polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies

resulting in significant functional impairment of ambulation and other activities of daily living;

11. Vasculitis: Systemic vasculidities with joint inflammation resulting in significant functional impairment of ambulation and other activities of daily living

12. Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease) involving two or more weight bearing joints (elbow, shoulders, hips, or knees but not counting a joint with a prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, and significant functional impairment of ambulation and other activities of daily living

13. Knee or hip joint replacement, or both, during an acute care hospitalization immediately preceding the inpatient rehabilitation stay and also meets one or more of the following specific criteria:

  • The patient underwent bilateral knee or bilateral hip joint replacement surgery during the acute care hospital admission immediately preceding the IRF admission
  • The patient is extremely obese with a Body Mass Index of at least 50 at the time of admission to the IRF or
  • The patient is age 85 or older at the time of admission to the IRF.

References:

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051177.htm

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/InpatRehabPaymtfctsht09-508.pdf

http://www.gpo.gov/fdsys/pkg/FR-2013-08-06/pdf/2013-18770.pdf

Federal Hospital Inspectors Miss True Dangers, Focus On Documentation Minutiae

In an effort to promote transparency in healthcare, the Association of Health Care Journalists (AHCJ) has published a database of recent hospital deficiencies discovered by Medicare and Medicaid  inspectors. They then highlighted 168 reports containing the phrase “immediate jeopardy.” This, of course, piqued my interest as I presumed that hospitals who were putting putting patients in “immediate jeopardy” must be some pretty bad actors.

After sifting through the hospital names, I saw no record of ones who should probably be on the list based on my personal experiences. I did find some surprises, including well respected academic centers (including Stanford, UCSD, and Intermountain Health). I did a “deep dive” on a hospital for which I have a good deal of respect and some familiarity. What I discovered was both funny and sad.

In the case of the hospital that I knew, the very grave concerns expressed by the inspectors turned out to revolve around patient signatures on HIPAA documentation, and physicians refreshing their electronic restraint orders on patients with traumatic brain injuries. These documentation mishaps had landed the hospital on the ominous list of institutions who are “putting patients lives in immediate jeopardy.”

What a waste of inspector time and hospital resources! Apparently, a hospital who passes CMS muster simply means that they are providing documentation correctness to patients. Forget the real sources of life-threatening dangers – medication errors, poor physician handoffs, unnecessary testing and treatment, and unsanitary conditions. What the safety police are focused upon is whether or not the sick and delirious signed their health information privacy paperwork.

Now don’t get me wrong, I think it’s important to let patients know their rights, etc. But I’ve yet to see more than 10% of patients even read the HIPAA-related documentation that they sign.  Surely an absent signature or two shouldn’t land a hospital on a humiliating federal watch list.

True patient safety cannot be regulated. It is far too complex and nuanced, requiring collaboration between all members of a hospital’s staff. From frequent nursing surveillance, to careful medication review, to laboratory critical value alerts, to conscientious sanitation practices – hospital culture dictates whether or not a patient receives excellent care. Watch lists would be far more accurate if they were simply based on hospital employee questionnaires. As Dr. Marty Makary has discovered, complicated care quality algorithms are no more accurate at predicting hospital excellence than simply asking staff if they’d recommend the place to family members.

So next time you see your hospital flagged by the feds, don’t assume that there is a serious problem going on – better to ask someone who works there if it’s a safe place for care.

The Underbelly Of Vendor Management Systems And The Commoditization Of Physicians And Nurses

In an effort to save on human resources costs, some hospitals have decided to make locum tenens* doctors and nurses line items in a supply list.  Next to IV tubing, liquid nutritional supplements and anti-bacterial wipes you’ll find slots for nurses, surgeons, and hospitalist positions. This depressing commoditization of professional staffing is a new trend in healthcare promoted by software companies promising to solve staffing shortages with vendor management systems (VMS). In reality, they are removing the careful provider recruiting process from job matching, causing a “race to the bottom” in care quality. Instead of filling a staff position with the most qualified candidates with a proven track record of excellent bedside manner and evidence-based practice, physicians and nurses with the lowest salary requirements are simply booked for work.

In a policy environment where quality measures and patient satisfaction ratings are becoming the basis for reimbursement rates, one wonders how VMS software is getting traction. Perhaps desperate times call for desperate measures, and the challenge of filling employment gaps is driving interest in impersonal digital match services? Rural hospitals are desperate to recruit quality candidates, and with a severe physician shortage looming, warm bodies are becoming an acceptable solution to staffing needs.

As distasteful as the thought of computer-matching physicians to hospitals may be, the real problems of VMS systems only become apparent with experience. After discussing user experience with several hospital system employees and reading various blogs and online debates here’s what I discovered:

1. Garbage In, Garbage Out. The people who input physician data (including their certifications, medical malpractice histories, and licensing data) have no incentive to insure accuracy of information. Head hunter agencies are paid when the physicians/nurses they enter into the database are matched to a hospital. To make sure that their providers get first dibs, they may leave out information, misrepresent availability, and in extreme cases, even falsify certification statuses. These errors are often caught during the hospital credentialing process, which results in many hours of wasted time on the part of internal credentialing personnel, and delays in filling the position. In other cases, the errors are not caught during credentialing and legal problems ensue when impaired providers are hired accidentally.

2. Limitation of choice. The non-compete contracts associated with VMS systems typically prevent hospital physician recruiters from contacting staffing agencies directly to fill their needs. This forces the hospital to rely on the database for all staffing leads. At least 68% of staffing agencies do not participate with VMS systems, so a large portion of the most carefully vetted professionals remain outside the VMS, inaccessible to those who contracted to use it.

3. Extra hospital employee training required. There are hundreds of proprietary VMS systems in use. Each one requires specialized training to manage everything from durable medical equipment to short term surgical staff. In cases where hospital staff are spread too thin to master this training, some VMS companies are pleased to provide a “managed service provider” or MSP to outsource the entire recruitment process. This adds additional layers, further removing the hospital recruiter from the physician.

4. Providers hate VMS systems. As anyone who has read a recent nursing blog can attest, VMS systems are universally despised by the potential employees they represent. VMS paints professionals in black and white, without the ability to distinguish quality, personality, or perform careful reference checks. They force down salaries, may rule out candidates based on where they live (travel costs), and provide no opportunity to negotiate salary vis-a-vis work load. When a hospital opts to use a VMS system as a middle man between them and the staffing agencies, the agencies often pass along the cost to the providers by offering them a lower hourly rate.

5. Provider privacy may be compromised. Once a physician or nurse curriculum vitae (CV) is entered into the VMS database the agency recruiter who entered it has 1 year (I can’t confirm that this is true for all systems) to represent them exclusively. After that, the CV is often available for any recruiter who has access to that VMS to view or pitch to any client. There is a wide variety of agency quality in the healthcare staffing industry, with some being highly ethical and selective in choosing their clients (only quality hospitals) and providers (carefully screened). Others are transactional, bottom-feeders with all the scruples of a used car salesman. When your data is in a VMS, one minute you might be represented by a caring, thoughtful recruiter who understands and respects your career needs, and the next (without your informed consent) you’ll be matched to a bankrupt hospital undergoing investigation by the Department of Health by a gum-chewing salesman who threatens you with a lawsuit if you don’t complete an assignment for half the pay you usually receive.

6. No cost savings, only increased liability. In the end, some hospitals who have tried VMS systems say that their decreased hiring costs have not resulted in overall savings. While they may see a downward shift in salary paid to their temporary work force, they get what they pay for. Just one “bad hire” who causes a medical malpractice lawsuit can eat up salary savings for an entire year of VMS. Not to mention the increased costs associated with a slower hiring process, attrition from poor fits, and the inconvenience of having to re-recruit for positions over and over again. Providers also lose out on career opportunities while they’re “on hold” during a prolonged hiring process. And for those who layer on a MSP, they lose control of the most important hospital quality and safety line of defense – choosing your own doctors and nurses.

In summary, while the idea of using a software matching service for recruiting physicians and nurses to hospitals sounds appealing at first, the bottom line is that reducing care providers to a group of numerical fields removes all the critical nuance from the hiring process. VMS, with their burdensome non-competes, cumbersome technology, and lack of quality control are an unwelcome new middle man in the healthcare staffing environment. It is my hope that they will be squeezed out of the business based on their own inability to provide value to a healthcare system that craves and rewards quality and excellence in its staff.

Job matching requires thoughtful hospital recruiters in partnership with ethical, experienced agencies. Choosing one’s hospital gauze vendor should involve a different selection algorithm than hiring a new chief of surgery. It’s time for physician and nurse groups to take a stand against this VMS-inspired commoditization of medicine before its roots sink in too deeply and we all become mere line items on a hospital vendor list. So next time you doctors and nurses plan to work a temporary assignment, ask your recruiter if they use a VMS system. Avoiding those agencies who do may mean a much better (and higher paying) work experience.

*Locum tenens (filling hospital staffing needs with part time or traveling physicians and nurses) is big business. Here is a run down of the estimated market size and its key industry leaders (provided by CompHealth):

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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