VOLUME 4 | 2021 2021: THE YEAR WE OVERCOME
WWW.PHYSICIANOUTLOOK.COM PUBLICATION DEDICATED SOLELY TO PHYSICIANS AND THEIR PATIENTS
Cover Art Created by Hollin Calloway, MD
P HOTO BY JON ATH A N Y BE M A ON U N SP L A SH
F R O M T H E P U B LIS H ER
Risky Business PROVIDERS AS PAWNS Wri t t en by Ma r l e n e Wu st- S mi t h, M . D.
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edicine is a “team sport.” ALL members - physician assistants, nurses, nurse midwives, nurse anesthetists, CRNAs, nurse practitioners and physicians - play vitally important roles, with patient outcomes dependent on excellent communication skills and coordination between all of the teammates. A well functioning medical team puts patients in the center of every play, and the physician in the lead role. The patient is THE reason that the game is played. The increasingly pervasive title of “provider” has permeated all of healthcare. Normally, I prefer to avoid using the word. It gets under my skin. In her 2018 article titled “Nope, “provider” still doesn’t work,” Dr. Jennifer Weiss hit the nail on the head and aptly described how the word makes most physicians feel. “Use of the term has been found to actually reduce morale, worth, purpose, and results in already overworked doctors finding less meaning in the work that they do.” 2 | 2 0 2 1 VO LU M E 4
Why, then, did I choose to use the word “provider” in the title of this article? Because whether you are a physician assistant, nurse, nurse midwife, nurse anesthetist, CRNA, nurse practitioner or a physician, we are ALL being played. We are collectively being used as pawns in an elaborate scheme to redefine healthcare - for profits at the expense of patients. Whoever is at the helm has been opaquely hiding in the shadows, and not being transparent about their motives. We need to all be wary of this “Oz” behind the curtain who has brought us clunky EMRs, MACRA and other unattainable quality metrics, meaningless Press-Ganey surveys, higher malpractice rates and payouts, ridiculously high deductibles, narrow provider networks, rising drug costs, and collusive Group Purchasing Organizations and Pharmaceutical Benefit Managers. We need to be brutally honest about the many different types of “providers” that comprise today’s modern healthcare
team. We can not continue to idly stand by as young, under-educated and under-trained non-physician providers are being put in positions by administrators and insurance companies to care for patients because it is a less expensive way of delivering care. These fiscally-driven changes are putting patients in harm’s way, and are causing a massive exodus of healthcare professionals who actually care about the Hippocratic Oath. We are creating a generation of non-physician providers who will be haunted by guilt and imposter syndrome when they realize what has been done to them, and the harm it is doing to patients. Two very brave physicians, Dr. Niran Al-Agba and Dr. Rebekah Bernard, have written a must-read provocatively titled book by the name “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.” The doctors are also cohosts of a podcast called “Patients At Risk.”The book and podcast should be required reading/listening for ALL pre-
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health students and are also invaluable tools for anyone who has to navigate the system as a patient. Through storytelling and factual patient-centered anecdotes, the book provides a very detailed account of the current state of American healthcare. Nurse practitioners are being churned out by online, non-standardized programs where a mere 500 hours of self-directed clinical shadowing allows the nurse to earn a degree. All graduates are being encouraged to obtain a “DNP” degree so that they can call themselves “Doctor” in the clinical setting. Patients are already confused when they intersect with the many members of a healthcare team, and it is frankly intentionally disingenuous and manipulative to have someone in a long white coat who introduces themselves as “Dr. So-and-So” misrepresent themself as the team leader. The book unfortunately does not go into great depths on how far-reaching the political maneuvering and corporate greed is, but once we all “pull back the curtain” together and realize that we are all being played, we can sit down to work together to take back what has become a very broken medical system. Many patients are being harmed at an alarming rate--with some even dying-- because non-physician providers “don’t know what they don’t know.” Patients and families who lose loved ones have very little recourse because in the majority of states the Boards of Nursing, not the Boards of Medicine, have jurisdiction over non-physician nursing providers. Unsupervised “Full Practice Authority” has passed in at least half of the United States and is constantly being introduced as legislation in the remainder. A run-away train is careening down the track, and we need to have the guts to speak out and reverse course. We need to stop allowing ourselves to be manipulated by profit-driven corporations and put our patients first. 1 Dr. Marlene Wüst-Smith Publisher
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Table Of Contents
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FROM THE PUBLISHER
Risky Business: Providers As Pawns, by Marlene Wust-Smith, MD/p.2 THE HUMANS IN MEDICINE
Success Knows No Bounds, by Alex Rubanenko, RN/p.6 A Letter To Future NPs, by Leslie Doran, NP/p.10 Great Nurses, by Dana Blue/p.14 THE DOCTOR’S BAG
How Direct Primary Care Shines A Light During Pandemic, by Marion Mass, MD/p.16 Dermatology “Providers,” by Katherine Trettin, MS-III and Jordan Creel, MD/p.20 The Death Of Paper Checks, by Craig Wax, DO/p.24 American College Of Healthcare Trustees, by David Levien, MD/p.26 PLEASURES AND PASTIMES
As It Sets, by Nana Dadzie Ghansah, MD/p.29 But Just Once, by Scott Abramson, MD/p.30 Maggie’s Musings: It Doesn’t Stop, by Margaret Hurley, MS-I/p.31 Prayers Of Diaspora Hearts, by Ayushi Chugh, MD/p.32
Cover Art Created by Hollin Calloway, MD WWW.PHYSICIANO U T LOOK . C OM | 5
T H E H U MAN S O F M ED IC IN E
Success Knows No Bounds WITHIN YOUR SCOPE OF PRACTICE
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Wri t t en by Ad a m Ru ba nenk o R . N.
y name is Adam Rubanenko. I am a proud Registered Nurse who grew up in a household of medical doctors. I am here to share my story and my passion for Nursing as a profession with the Physician Outlook family. I was born in Los Angeles, California to Nina & Gabriel Rubanenko, immigrants from Israel. My father, Dr. Gabriel Rubanenko, immigrated to Israel as a young MD from Latvia which was part of the former USSR. He served as a doctor in the Israeli military when he met my mother Nina who was also in the Israeli military known as the IDF - Israel Defense Force) in the 1970’s. My mother was part of a special unit that worked with the U.N. 6 | 2 0 2 1 VO LU M E 4
envoys stationed in Israel. My parents met in the military and my mom introduced my dad to my grandfather. At that time my grandfather Zev Ruderman was a partner in the first ever nursing home in Israel and was in the process of helping the Israeli Parliament in writing the rules and regulations for nursing homes in Israel. My grandfather was impressed and hired my father to work as a medical doctor in the nursing home. At the time my father was also a Judo champion, former Latvia champion and he also became an Israeli judo champion. He was always very fit, ate the best in nutrition and was also doctor for the Israeli national Olympic judo team.
As things took off and blossomed in my parents relationship, my father had dreams of becoming an orthopedic surgeon. Eventually my parents decided to move to Los Angeles in 1980 and my father was accepted into the USC orthopedic residency program. I was born in 1981 in Los Angeles. My father was working hard in his residency and moonlighting a lot (later I found out that meant he was spending 48-72 hours at a time at the county hospital of USC for most of his shifts.) and I barely saw him as a young child. At that same time my grandfather in Israel had built multiple more nursing homes with his partners - he had the biggest network of nursing homes
P HOTO CR ED IT BY A DA M RU BA N E N KO, RN
and their nursing homes were the gold standard in Israel. As time went on my father graduated from his residency and became a Board-Certified Orthopedic Surgeon and received privileges to operate at Cedars Sinai Hospital in Los Angeles. He became recognized very quickly as a top orthopedic surgeon and well known for his work in sports medicine and sports related injuries, as he himself was a sports champion. Since he spoke Russian and Hebrew, he quickly had a thriving practice in Beverly Hills, and the Russian and Israeli community was frequenting his office along with the general populous. Not long after, my grandparents sold their stake in their
nursing homes to move close to us in Los Angeles. Growing up with my dad, my brother (4yrs younger than me) and I played many sports (soccer, tennis, judo etc.), were always active and taught to eat well with proper nutrition. My father educated us about the body, anatomy, physiology, and how sports and proper nutrition are so important and how they positively affect the body. By the 90’s my father continued to grow his private practice and his surgical presence. My grandfather opened a nursing home in Anaheim California As a child, I grew up in hospitals with my father frequently taking me with
him while rounding at the hospitals he was operating in, sitting in the nurses stations. I became friendly and very familiar with all the nurses at those hospitals. I loved the nurses and they loved me, they took care of me while my dad was rounding and taught me so much. I never forgot how they cared for me and this was one of the main reasons why I went into nursing. I grew up in hospitals and my grandparents nursing homes in Israel and California. My parents divorced when I was 10 and mom and grandparents moved back to Israel. My brother and I moved to Israel with them. My grandfather had built new nursing homes and I was also spending so much time in the nursing home with the nurses. I was inspired to study nutrition and exercise and became a fitness instructor in Israel. Nurses raised me in Israel and in the US. I spent most of my childhood surrounded by nurses. Their love and compassion inspired me to move back to the USA, and go to school. I moved back to the US in my early 20’s and moved in with my dad. I loved the OR growing up so my father encouraged me to study surgical technology. I became a certified surgical technologist and worked with my dad and his surgeon friends for a year before I decided to go back to school to become a nurse. (never forgetting the lessons nurses taught me growing up.. love, compassion and dedication for patient care) I went back to school and became a Licensed Vocational Nurse. I worked at one of the same hospitals my dad operated in for many years and many of the nurses were still there. They continued with the same lessons they taught me as a kid - but now as a professional nurse - so it came full circle. After a year working in the hospital as an LVN I decided to go back to school to become a registered nurse, while working as an LVN. It was difficult to work fulltime in the hospital and go back to nursing school, so WWW.PHYSICIANO U T LOOK . C OM | 7
P HOTO CR ED IT BY A DA M RU BA N E N KO, RN
a friend of mine told me about home health. Once I realized that a nurse can work outside of the hospital or nursing home and that in home health I was able to make my own schedule and spend 1 on 1 time with the patient to really get to know them.. I jumped on that opportunity. I started home health visits as an LVN while finishing up my RN program. Eventually I left my hospital floor nurse position to work in home health full time, as it just fit my schedule much better and allowed me to study more. Once I became an RN, I had over a year’s experience in home health, so naturally I continued working as an RN field nurse, visiting patients at home. I was providing initial assessments, resumption of care after hospitalization and discharge/recertification for more home health care. After working for a year as a field RN, I was promoted to a case manager position inside the office. By then I had learned the business aspect of home health, and grew up with many doctors around my dad so I did marketing as well. Also growing up in a nursing home taught me a lot about the business of medicine. I worked as a case manager for a year and excelled in business development. I brought referrals from many doctors, hospitals, nursing homes, that would direct patients to them for home 8 | 2 0 2 1 VO LU M E 4
health care. Soon after I was promoted to be Director of Nursing for the home health care arm of where I was working. I revamped the office completely. I hired a full new office staff, and many new field staff nurses. It got to a point where I hired all the company staff, brought in most of the business as patient referrals, and managed the office clinically. I was doing everything except signing the paychecks. I wanted a partnership stake in the business, but my boss considered and eventually declined my offer. My grandfather/father loaned me the funds to acquire a home health agency that was for sale in my area and I purchased the agency. The office staff and referral sources naturally gravitated to my new company to the point they all left the previous home health agency where I was employed. We were getting busy rapidly as my staff was loyal to me, very seasoned since I was the one that trained them. I had the best IV infusion nurse, the best wound care nurses etc. most of the hospitals, nursing homes and many medical groups and private clinics were working with us and referring to us. My dad became my medical director and all his friends and colleagues were referring to us. We did such great work that I had to open another home health office to accommodate all the referrals. Our good name and reputation spread very rapidly.
We were getting referrals from LA County, Orange County, Riverside, San Bernardino, Ventura County and other counties throughout Southern California. Many doctors, hospitals, nursing homes, and rehab centers were relying on us to provide great quality care for the patient after discharge from inpatient facilities and to prevent rehospitalization. I subsequently opened a hospice company to be able to provide the whole continuum of care in the home. My staff was cross trained to care for issues as simple as hypertension all the way to end-stage carcinoma. Two years ago I received a great offer to sell my companies. I entertained the offer as I wanted to get into the business of nursing homes and assisted living facilities so I sold my businesses. I am now a partner in a small nursing home but ever since I sold, my referring doctors and my old office staff and field nurses have not stopped calling me about opening up another home health agency stating that we were the best and provided top quality care that that was unrivaled. A year and half later my doctor and nurses finally convinced me to open a home health office again.. so as I write this I opened a new home health agency less than a month ago and we are thriving. All my doctors, hospitals, nursing homes etc are referring as they were the ones that convinced me to go back into my specialty. The Sky is the Limit P.S. During the pandemic I obtained my Gerontological Nursing Certification (GERO-BC™), got licensed as an assisted living administrator, and got DSD licensed (Director of Staff Development) which allowed me to become a nursing school program director, and qualified to teach nurses and issue them Continuing Education credits. I continue to work closely with physicians and others on a multi-disciplinary team, and I am fortunate to ensure that all Home Health patients are getting the very best care. 1
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T H E H U MAN S O F M ED IC IN E
An Open Letter To Future NPs DON’T RUSH THE PROCESS
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Wri t t en by L esl i e D o ra n, N P, C i t i z en’ s H ea l t h
ello fellow Registered Nurses (RN) who are contemplating the Nurse Practitioner (NP) route in furthering your healthcare career. I have been an NP since 2015, specializing in cardiology, after being an RN for 27 years. I recently retired in August of 2020, as I was witnessing a decline in healthcare that was very concerning to me. Healthcare now is not what it was when I started nursing school in 1985. So much of the education is online and not in person. One cannot practice effectively in healthcare if the bulk of the education received is through a computer screen. This is how much of the NP education is now being given and makes hands-on experience as a nurse - in advance of pursuing an NP degree - so critical. If you are indeed considering this path, I 1 0 | 2 0 2 1 VO LU M E 4
have some advice for you, questions for you to ponder. When you graduate from a nursing program it’s a HUGE accomplishment, then come boards! Talk about stress! OMG! You find out you passed boards and are so elated thinking “yes I am a nurse!” You think you’ve learned everything you need to know and are ready to take on the entire medical field, ready to be a team player, make a difference because getting through school and boards was the toughest part. Right? Wrong! Starting as an RN at the bedside in a hospital is step one! You have enough experience to take vitals and do an assessment. What happens if something is wrong, vitals are off, lungs aren’t clear, extremities are edematous, what do you do because NOW you are the nurse, not the student? This is the start of your
“professional experience” and you will have to go through this experience, plus many others, for 5 to 7 years to be considered an expert in the nursing profession. In addition to your assessment skills and ability to administer medications and treatments, you will also need to be able to incorporate lab results, diagnostic imaging reports, and perform patient teaching so the patient truly understands their disease and why the treatment plan is what it is. Sounds doable right? So then the next step is to become an NP because your attitude now is “I can do this and I can do what doctors do.” Problem is many nurses don’t want to be at the bedside for 5-7 years because they are tired of being told what to do or yelled at for doing something wrong or not in a timely manner. Your evaluation from
P HOTO BY C A RLOS M AGN O ON U N SP L A SH
your manager states you aren’t meeting the standard, or you are meeting the standard but you think you are exceeding the standard. You get frustrated and your ego is hurt because you think you are better than what others think of you. So you decide to leave the bedside after 2 years and go back to school to be an NP because you know this is going to be easier. Easier for who? You? The patients? The doctor(s) you work for/with? Throughout my nursing career I was always thinking about Patricia Brenner’s Novice to Expert Nursing Theory, it is spot on with the Five States of Clinical Competence. Stage One is the Novice, you’re first starting out and you have limited knowledge of what could happen to the patient. Stage Two is the Beginner, which encompasses your first 1-2 years in practice at the bedside. During these
formative years you will gain experience from which you can draw from to your further practice. Stage Three is Competence, you can now organize, prioritize, and are able to be flexible with patient care. Stage Four is Proficiency, this is the stage where you are not only able to react effectively, but you are a proactive patient advocate. Stage Five is the Expert stage, this is where you know what needs to be done, can implement care effectively and efficiently, and have the ability to be intuitive because you have experience from which you can draw on. This stage is where you become an effective leader and teacher to other nurses. Why did I just go through that? What does it really mean? It’s a great tool that I have always relied on when I have either started on a new unit or when I have been teaching students or orienting new employees. In my experience I feel that it is of utmost importance for RN’s wanting to become NP’s that they are competent in bedside nursing before they become an NP. Experience at the bedside is priceless, which I think we can all agree on, as we know so many things are not textbook. You can’t read about intuition, it comes with experience and the only way you get experience is by working. You need to be an important part of the healthcare team which means getting along with doctors, nurses, pharmacists, respiratory therapists, physical therapists, etc. This takes years, 5-7 at least. Any less than that is not going to benefit you, the doctor, the patient, or any of the other entities involved. We all know medical school is different from nursing school. Doctors are trained to be the leaders of the healthcare team. It is who nurses go to for direction on tests, medications, therapies. Doctors have the most experience on the healthcare team as we know from all of their years of schooling, residency, and fellowships. Nurses on the other hand are mostly Bachelor’s prepared now which means 2 years of general education and then 2 years of nursing and theory. Therefore it is imperative for RN’s to work at the bedside for at least
5-7 years before going back to school to obtain the NP degree. These questions are ones that should be answered with honesty and integrity before you decide to pursue the NP route: -Do I feel confident in my one on one assessment skills of any patient I encounter? Am I able to have an idea of what tests and medications may be ordered when I call the doctor to let him/her know the status of the patient? -Am I afraid to ask questions if I don’t know? -Am I able to handle constructive, as well as destructive, criticism? -Am I ready to take on this new challenge as I know it will take 5-7 years to become an expert in this field? -Do I feel I can treat patients competently? Am I willing to continue to learn even when I get upset if I am wrong? Remember that, in most circumstances, as an NP you are functioning under the license of the physician you are with. Do not put him/her in a bad spot. Be confident and competent for the physician as well as the patient. Make sure you are not afraid to ask questions or clarify something you are unsure about. The physician, as well as the patient, will be glad you did. An unpopular opinion, but one I will state anyway. New NPs have no business having “Full Practice Authority” or practicing unsupervised. This is dangerous for patients, and puts them (and the NP) at significant medicolegal risk. Best wishes to those who choose the journey to being a well respected NP! It takes years and it takes a lot of determination. Remember you are a part of a healthcare team and others are relying upon you, don’t let them down. 1 Sincerely, Leslie Doran, FNP-BC, MSN, BSN, BS
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Re-Thinking Things The Importance Of Making Sense Of Things That Have Become Nonsensical
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here are LOTS of things in this world that make the average person stop and scratch their head to wonder…”why exactly are we doing things this way?” We all know that Electronic Health Records have made patients’ health records legible and readable--the days of illegible, one or two line patient notes written in doctors’ hieroglyphic “chicken scratch” penmanship are a thing of the past. As aptly described by Dr. Fred Pelzman1, electronic medical records were supposed to make our lives easier, communicate our thoughts in the moment of taking care of our patients, and leave a record that would help to make sure the next person taking up the care of that patient knows what came before. But...the exact OPPOSITE is the net result across our nation. Electronic health records are one of the most commonly cited contributing factors that are thought to be a root cause of physician burn-out. Most Electronic Health Records produce a document that is very lengthy and detailed, but the resultant “note bloat” actually makes it more difficult to decipher what is going on with the patient. Does that make sense??!! Of course, not. We need sense-making in medicine and at Physician Outlook we are fortunate to be partnering with Let’s Rethink This, whose mission is to build and connect communities of like-minded individuals and organizations devoted to rethinking solutions to today’s biggest challenges. Through LRT I “met” a bright young entrepreneur and film-maker, Kistien Monkhouse, who is one of these ‘sense-making’ individuals. 1 Who writes often for www.kevinmd.com 1 2 | 2 0 2 1 VO LU M E 4
Monkhouse is the creator of Patient Orator, an easy-to-use”app” that helps ALL patients get equal medical treatment and facilitates care collaboration for patients,caregivers and the entire medical team AND she is also a film producer. Humanizing Health Care is a narrativedriven emotionally paced documentary produced by Kistien Monkhouse about healthcare experiences in the U.S. The film explores deeply
Kistein Monkhouse, MPA Founder of Patient Orator Kistein Monkhouse is a “sense-maker.”
S www.LetsRethinkThis.com “Physician Outlook” is a proud founding Impact Organization.
rooted systemic issues across the healthcare ecosystem and the barriers they present to people at each touchpoint in care delivery. By learning the history of institutionalized healthcare delivery, we can re-think how ALL Americans can work together to truly humanize healthcare. Use code PatientOrator to view the film for free, and join us on the Let’s Rethink This platform for group discussions on how we can change physician and patient stories into solutions.
he is a Patient Orator who worked in the front lines of healthcare to help finance her education. While caring for underserved patients she identified a huge problem and came up with a solution. Patients of color from marginalized communities were not getting the same standard of care as other patients. She is teaching patients (through the app) how to get equal medical treatment, how to record, track and share medical issues and social needs and how to better communicate medical symptoms. She also teaches patients how to get support with managing their health, connect to resources close to where they live, and make care collaboration easy for the patient, their caregiver and for the patient’s medical team. She has developed a tool that is improving care coordination, empowering the voice of the patient and reducing the documentation burden of the clinician. Frustrated with a healthcare system that consistently placed value on profits above patients, she decided to do something about it. She founded a company that has created an easy way for patients and providers to have meaningful conversations. Their team of experts have standardized how patients identify their health concerns, care preferences, and social needs. They are aligning social care organizations and medical providers with individuals to improve patient and community engagement, leveraging technology to improve health outcomes. To learn more about the app, which is currently in development, visit Patients — Patient Orator (www.patientorator.com) WWW.PHYSICIANOU T LOOK . C OM | 13
T H E H U MAN S O F M ED IC IN E
How Great Nurses Make a Physician’s Job Easier
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Wri t t en by D a na B l u e
hether they work in an office, hospital, or healthcare facility, physicians rely on nurses to ensure that they can give the best patient care possible. This is especially important now that there’s an ongoing physician shortage in the US. In fact, by 2025, we’ll be 46,000 to 90,000 physicians short. It certainly doesn’t help that by the same year, the demand for physicians will grow by at least 17% due to the growth in population. As such, physicians tend to handle more tasks to make up for the lack of people. Fortunately, great nurses can help make their lives a little easier. Here’s how: They provide much-needed assistance It’s no secret that physicians don’t have enough time to accommodate all their patients — that’s why they have trusted nurses to help with some of their 1 4 | 2 0 2 1 VO LU M E 4
tasks. For instance, a clinical nurse can update the medical profile of every patient (such as their weight) while they wait for the doctor to see them in. With updated information on hand, the attending physician can conduct faster check-ups. This situation is much the same in hospitals. Nurses’ help is especially prevalent in overcrowded departments like the ED. It certainly doesn’t help how the more patients that are admitted into the ED at a time, the more medical attention all the other patients need. Fortunately, as one of the top careers in nursing, more BSN graduates are choosing to go into critical care. Critical care nurses handle a lot of tasks, from redressing wounds to administering medication, but their primary role is to monitor patients and report any changes to the attending physician. Cardiac nurses, RN anesthetist, and other nursing roles provide similar assistive roles.
They serve as the connection between physician and patient Nurses spend more time with patients than their doctors, so they tend to form closer connections with them. True enough, our research on the topic shows that nurses can better fulfill the human connection part of patient care. Therefore, it’s no surprise that patients are more willing to engage in small talk with their nurses. Incidentally, great nurses know how to use this opportunity to uncover important health information, especially those that patients are not willing to tell their physician. Nurses are also more than equipped to answer basic patient inquiries like how a procedure is done. This lets physicians focus on the more clinical parts of the procedure. They can help with administrative tasks Nurses aren’t just well versed in patient care, they can also handle admin-
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PHOTO BY MATTHEW WARING ON UNSPL ASH
istrative tasks like scheduling physician appointments and organizing the flow of payments. Of course, there are different nurse types that are best suited for each task. For example, a nurse case manager is a type of registered nurse that’s in charge of updating and revising patient healthcare plans. This includes getting in contact with the patient’s insurance provider. Since they hold all the data, nurse case managers are also pivotal in estimating the patient’s recovery period. There are also nurse informaticists. These are the people who store your patients’ electronic health records and pull them out upon request. Some clinical nurses also help in administrative tasks. The best nurses can fulfill different roles, from informatics to pediatrics that can make a physician’s job easier. But because of the specialized nature of some of these fields, it’s important to assess if your nurses are up to the tasks. 1 WWW.PHYSICIANOU T LOOK . C OM | 15
T H E D O C TO R’ S B AG
How Direct Primary Care
SHINES A LIGHT DURING PANDEMIC
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Wri t t en by Mari o n M a ss, M . D.
n our previous piece, we discussed how the lack of price transparency in the American healthcare system has become an addictive painkiller — the “opiate of the masses.” Protection from the pain of prices that are hidden (opaque) dulls our thinking just enough so that we don’t get too worked up. There’s a different model for the practice of medicine that is gaining increasing support among physicians and patients. Direct Primary Care (DPC) is a timely subject because physicians using this model are among the best equipped, best prepared, and most effective on the front lines of the fight against the pandemic. 1 6 | 2 0 2 1 VO LU M E 4
Pennsylvania is the first state to begin educating the general public, business groups, and medical schools about this model, and the first state to receive a grant from its medical society for that purpose. But DPC practices are springing up all over the country, with general practitioners leading the way, although specialists have started to follow. Under this “membership model,” a member-patient has around-the-clock access to the services of the physician. On average, the monthly fee is $60 per patient. DPC physicians recommend insurance solely as a hedge against a financially catastrophic medical event. Apart from that recommendation, they want no entanglement with health
insurers, and take no payments from them. Prices for services in the DPC model are fully transparent. Most importantly, the DPC model allows patients to use one of the keys to lifelong health: an enduring, personal relationship with a physician. Kimberly Corba, D.O., a DPC physician in Allentown, explains how DPC doctors are responding to the current pandemic: “During COVID-19, we are able to tele-med with our patients, and keep them out of the ER and urgent-care facility, thus preventing more exposure to COVID-19.” Dr. Corba described a critical advantage of not being owned by a cor-
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porate hospital system or beholden to insurers. “We didn’t have to wait for the suits in the C-suites to get moving. We did what was best for our patients. Like other DPC offices, we had the kits for COVID testing weeks ago. We are unconstrained by bureaucracy, and thus improvised to make masks and gowns so that we could continue to provide attention to our patients.” Have you ever heard the legends about house calls by doctors? “Many of the thousands of DPC physicians around the country are making house calls, drawing blood while there, caring for our patients with chronic issues who need continued monitoring,” Dr. Corba said.
As for the savings achieved under this model, she offered the following: “Chronically ill patients save thousands of dollars every year because DPC physicians dispense medications at cost; and we contract transparently with labs and imaging centers to secure better value for our patients.” Yes, America needs to disinfect its system of the coronavirus as quickly as possible. DPC medicine, with its hallmark of price transparency, can allow the sunlight to shine through and disinfect a healthcare system that is itself deeply sick, stopping the contagion of hyperinflation in its tracks and restoring it to better health.
Look into it, won’t you? At the moment, physicians are being hailed, deservedly, as heroes who are risking their own health in the struggle against the pandemic. It’s especially apt that I write this as National Physicians Week (March 25-31) nears its end and on March 30, designated as National Doctors’ Day. But when it comes to the dysfunction in American healthcare, not all physicians are blameless. Some have abetted it. Our next installment will tell you about them — some of the fattest fat cats in the medical industry. 1 Originally pubished March 31, 2020 https://www.buckscountycouriertimes.com/ opinion/20200331/guest-opinion-how-directprimary-care-shines-light-during-pandemic/1. WWW.PHYSICIANOU T LOOK . C OM | 17
T H E D O C TO R’ S B AG
Dermatology “Providers”
DIFFERENCES IN TRAINING: MORE THAN SKIN DEEP
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Wri t t en by J u s ti n C reel , M D a nd Ka th e r i n e Tret t i n, M S -III
upply and demand: the oversimplified algorithm of any free market enterprise. When there is shortage in supply and/or swelling of demand, the value of an item becomes inherently inflated. The market may respond to such fluctuations with alternative replacements that are more accessible or reproducible and thus more cost-effective. It’s a tale as old as time and an underlying theme of this great nation – but what happens when there are competing variables that are non-financial? When free market enterprise clashes with individual well-being? Well, some may say this represents the unfortunate setting of modern health care – a notion perhaps 1 8 | 2 0 2 1 VO LU M E 4
best illustrated by the pseudo-battle of physician versus mid-level providers. For the past several years, as with many specialties, the shortage of board-certified dermatologists has steadily risen. Not surprisingly, this has led to an explosion of non-physician clinicians within the field. When used correctly, these “mid-levels” can be masterful instruments of efficiency, extending the reach of an overextended physician. Patients see shorter wait times and improved accessibility; physicians see less redundancies and amplified care delivery. As with most things, however, such benefits may come with unforeseen ramifications.
The evolution has been slow but unmistakably persistent, with midlevel providers ever growing their presence within the field. Growth not only in number of provider numbers but also in terms of scope and responsibility. What started as “straightforward follow-ups” transitioned to “all established patients” and eventually “every level of service.” Likewise biopsy led to excision and neurotoxin…filler injection. In the most American fashion, we exploited the aforementioned benefits of our extenders and perversely created a faux-physician “provider” – one that has become harder and harder for patients to distinguish. And to be blunt, such “provider” confusion is truly inexcusable.
P HOTO C RE DIT BY IN GRA M IM AGE S
Mid-levels do not receive the training that is necessary to function as independent dermatologists. A practicing NP or PA in dermatology requires roughly five to six years of study, none being dermatology-specific. Further, there is but one dermatology “NP fellowship” in the United States and zero such equivalents for PAs. Instead, the vast majority of mid-levels are primarily trained on-the-job by fellow nurses and other medical professionals, leaving no procedures of standardization or competency assessment. What’s worse, many nurse practitioner degrees can be obtained online without any additional clinical training but rather with
significant focus on health policy and administration. In total, mid-level providers often finish their degree with just 1,000-1,500 hours of clinical training, potentially 0 of which taking place in dermatology. In contrast, the training of a board-certified dermatologist involves twelve years of study and over 12,000 hours of practice, the majority of which being specific to their field of expertise. Overall, the education consists of 4 years undergraduate (e.g. basic science), 4 years medical school (MD/ OD), 1 year preliminary (e.g. internal medicine), and 3 years dermatologic residency. Furthermore, dermatologists
Mid-levels do not receive the training that is necessary to function as independent dermatologists. may then pursue post-residency fellowships of 1-2 years in subspecialties such as Mohs Surgery, Aesthetic Medicine, Dermatopathology, and Pediatric Dermatology. Equally important to duration, the training curriculum is standardized across programs and includes rigorous assessment that ensures basic competency prior to board-certification. So supply, demand, worth, and cost – these are all integral components to a functional economy. In order to effectively communicate these principles, we rely on systems of currency or legal tender. Money allows comparison of objects that are otherwise incomparable (e.g. the value of toilet paper versus school tuition or an apple versus an orange), but this is only possible through the use of a universal metric. Well, just as there’s a difference between US and Canadian dollars, medical “providers” are in no way an interchangeable currency – though some would suggest otherwise, in what I call healthcare racketeering. 1
DERMATOLOGY PA, NP, MD… Can YOU tell the difference?! Test your knowledge of these medical professionals by taking our research survey! 1. Open your phone’s camera. 2. Scan the QR code here. 3. Follow the survey link!
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T H E D O C TO R’ S B AG
Latest Insurance Scam THE DEATH OF PAPER CHECKS
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Wri t t en by Cr a i g M . Wa x , D. O.
uring the global pandemic of 2019-2021, the managed-care insurance industry has the chutzpah to stop paying for medical care by checks as they have for the last hundred years. Many are now issuing “gift cards,“ weeks after the care was delivered, that require a credit card machine, monthly service fees to a bank, and a percentage lost to processing fees. Horizon Blue Cross Blue Shield of New Jersey, our local 800 pound gorilla example, and United Healthcare (UHC), the largest health insurance company in the United States and perhaps the world, is another monster pursuing this costly farce. To compound insult with injury, they expire generally in 90-120 days. It could take that long just to figure out the byzantine four-stage insurance-web interface-bank process and be credentialed to be authorized to deposit them! 2 0 | 2 0 2 1 VO LU M E 4
Another option is direct deposit but gone are the days of mailed printed explanation of benefits (EOB) statements detailing the transactions. With paper trail and check reimbursement, there was a physical record of transaction details that was easier to read and not dependent on electricity or internet connectivity. With purely electronic transactions, mistakes are frequent, easy to miss, and are costly to your business. Keeping up with medical coding and billing has become more than a fulltime job, but a full-time job with many intermediates and, “business associates,“ on whom you are now dependent and having to pay without the ability to raise your prices like normal service businesses. Pursuing insurance company denials, errors, and reclamation efforts requires much diligence and costs both time and money.
Imagine you run a business and perform costly services in advance of potential payment (already a stretch to imagine...). You perform the procedure or consultation for the patient, while you have to deal with a multi-million or multi-billion dollar corporate or government third-party to determine payment. Remember, you are accountable and liable for any issues coming from that service, and the third-party has zero liability. Finally, you have to wait 2 to 4 weeks to find out the disposition of your payment. Will your payment get denied? Will the payer demand private patient information? Will the payer downgrade your payment? Will the payer send you a gift card, costing you time and money to process? Will the payer make a direct deposit in your account, with no explanation of benefits distribution, and be able to reclaim the payment at any time
P HOTO BY WWW.P OWE RTOTH E PATIE N TS.ORG
in the future? Ridiculous, right? Who would agree to such an arrangement? Physicians… The only winners are the insurance companies. There are virtually no advantages for the physician or medical care institution. The costs from time involved of reconciling and posting EOBs, e.g. paper, toner, etc (both paid and denied), now become the overhead of the practice with no incentive or fee increase from the insurance company to cover these costs. Some would say that the cost of insurance bureaucrats adding their two cents to decisions made by patients and physicians is devastatingly expensive in terms of both quality and increased red tape. The harmful intrusion of managed-care insurance third parties and their designees and business associates has been incrementally enabled by misguided government programs, like the formation
of Medicare and Medicaid in 1965, and tax laws that incentivize employers to offer and control employee health plans. Historically physicians and healthcare entities competed with each other on price and quality. They billed the patient directly at the time of service and costs remained low. But since Congress has imposed intermediaries in the process, costs have been raised exponentially by entities outside the Patient-Physician relationship. New “costs-of-doing-business,“ and cost of complying with government mandates are forever compounding costs everyone pays for “healthcare.“ Payment should be due, or at least payment terms arranged prior to or at time of care, as is done with direct primary care and other direct payment arrangements. Physicians and medical care facilities should have all options of payment available and not be limited
Congress has imposed intermediaries in the process raising costs exponentially to insurance company diktats. United States paper money is legal tender “for all debts public and private.“ This is no longer so with big banks, insurance and government? When managed-care insurance or a government entity makes determinations on the fly and at their whim, it hurts patients, physicians, and all healthcare entities. It only benefits managed care insurance conglomerates and their crony business associates, and perhaps the politicians they pay off with lobbying,campaign donations, and paid board positions with exorbitant salaries after they leave office. The managed-care insurance industry and government “tail” should never wag the healthcare “dog.” 1 WWW.PHYSICIANOU T LOOK . C OM | 21
PHOTO BY JANKO FERLIČ ON UNSPL ASH
T H E D O C TO R’ S B AG
American College OF HEALTHCARE TRUSTEES Wri t t en by D a vi d L e vi e n , M . D. , A meri ca n C ol l e g e o f H e al t hca re Tru st ees
T
he American College of Healthcare Trustees brings significant value to our physician members who are the most dedicated and highly educated people in healthcare. Physicians and surgeons have long been the patient’s best advocate yet in recent decades physicians and surgeons have been marginalized. The American College of Healthcare Trustees provides resources to support physicians and surgeons and provide the tools required to exert authority, power, and influence at the highest levers of decision-making. 2 2 | 2 0 2 1 VO LU M E 4
The American College of Healthcare Trustees uses the terms Member and Fellow synonymously and provides a platform to earn blue, brown, and black belts in the various curriculum categories as well as the designations of Fellow with Special Merit, FACHT(SM) and Fellow with Distinction, FACHT(D). The American College of Healthcare Trustees treats its fellows with great respect. In contradistinction to other organizations, some of which have made continuing education a cottage industry, The American College of Healthcare Trustees does NOT require
our Fellows to take OUR courses or attend OUR conferences to earn credit toward belts and distinctions, although one can do so, hour for hour. Fellows can claim credit for committee service in their hospital or at their practice, for reading or writing in journals, blogs, or any relevant medium such as watching videos or listening to podcasts or even exerting leadership at the local PTA or city council. Come join us to teach, to network, to grow. Come to our next conference to rejuvenate, to network, to make your opinions heard. 1
AM ERIC AN CO LLE GE OF H EAL T HC ARE T RU STEE S
A P R OFESS I ONAL ASSOCI AT ION DE D IC AT ED TO P RO MOT ING G OOD GO VERN AN CE A N D LEA DER SHIP IN TH E H EA L THCA RE SE CTOR W WW .FAC H T .ORG
Al-Agba and Bernard tell a frightening story that insiders know all too well. As mega corporations push for efficiency and tout consumer focused retail services, American healthcare is being dumbed down to the point of no return. It’s a story that many media outlets are missing and one that puts you and your family’s health at real risk. JOHN IRVINE, DEDUCTIBLE MEDIA
Laced with actual patient cases, the book’s data and patterns of large corporations replacing physicians with non-physician practitioners, despite the vast difference in training is enlightening and astounding. The authors’ extensively researched book methodically lays out the problems of our changing medical care landscape and solutions to ensure quality care. MARILYN M. SINGLETON, MD, JD
A must read for patients attempting to navigate today's healthcare marketplace. BRIAN WILHELMI MD, JD, FASA
This book is a warning of what is to come if we ignore training and education. Share this book or tell others to buy it. We cannot wait to act on this.” DOUGLAS FARRAGO MD AUTHENTICMEDICINE.COM
This book exposes one of the best kept secrets in our current healthcare jungle created through the corporatization of medicine. Filled with relevant examples and anecdotes to help the reader understand the issues being addressed, this book captivated and held my interest from beginning to end. AINEL SEWELL MD
Inspiring, inciteful, and eye-opening! An in-depth and thought-provoking examination of important decisions affecting modern healthcare in America. This work should be mandatory reading for all administrators and policymakers influencing the US healthcare industry. KEVIN LASAGNA, LTC, US ARMY
A masterful job of bringing to light a rapidly growing issue of what should be great concern to all of us: the proliferation of non-physician practitioners that work predominantly inside algorithms rather than applying years of training, clinical knowledge, and experience. Instead of a patient-first mentality, we are increasingly met with the sad statement of Profits Over Patients, echoed by hospitals and health insurance companies. JOHN M. CHAMBERLAIN, MHA, LFACHE, BOARD CHAIRMAN, CITIZEN HEALTH
P HOTO BY VIVEK DOSH I ON U N SP L A SH
P L EA SU RES A N D PA ST I MES
As It Sets Poem b y Nana D a d z i e Gh a nsa h, M . D.
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ever give up! Not even when the years creep up on you and the bones crea k like f loorboards from yester year. Do not let Father Time ta ke away your will, courage and dreams. Push
on! Push on even if a ll looks lost and the heart is faint. A nd when the going gets tough, look at the evening sky! The most amazing colors are painted on that canvas by the Sun.... “A s It Sets” 1
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P L EA SU RES A N D PA ST I MES
But Just Once… Writte n b y Scott A b ram s on, M. D.
Bob and Susan were my friends. Severa l years ago, Bob was diagnosed with cancer. Susan spent a lot of time at our hospita l. She spent a lot of time ta lk ing with nurses, doctors, and a ll sorts of specia lists. Bob died t wo years later. I asked Susan what it was like for her during a ll those interactions with the medica l world. I k new our hospita l had given excellent medica l care to Bob, but I wondered how we had scored in the communication of that care. I wondered how we scored… on the compassion meter. “Oh,” said Susan, “The doctors and the nurses were wonderful to Bob.” “They were k ind.” “They were caring.” “They were compassionate.” “But just once, in a ll that time,” Susan said, “I wish they would have asked about me.” 1 Respectfully submitted, Scott Abramson, M.D
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P HOTO C RE DIT M A RGA RE T H U RLE Y.
PL E ASU R E S A N D PA S TIM ES
Maggie’s Musings It Never Stops “D.O.”ING MEDICAL SCHOOL
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Wri t t en by M a rga ret H u rl ey, S t u dent P hy si c i a n
hey weren’t kidding when they said… it never stops. In all aspects of life, I feel my never ending responsibilities piling up. The school work is constant, but so are the stresses that come outside of school. Loans and finances, making connections in fields I am interested in, extracurriculars to stay in touch with my passions, and the pressure of “building a resume.” With boards moving to a pass/fail system, the current talk is about how important other things will be to making yourself a competitive applicant - and with that, a lot of stress has accompanied the transition. I am fed 15+ hours of dense lecture material a week (and double/triple
that time to study it!), 1-2 labs a week, occasional long zoom meetings for our wellness and medical humanities courses, but I am also expected to do things outside of school. The things outside of school can quickly break you down if you are doing them to just do them. I have learned the importance of only taking on things that are important and interesting to me because this makes spending time on them enjoyable and it makes my study time more productive! This summer is my only extended time off … everyone calls it “the last summer.” I am excited to engage in what that truly makes me happy. I will
be teaching at our high school summer program. I have been in contact with Dr. Sabine Hazan, an esteemed and innovative researcher whose current focuses include the microbiome and COVID-19, and I am trying to set up some shadowing in fields that interest me. I recently learned about Physical Medicine and Rehabilitation, and I hope to find some mentors in the field. Lastly, I am going to spend the rest of my 5 weeks of summer relaxing. Sitting by the pool, listening to music and hopefully not having flashbacks to learning the Krebs Cycle :) I hope you all get some time this summer to do something for YOU. 1 WWW.PHYSICIANOU T LOOK . C OM | 27
Poe m b y A y us hi C hug h, M. D.
May ever y silent prayer In unimaginable downtime Curb this roaring danger May ever y wish turn sublime
Things often get harder Before they get better Respect Circle of Life’s juggle Respect ever y struggle
Our world is a light So far yet so close those f ires burn Pray ever y soul arise In rebirth as Phoenix humbly yearns
Grow th sprouts from Roots Not in frivolit y But in sadness, in failure, Through hearts that deeply care
Through Filters and Layers Through f low of endless tears Prayers in stolen hours Build interna l powers
In Life’s transitions, The same place so different, The same face so different, A s dance of illusions
A s that bandaid box runs empt y Stream of tears runs dr y Watching helpless as Hearts melt away Pray tomorrow brings a better day
Changes stark as Night & Day, Yet after a sleepless night, Braving obstacles in f ight Comes dance of a brand new day
A s smiles get elusive In that distant happy place Laughter inaccessible Escapes our Inner Space
For life doesn’t get easier May we get stronger.. Through Hide-Seek of smile escapades Even in a once happy place 1
The Indian subcontinent is burning in a humanitarian crisis of pandemic wildfire. A constant reminder of how our skies are the same and how fragile and unpredictable life is. Watching helplessly from afar as our human counterparts suffer unimaginable tragedies. One doesn’t have to be from a particular race to empathize with another end of the planet. Sometimes even a humble prayer can curb a storm. It takes a Village. One Human Race.
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P HOTO BY SU DA RSH A N P OOJA RY ON U N SP L A SH
Prayers of Diaspora Hearts
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Dr. Draghinas and Ryan are both podcasters. Desiree built their teams to help support them and others to consistently produce content. All three knew how challenging that was to do in the midst of busy schedules, competing priorities, unpredictable monetary compensation, and fluctuating motivation. Physician podcasters are there for the doctors and healthcare providers that make up their podcasting audience. But “this can be a tough and lonely journey for the podcast creator.” Doctor Podcast Network is there for the physician podcaster. It’s a place where they can come together, learn from, collaborate, and confide in one another, as well as facilitate the monetization of their shows. Having soft launched with 15 founding members in October 2020 and formally launching in January 2021 with 17 shows, the network has shown its capability of creating the community and environment that podcasters need to thrive.
Doctors Unbound is a podcast created for doctors who are busy with unique side passions outside of their normal schedule. Dr. David Draghinas shares their stories of triumph, learned lessons, and, ultimately, their humanity. Financial Residency is geared toward early-careered physicians looking for practical ways to manage their finances. Ryan Inman is usually found nerding out over phoned-in questions by his listeners asking about student debt, investing, insurance, and balancing budgets. The Physicians Guide to Doctoring is hosted by Dr. Bradley B. Block where he seeks to answer the question, "what should we have been learning while we were memorizing Kreb's cycle?" His podcast is a practical guide for practicing physicians and other healthcare practitioners looking to improve in any and all aspects of their lives and practices.
AMPLIFYING PHYSICIAN VOICES
VISIT US TODAY AT WWW.DOCTORPODCASTNETWORK.COM Find other physician-hosted shows on Doctor Podcast Network’s website, www.doctorpodcastnetwork.com. You’ll find a list of amazing shows, focused on various aspects of physician life. They’d appreciate your support by subscribing to (for free) and sharing their shows. If you’re a doctor who is either wanting to launch your own podcast or join with your existing show, the network is accepting submissions. If you are a physician that enjoys listening to podcasts, check out DPN for new shows that will bring value into your life.
WWW.PHYSICIANOU T LOOK . C OM | 29
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Publisher: Marlene Wüst-Smith, MD Editor in Chief: Alicia Roselli Managing Editor: Alyssa Dean VP of Advertising: Pamela Ferman Director of Art and Production: Ricardo Castillo Marketing/Social Media Intern: Samantha Petzold, Pennsylvania State University and Riley Snowden, Pennsylvania State University; Marianna Seefeldt, Saint Bonaventure University Contributing Authors: Scott Abramson, MD; Dana Blue; Ayushi Chugh, MD; Leslie Doran, NP; Nana Dadzie Ghansah, MD; Margaret Hurley, MS-I; David Levein, MD; Marion Mass, MD; Alex Rubanenko, RN; Katherine Trettin, MS-III; Jordan Creel, MD; Craig Wax, DO; Cover Art: Hollin Calloway, MD; Other Art: Nana Dadzie Ghansah, MD. Published By “Physician Outlook Publishing” Editorial Policy Physician Outlook Magazine is a national magazine dedicated to empowering physicians and their patients to improve the world of medicine together. Editorial decisions are based on the editor’s judgement of the quality of the writing, the timeliness of the content and the potential interest to the readers of The Physician Outlook Magazine. The magazine may publish articles dealing with controversial issues. The views expressed herein are those of the authors and/or those interviewed and might not reflect the official policy of the magazine. Physician Outlook neither agrees nor disagrees with those ideas expressed, and no endorsement of those views should be inferred unless specifically identified as officially endorsed by the magazine. Letters to the Editor Email: aroselli@physicianoutlook.com Information on Advertising, Subscriptions, Job Board Email: hello@ physicianoutlook.com “Physician Outlook is a registered trademark” WWW.PHYSICIANOU T LOOK . C OM | 31
