The primary care reimbursement mess

[JackADeli]

No, you suggested that one group could be working twice as many hours as the other. Clearly, that isn't the case...

No, it's not "clearly". That is why I pose the questions for exactly what these data points are referring to. I would do the same when critically analysizing a scientific journal article. To simply say something like "full time" (i.e. ppt) is a generalization with a very broad possible range. To give data points on average work hrs/wk, it is important to assure you know what exactly was counted or not. It goes both ways. Maybe the primary care physician on AAMC data does after hours emergency patient care and that is not calculated. I don't know, thus the questions.

...You can't just keep saying "out of context" every time the data doesn't support your argument. If you have better data, post it.

Again, it's not about my "argument". That is not the point. I am not simply trying to engage in endless combat with you or anyone. I am trying to identify more accurate data and with reference to context, identify exactly what the data points represent. You presented data on average work hours for a surgeon with a single number excerpt from AAMC. You then proceeded to compare it to a number derived fro the AAFP. In any journal article looking at data points of different populations, it is reasonable to look to see if the data points are standardized. I don't see that as unreasonable to ask, i.e. the context, i.e. information to enable accurate comparisons. The ppt makes comparisons out of context, i.e. ignores factors of additional care required for the increased RVUs for operative procedures. And, the two data points on surgeons vs FM work hours provided based on what appears to be two different sources does not specifiy possible confounding information. Thus:

...The AAMC average presented on that webpage again may very well be out of context... Often, average hours per week published excludes hours outside of office and regular scheduled OR times. They will often fail to account for trips into the hospital and/or graveyard and or weekend/premioum times. Is that what the AAMC source being cited used? I don't know...

Instead of refusing to consider the whole picture and possible important additional information and instead of using fairly accusatory tactics and distractors throughout, you could look at the possibilities that additional data may be relevant for accurate understanding and discussion.

...If we are to go on median incomes alone we would at least have to study the distribution of income, RVUs produced, total revenues, and compensation per RVU within each repspective specialty...

Which is why I think it is important to look closely and identify the full picture as opposed to simply taking a few isolated data points.

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[deleted87716]

^ Dude, seriously...you have no idea how close you are to being on my ignore list.

 

[JackADeli]

^ Dude, seriously...you have no idea how close you are to being on my ignore list.

And what? I guess somehow that is suppose to represent a punishment or something, or just being cute?

You seem to make a point of commenting but in many instances ignoring the actual issue of considering the whole picture. Place me on ignore if that makes you feel better. As I stated, I will continue to encourage others to critically analyze this and other issues and ask questions and seek clarification.

...If you have better data, post it.

Forgot this one. My answer is, if you can provide more complete data please do. This insistance on providing often isolated data points reminds me of med-school when someone would answer with the new report or internet headline. The only difference now, in med-school the individual didn't fight against having the more complete story considered. Here, it seems like one is expected to not challenge the data or ask for the complete picture.

 

[deleted87716]

Alrighty then.

 

[JackADeli]

alrighty then.

???ok???

 

[bronx43]

Alrighty then.

BD, I don't know why you try. Jack is a frickin' idiot.

 

[loveoforganic]

Jack doesn't seem to be that abrasive to me... Just seems like he's trying to offer insight from a specialist's perspective and potential methodological flaws in what's being presented. I don't really see too many ad hominems coming from him..

I am interested in FM, for whatever that's worth.

 

[deleted87716]

Jack doesn't seem to be that abrasive to me.

You just got here. Give it time.

The issue with Jack, at least in this forum, is that if you've read one of his posts, you've read them all.

 

[JackADeli]

...The issue with Jack, at least in this forum, is that if you've read one of his posts, you've read them all.

Because the issues remain the same, i.e. lack of complete analysis, innacurate albeit dramatic comparisons, etc... These issues get pointed out and the primary response is to ignore them or attack the messenger.

If we are to predominantly look at the difference in end of the year gross incomes, it begs the question what is the problem you want to address, the difference between specialties? So, does one simply subtract from one and add to another without consideration as to what is done/involved in the differences. If you look at what is involved in the differences, the "solution" may be different and/or more effective. If we are to predominantly look at the difference in RVUs based on primary care clinic time (?30 minutes) vs skin-to-skin procedural time, it begs the same question. If that is your comparison and one wants to consider decreasing RVUs for procedures (or increase for clinic visit of similar time) based on pure operative time, then you exclude the global. Thus, is the solution operative time to clinic time. Then with no global period, surgeons would/should start billing for care over that 90 days over and above the 30 minute operation. This would include possible pre-op face to face care, 1-2 days face to face care rounding time post-op, and each post-op clinic visit.

So, failure to consider the factors that make up a difference can possibly overstate or understate "gaps" or "disparities". To answer the question and come up with real solutions, you need the full picture.

For an analogy, politicians and some physicians ran around barking about "x" millions of un-insured. It was an "emergency". Individuals tried to identify what comprised those "x" millions and why they were un-insured. Many were shouted down, etc. But, when examining that gross number, it was identified a certain significant component was illegal residents, a certain component was individuals choosing to be uninsured and place their monies into other things, etc.... Instead of focusing on the specific "unfortunate" group that was unable to be insured for whatever reason and not by direct choice of their own, sweeping healthcare legislation was passed based in large part on the dramatic propaganda numbers.

 

[lowbudget]

Because the issues remain the same, i.e. lack of complete analysis, innacurate albeit dramatic comparisons, etc... These issues get pointed out and the primary response is to ignore them or attack the messenger.

Everything I've read from the business/economic side, the policy side, to the medical and patient side all point to how primary care reimbursement is fubar. The only person, after reading most/all of the posts here, who doesn't believe it is... is you. Even MOH will conceed that RUC is messed up, and that's good enough for me.

Yea, ok, maybe everything Blue Dog has thrown at you is methodologically flawed or incomplete or whatever. Ok, maybe. And he has thrown a lot at you, evidence-wise. Realize however that the preponderance of the literature points toward a common position: That the system is jacked up and there's a call for reform. What I *haven't* seen is evidence that points to the contrary. I mean, sure Jack, you can criticize data like we're at some alcohol-less-journal-club-academic-ritual all you want and talk about how the authors fail to consider this, that, and what not because in a perfect world, a perfect study would (have) consider(ed) all that. But show me something that supports what you believe in.

Show me something that says that US health care policy regarding primary care and medical care as a whole is a-ok. Stop this noisy Tea Party criticism and faux-analytical superiority, and advance your thinking. Give me some real, substantive health care policy ideas to digest.

 

[lowbudget]

Just seems like he's trying to offer insight from a specialist's perspective and potential methodological flaws in what's being presented.

What you will find is that, unfortunately, many specialists feel that they are under assault. In my humble opinion, some deservingly so, others not so much.

We live in a world with limited resources, and we live in a time when the fundamental way we do things is/are going to change. All doctors are competing for a limited pool of money in a time when US exports are low, domestic consumptions/output (and thus tax revenue) is falling, and federal spending on items that do *not* require a Congressional vote (i.e. "entitlement" programs otherwise known as non-"discretionary" spending) is at odds with each other (ever increasing Medicare/Medicaid spending versus the military budget in 2 nation-building efforts). And, as long as military spending takes center stage, medical spending (i.e. your salary) will be increasingly scrutinized, in an era of contracting tax revenues. The only good news out of all this that our interest rate (i.e. cost of borrowing) is near zero but we're having a hard time devaluing our currency low enough to stimulate exports. All of these economic measures are meaningless unless we put those dollars towards rebuilding economic infrastructure so that we can make more money in the future to pay back the debt we are currently incurring.

The issues with primary care has been brewing for years, going back to Nixon, maybe even earlier. Efforts to shore up primary care failed in the 90's, and yet, people keep coming back to primary care as a way to save the system. Why? How is it possible that a medical system so invested in specialty care would keep coming back to primary care as a way to hold the health care system together if our entire understanding of the problem has been that flawed?

I'm willing to argue that while our understanding of the problem may not be perfect, there must be some truth to what everyone has been saying. Maybe we have been underinvested in primary care during all these years, which *is* a vital part of the economic infrastructure. It keeps workers and the military healthy and productive, and it saves money that could be spent elsewhere.

With increase in military spending, you have a decrease in health care spending. At least for the time being. Some people are moving to get out in front, some people are resisting, and some people are waiting to see. As a medical student, you have to decide where you want to stand, economically.

You can listen to specialists talk all you want, but their word is only as good as mine as a general doctor because both of us are scrounging for the same economic scraps. What you have to look at is the bigger macroeconomic picture and position yourself within all that on the most microeconomic level in a way that you will succeed.

To date unfortunately, it's going to suck to be a specialist because they're the ones getting most of the squeeze, more so than primary care. I wish I could stop the momentum.

 

[JackADeli]

Everything I've read from the business/economic side, the policy side, to the medical and patient side all point to how primary care reimbursement is fubar. The only person, after reading most/all of the posts here, who doesn't believe it is... is you...

Which suggests a reading comprehension difficulty. I have not stated or suggested the system is correct or perfect or etc.... as Mohs has stated, it is flawed. That point I have not disagreed with. My disagreement has been that many of the data points have not accurately demonstrated the flaws and/or shown how they can be addressed or fixed.

...If you look at what is involved in the differences, the "solution" may be different and/or more effective...

So, failure to consider the factors that make up a difference can possibly overstate or understate "gaps" or "disparities". To answer the question and come up with real solutions, you need the full picture...

Thus my most recent analogy to the "emergency" healthcare reform. Politicians cited "x" million of uninsured as a reason to revamp the entire system. But, when you start to ask the question of who really is uninsured, you may find the solution that is more refined and appropriately targeted.

...Show me something that says that US health care policy regarding primary care and medical care as a whole is a-ok. Stop this noisy Tea Party criticism and faux-analytical superiority, and advance your thinking. Give me some real, substantive health care policy ideas to digest.

Again, there is no faux analytical superiority. I would like the system improved. But, I would like it improved based on data points that are taken in context and accurate. The pointing to dramatic numbers without refining or accurately identifying what these data points represent precludes well thought out solutions. i.e., if one simply compares the RVUs on a 30 minute clinic visit to a 30 minute skin-to-skin time, maybe the RVUs for the procedure will be decreased or the RVUs for the clinic increased. However, by treating the problem by effectively eliminating the global period, the surgeon would also expect to start billing for the face to face care provided around the procedure and during the 90 days. Thus, that comparison I do not believe will answer the primary care problem/concerns.

 

[JackADeli]

First, again I do not think the comparisons are accurate or necessarily reasonable and I do think they fail to provide appropriate information to properly address the matter. The discussion of comparing a 30 minute skin to skin time to a 30 minute clinic visit is in effect "unbundling" the surgical care. But, for discussion sake, I looked at the CPT online page.

So, looking at CPT code 99214 as noted in the ppt.
CPT on-line lists that for 1.5 work
Looking at cholecystectomy (open), 47600.
CPT on-line lists that for ~17.5 work. Granted, an open is likely longer then 30 minutes.
Looking at cholecystectomy (Lap), 47562.
CPT on-line lists that for ~12 work.

I/most can in a straight forward, elective lap cholecystectomy, probably complete the skin to skin component of the case in 45 minutes or less. Suppose we try to "balance" the work RVUs based on direct patient contact care, i.e. unbundle, thus eliminate the surgical global. What do we increase the primary care RVU to vs decrease the unbundled surgical procedure to? primary care from 1.5 to 5? The procedure from 12 to 5?

Ok, so for discussion sake we do that. But, now, as we are unbundled, we need to contend with the value of the 30 or more minutes of the surgical H&P in pre-op clinic evaluation. It is direct patient contact care encounter. Let us presume everything went perfect and the patient after 10-30 minute exam/assessment/instructions/etc... in the morning is discharged. That is another direct patient care encounter. Let us assume the patient has zeroe complications and comes in for just one clinic follow-up. That is another direct patient contact care encounter. That equates to 4 direct patient care encounters. If they are all in the range of 5 RVUs, you are looking at 15-20 RVUs for the lap chole as opposed to the 12. On the otherhand, the primary care encounter is 5. Thus, a 3.5 increase for primary care vs the 3-8 total RVU increase if the elective case is ideal outcome.

The global period was in part a cost containment effort. I am caged into a set RVU value if my patient is perfect or requires prolonged amounts of direct patient care encounters over 90 days. The argument posed is in effect an "unbundlement" argument. Without basic analysis and appreciation of the significant components of RVUs, it may seem both like a dramatic "gap" or "disparity". This can lead to the perspective that ~unbundles. However, it markedly explodes costs and removes the cost containment a global period provides. Under the rough scenario outlined above, the graphic/chart would still show a difference in gross end of the year incomes. So, the argument fails to really address the "image"/"graphic".

So, since people seem to imply or say I have said something I have not, again, I am NOT claiming the system is great or perfect or that primary care or any other specialty is perfectly treated under the system. I have NOT said that nor is that my position. I am simply asking/proposing that we need to really understand beyond headline grabbing graphics and simplistic data points that are not appropriately compared. I do not think that is excessively scientific or cerebral or etc... Trying to correct it by an ~unbundle comparison does not appear to to solve it and may make it worse.... From a purely financial standpoint, I would be better off with an unbundle sort of scenario above. I could potentially go from 12 RVUs to 20. If the patients have complications or need some extra clinic visits, my RVUs continue to rise. If there is a "gap" or "disparity", it should be better identified and defined then a dramatic graph or incomplete RVU comparisons in order to correct it.

 

[MedicineDoc]

The fact is no one in the fm forum is interested in your treatise on bundling of surgical services. You appear to have way too much time on your hands. I spend hours in nonbillable services to patients in the form of phone calls and forms. Why don't you go post in the surgical forum or have they had enough of you there as well.

 

[JackADeli]

The fact is no one in the fm forum is interested in your treatise on bundling of surgical services. ...I spend hours in nonbillable services to patients in the form of phone calls and forms...

"The fact is" I do not deny the non-direct patient contact care is provided by many specialties. I also am not at all opposed to identifying ways of compensating for this uncompensated care. I have repeatedly in this thread and others supported identifying uncompensated care and trying to find a means of compensating for it. I do not support giving it away as is now forced upon many specialties.

The RVU comparison is derived from the ppt presentation at the opening of this thread. What I have described in the previous post does not in anyway discuss the surgeon or primary care physician's time spent outside of direct contact care. Both surgeons and primary care have additional time and services given to patients that is ~ not compensated, i.e. forms, phone calls, phone scripts, etc.... In the surgeons' case, that time is also presumed to be bundled into the package in addition to the other direct contact care. Thus, again, unbundling it and comparing 30 minute clinic to 30 minute OR removes the cost containment that a global period puts on procedures.

 

[MOHS_01]

The fact is no one in the fm forum is interested in your treatise on bundling of surgical services. You appear to have way too much time on your hands. I spend hours in nonbillable services to patients in the form of phone calls and forms. Why don't you go post in the surgical forum or have they had enough of you there as well.

Yes, the community program in M'ville is rough. I know, I rotated through there back in the day.... and have helped out an attending or two (of yours) with family skin issues that defied diagnosis and treatments.

The "hours of phone calls and forms" will largely be delegated upon graduation and entrance into the RVU rat race... if the practice you join is worth a ****, that is. That's a good thing. The fact that it remains without reimbursement still sucks, but at least at that point you should have a $10-12/hr person doing it rather than a $100-150/hr person doing it.

You sure seem to have the world figured out for a junior resident....

 

[deleted87716]

Yes, the community program in M'ville is rough.

Probably not, compared to those super-malignant dermatology residencies.

Oh, wait...

 

[MOHS_01]

Probably not, compared to those super-malignant dermatology residencies.

Oh, wait...

Don't hate, now....

In all seriousness, though -- if it were not for the insane reading requirement derm residency would have been cush; as it was, I routinely dedicated more hours to work related projects / services / etc as a derm resident than I did during my intern year -- including my three unit months.

 

[lowbudget]

The RVU comparison is derived from the ppt presentation at the opening of this thread. What I have described in the previous post does not in anyway discuss the surgeon or primary care physician's time spent outside of direct contact care. Both surgeons and primary care have additional time and services given to patients that is ~ not compensated, i.e. forms, phone calls, phone scripts, etc.... In the surgeons' case, that time is also presumed to be bundled into the package in addition to the other direct contact care. Thus, again, unbundling it and comparing 30 minute clinic to 30 minute OR removes the cost containment that a global period puts on procedures.

I appreciate your effort. But it's not good enough.
1) We all agree and have established that the Work RVU system that tries to form a least common demoninator with what we do is at best imperfect and at worst a conspiracy. Basing your analysis on those flawed numbers and arguing that bundling makes it all worse is just as flawed as looking at the "paystub" take-home pay. This is a moot issue as both approaches are equally flawed.

2) The number of unbillable hours that we experience is well known, felt anecdotally by all of us and well documented in that one NEJM study with internist group on the east coast. The pissing contest over who has more unbillable services/hours varies individually as MedicineDoc and Moh's conversation above demonstrates and is therefore also a moot issue.

3) Bundling of surgical services with post-op visits does assume a perfect patient. CMS gives you an "out" in that you can bill a -24 modifier (or -78 modifier) for post-operative complications if your patients require more attention and bill an E&M visit on top of what you already got for the procedure. If you're not doing this, you're under-billing but don't interpret this as surgeons have it worse, because the mechanism is there for you to capture more revenue for more complicated patients.

4) Surgery & procedural billing is not the only service subjected to bundling. We experience it also under HMO contracts that are capitated.

5) *Even if* all services provided by primary care physicians are provided fee-for-service and all procedural services are global/bundled like the way you're illustrating it above, who cares? Going forward, the momentum of the payment structure is to bundle *everyone*(!!!)... primary care included. And I mean, outpatient with inpatient care and surgical procedures and post-all-of-that care. Put it simply, the way ACO's work (to my understanding) is that the government pays me (primary care) to prevent patient from seeing you (specialist/surgery) and the cost savings we get out of it is then divided between you and me. So, you're argument about how bundling sucks is duly noted, but irrelevant, since we will be subjected to the same economic forces in the near future.

(A Guide to Accountable Care Organizations)http://www.healthreformwatch.com/20...their-role-in-the-senates-health-reform-bill/

So, I'm still unimpressed. I still don't believe that specialists have it worse than primary care. I still don't believe that the state of primary care is copacetic, and I therefore am apt to believe the preponderance of the evidence that Blue Dog has thrown at you that primary care reimbursement, therefore recruitment sucks in its current state and any attempts to rectify the situation needs to into overtime. I still stand by my position that if we are to accept the current order as it is, I would rather be a primary care doctor standing in front of this huge unknown thing called an ACO than be a specialist doctor standing on the backside of this huge unknown.

Convince me otherwise. What else do you have?

 

[JackADeli]

...We all agree and have established that the Work RVU system that tries to form a least common demoninator with what we do is at best imperfect and at worst a conspiracy. Basing your analysis on those flawed numbers and arguing that bundling makes it all worse is just as flawed as looking at the "paystub" take-home pay...

I am not arguing bundling makes it all worse. I agree simply looking at RVUs is just as flawed as looking at the paycheck stubs. I have stated that point repeatedly! As to making it worse, my point is that incomplete or innacurate information and/or comparisons allows for a bad solution. Again, I stated that previously.

...The number of unbillable hours that we experience is well known, felt anecdotally by all of us and well documented in that one NEJM study with internist group on the east coast. The pissing contest over who has more unbillable services/hours varies individually as MedicineDoc and Moh's conversation above demonstrates and is therefore also a moot issue...

And again, I am not arguing I have less, the same, or more unbillable/uncompensated hours. I am not engaged in a pissing contest of such.

...Bundling of surgical services with post-op visits does assume a perfect patient. CMS gives you an "out" in that you can bill a -24 modifier (or -78 modifier) for post-operative complications if your patients require more attention and bill an E&M visit on top of what you already got for the procedure. If you're not doing this, you're under-billing but don't interpret this as surgeons have it worse, because the mechanism is there for you to capture more revenue for more complicated patients...

Agreed there are some circumstances and means of billing for some additional compensation. The discussion points are not intended to say I or anyone else in any particular specialty is so bad off. I again have been and continue to say a good fix to healthcare compensation problems requires an accurate assessment and not dramatizing headline grabbing graphics of data points out of context be it RVU "30 minute" comparisons or a chart showing median end of the year gross incomes.

...Surgery & procedural billing is not the only service subjected to bundling. We experience it also under HMO contracts that are capitated...

Never said that. The point about bundling and/or unbundling goes back to the 30 minute clinic visit RVU comparison. It was out of context and innacurate comparison.

...*Even if* all services provided by primary care physicians are provided fee-for-service and all procedural services are global/bundled like the way you're illustrating it above, who cares? Going forward, the momentum of the payment structure is to bundle *everyone*(!!!)... primary care included. ...So, you're argument about how bundling sucks is duly noted, but irrelevant, since we will be subjected to the same economic forces in the near future...

Yes, I do in general think bundling sucks for the bank account but understand it was in part for cost containment. Again, the move to bundling for everyone is a reality. However, that also goes back to my point of understanding what one is arguing about and what may be the unexpected consequences. I gave a gross generic example of unbundling based on the RVU argument from the ppt. The oposite is quite the ever increasing reality.... i.e. bundling everyone and everything. Again, this could make things worse for primary care; a point I have made repeatedly. If primary care or any specialty makes such an ~ unbundled argument as the ppt RVU comparison, the response is at some point to look at more details to find out why there are these differences for "30 minute" units of care. Someone will recognize the bundle issue between the two.... then move to incorporate a bundling system for everyone... and possibly make it worse for primary care.

...I still don't believe that specialists have it worse than primary care. I still don't believe that the state of primary care is copacetic...

Amazing. For whatever reason, instead of reading what I have written/said, plenty of individuals keep attributing statements and beliefs to me that I have NOT made or claimed. Then they spend alot of time arguing against these misrepresented claims. I have NOT said in anyway that specialists have it worse. I have NOT stated that I or any specialists works harder. I have NOT said everything is copacetic/good/fine/etc... under the current system for primary care. So, I am NOT going to spend time trying to argue these points/positions which are NOT my points/positions.

I have pointed out concerns with some of the approaches being used to fight for reform. IMHO, they can be counter productive and hinder different specialties from working together. As I stated, it can be classwarfare like. I have pointed out that the 30 minute RVU comparison from the ppt or a graphic of end of the year incomes has significant failings toward the issue of accurate discussion and... ultimately finding a good, refined and appropriately targeted solution. I do not believe these gross data points out of context are good for defining "gaps" and "disparity". But saying that does NOT mean I think all is great in healthcare or all is great for primary care or that I work harder or that primary care works less, etc., etc... Challenging flawed data does NOT mean any of that.

I am pretty sure you and I have had that discussion as to false representation and trying to argue or have me argue a position I do not hold....

Because, some have a clear difficulty with reading comprehension...Absolutely false statement! I have in this thread and others stated I believe PC can and probably should be paid more. I appreciate the folks trying to twist and flame the issue and create a ~you against us discussion. However, I don't appreciate misrepresentation to further your debate. You want to discuss/debate something I have NOT said.... you should probably create a new SDN account name and then debate yourself.

Ultimately, you are free to debate these issues how see fit. I think a big part of the problem/fallacy is this need to use comparisons to FM & surgical subspecialties to determine your "worth" and or "prestige". I don't care what social "worth" or "prestige" Bill Gates, Steve Jobs, President, LASIK surgeon may enjoy. I don't sit back and argue I should get "x" dollars because the LASIK guy makes 1k/10minutes. In essence, this "paycheck stube" comparison approach puts FM/PC (and other specialties) ~subserviant to what they are being compared to... i.e. ~ I have less prestige then the LASIK surgeon or dermatologist...

The question/s is/are, what do you think you should be paid? How should it be calculated? To contiunually say, "I am underpaid because specialty "X" makes this much more then I...", IMHO is a problem. It hurts your argument, it creates a "classwarfare-esqu" scenario, it divides you from those that could be advocating along side of you...

 

[MedicineDoc]

Yes, the community program in M'ville is rough. I know, I rotated through there back in the day.... and have helped out an attending or two (of yours) with family skin issues that defied diagnosis and treatments.

The "hours of phone calls and forms" will largely be delegated upon graduation and entrance into the RVU rat race... if the practice you join is worth a ****, that is. That's a good thing. The fact that it remains without reimbursement still sucks, but at least at that point you should have a $10-12/hr person doing it rather than a $100-150/hr person doing it.

You sure seem to have the world figured out for a junior resident....

The program in madisonville is excellent. I am a senior resident and having started out doing a prelim yr in neurology I know how it compares with a university program internal medicine. If you rotated through madisonville it wad as a med student otherwise known as a "barnacle". We are fm and act as internal medicine and are allowed to manage our own icu patients in our 400 bed 25 bed icu hospital otherwise known as west ky regional medical center which is affiliated with the university of Louisville. I have personally managed 15 icu pts with the help of consultants in the last 3 wks. I am running the senior medicine service. The learning in madisonville is much better than the crappy university based prelim I did prior to transfer and I am ready to manage all levels of illness.

 

[lowbudget]

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