toenail clipper

[abraham917]

OK so I know this is gonna sound bad, but my grandparents keep tellin me that podiatrists are glorified pedicurists that work on old peoples feet. I have shadowed a podiatrist and it seems that he puts his students to work clipping toenails and scraping calluses off every patient. Is this what my life is going to be through school and beyond or what? I am very excited about podiatry, and interested in surgery and biomechanics, but I do not want to spend the next four years trimming toenails and certainly dont want to spend my career that way (for those podiatrists without students).

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[165007]

OK so I know this is gonna sound bad, but my grandparents keep tellin me that podiatrists are glorified pedicurists that work on old peoples feet. I have shadowed a podiatrist and it seems that he puts his students to work clipping toenails and scraping calluses off every patient. Is this what my life is going to be through school and beyond or what? I am very excited about podiatry, and interested in surgery and biomechanics, but I do not want to spend the next four years trimming toenails and certainly dont want to spend my career that way (for those podiatrists without students).

This why shadowing is very important.
This is what pods do, if you dont like it then dont attend pod school.

easy

 

[abraham917]

wow that was straightforward, and not what i was wanting to hear either. As i said, i have been shadowing a podiatrist, and he doesn't do much of the trimming or shaving that i have seen. Did u really choose podiatry to become a toenail clipper? i dont think so. anyone else have comments

 

[air bud]

its part of the game. accept it. in fact, many on here would suggest embracing it as well in order to increase your chances of success.

 

[dyk343]

I'm pre-podiatry so I dont really have much weight in my input, but hey... it pays the bills.

30 people coming thru all needing a very short visit adds up. But its not about the money. You should like podiatry...

The pod I shadowed appeared to have a schedule of: surgery in the mornings and trimmed nails/post op care in the evening.

 

[PMSIII]

OK so I know this is gonna sound bad, but my grandparents keep tellin me that podiatrists are glorified pedicurists that work on old peoples feet. I have shadowed a podiatrist and it seems that he puts his students to work clipping toenails and scraping calluses off every patient. Is this what my life is going to be through school and beyond or what? I am very excited about podiatry, and interested in surgery and biomechanics, but I do not want to spend the next four years trimming toenails and certainly dont want to spend my career that way (for those podiatrists without students).

Some podiatrists out there do alot of pallative care (nails, calluses, orthotics, tapings) while others do woundcare (Diabetic patients, Lymphedemas, venous stasis, etc), and others do lots of surgery (forefoot, reconstructions, ankles, and trauma). The point here is that there is an array of clinical venues in the practice of podiatry - and it is upto you to do well in school, match into a good program that addresses your niche, and finally doing well in that program. With no disrespect to your grandparents, but their opinions couldn't be further than the truth. I recommend that you shadow podiatric surgeons who operate routinely to appreciate the difference in training and options available to a DPM.

Also no offence but there's alot of involvement with "nail" patients that many pre-meds and other folk don't appreciate. For example, aside from "trimming the nails", the DPM conducts a physical exam, and reviews the medical history of this patient - during this time, we make assessments about the patient's vascular, neurological, dermatologic, and musculoskeletal status - a "routine nails" visit can and often turns into a vascular surgery consult which ultimately ends up saving this patient's limb. I think we can agree that this certainly far beyond the scope of practice for a "glorified pedicurist". Remember, we spend 4 years in podiatric medical school as well as 3 years of residency. There's alot involved with each patient encounter (if done properly and ethically).

I just started my residency orientation today and believe me this field has plenty to offer. I've been getting nothing but tremendous support and positive feedback from colleagues, friends, nurses, and other hospital physicians about our field - it'll only continue to get better. Anyhow, I think if you do have interest in this field, then you should put some effort to shadow other DPM's and specifically those who operate routinely and take calls at the ER to get a wider scope/understanding.

Hope this helps and good luck to you.

 

[PharoPod]

Some podiatrists out there do alot of pallative care (nails, calluses, orthotics, tapings) while others do woundcare (Diabetic patients, Lymphedemas, venous stasis, etc), and others do lots of surgery (forefoot, reconstructions, ankles, and trauma). The point here is that there is an array of clinical venues in the practice of podiatry - and it is upto you to do well in school, match into a good program that addresses your niche, and finally doing well in that program. With no disrespect to your grandparents, but their opinions couldn't be further than the truth. I recommend that you shadow podiatric surgeons who operate routinely to appreciate the difference in training and options available to a DPM.

Also no offence but there's alot of involvement with "nail" patients that many pre-meds and other folk don't appreciate. For example, aside from "trimming the nails", the DPM conducts a physical exam, and reviews the medical history of this patient - during this time, we make assessments about the patient's vascular, neurological, dermatologic, and musculoskeletal status - a "routine nails" visit can and often turns into a vascular surgery consult which ultimately ends up saving this patient's limb. I think we can agree that this certainly far beyond the scope of practice for a "glorified pedicurist". Remember, we spend 4 years in podiatric medical school as well as 3 years of residency. There's alot involved with each patient encounter (if done properly and ethically).

I just started my residency orientation today and believe me this field has plenty to offer. I've been getting nothing but tremendous support and positive feedback from colleagues, friends, nurses, and other hospital physicians about our field - it'll only continue to get better. Anyhow, I think if you do have interest in this field, then you should put some effort to shadow other DPM's and specifically those who operate routinely and take calls at the ER to get a wider scope/understanding.

Hope this helps and good luck to you.

PMIII post is the reality. Practicing podiatrists can be devided into 3 categories:

Podiatrists who do alot of pallative care (nails, calluses, orthotics, tapings)

Podiatrists who do woundcare (Diabetic patients, Lymphedemas, venous stasis, etc)

Podiatrists who do lots of surgery (forefoot, reconstructions, ankles, and trauma).

The choice is yours and it depends on what kinda of residency program you will do. The other issue is some podiatrists thinks about their practice from a biusiness point of view. In one day he can do a maximum of two major surgeries getting $xx net, on the other hand in one day he can see 40 patients (I know people who do see this number in one day) in outpatient practice doing easy short time procedures and net $xxxx per day, at the same time avoiding high malpractice insurance that will necessarily go up when you do major surgeries.

It is true that the specialty has alot to offer and you choose what fits your needs and your skills.

 

[Feli]

Some DPMs do a higher/lower % routine clip and callus ("C&C") care than others. While that's usually based on training, it's also just based on what the patients in your area/office need. Keep in mind the saying "like refers like." If you do good work for a lot of sports med patient, guess who their friends probably are? Other athletes. If you treat a lot of diabetic patients well, they will probably refer fellow diabetics who they think you could help. If you treat a lot of geriatric nail patients? You guessed it.

If you want to refuse/refer or minimize your amount C&C patients, that's fine (and many pods do), but you are missing regular income with very low lawsuit/complication risk. Not every patient will need an ankle fusion, skin graft, or Charcot recon, and if you do a reasonable amount of surgery, you have complications, and you will get sued. Sucks, but it's a fact of life.

One option is having "nail techs" (RN, med assist, etc who trim or file patient nails) if state laws permit it, but the patients still need complete eval by the podiatrist before/after the nail care. The "nail tech" function is often filled by students (sometimes residents), and while it seems "boring," it's a good way to practice your H&Ps and free up more time for the attendings or senior residents to see more patients, teach you, or show you other cases. That said, some clinics are basically just nails by the thousands with little/no other pathology, and that is kinda BS, IMO. If you see that happening regularly at a pod school clinic or residency clinic, think for awhile whether it's truly a "teaching clinic" or if it's a factory to make money for the attendings... and if you want that "training."

...there's alot of involvement with "nail" patients that many pre-meds and other folk don't appreciate. For example, aside from "trimming the nails", the DPM conducts a physical exam, and reviews the medical history of this patient ...

Nail care is part of comprehensive foot and ankle care. A lot of patients who present for nail care also need good diabetic education, and the podiatrist's complete H&P often turns up other symptoms which need treatment, referral, or monitoring.

Being comprehensive is part of what makes podiatry interesting IMO. A F&A ortho could do the bone/joint procedures but would probably refer out most lower extremity wound care, derm conditions, or routine nail and callus care. A vasc surgeon or wound care specialist could evaluate lower extremity wounds and blood flow, but they wouldn't be correcting bony deformities, tendon tears, orthotics, etc. A dermatologist or infectous disease doc could treat skin/nail fungus or conditions, but they wouldn't mess with any major surgery, wound care, etc. A DPM with good training can take on any/all of the above. Comprehensive one stop shopping for F&A care.

 

[244869]

Great posts everyone! Very informative!

Oh and I would rather cut old people's toe nails and calluses than perform rectal exams in the ER.

 

[jonwill]

I'm gearing up for two flatfoot reconstructions this Wednesday. Podiatrists don't just cut toenails randomly. There has to be a reason as to why the patient cannot do it for him/herself (or else you cannot bill it). Usually, we are caring for the diabetic patient and this is extremely important. Long, incurvated, and thick nails can lead to infections, ulcerations, and amputations. Diabetics have a compromised healing potential and small nicks and cuts when attempting to cut them by themselves can often result in horrid complications as well.

So no, we are not pedicurists. However, I'm more than happy to debride my diabetic patient's nails because it will most likely save us both the trouble of having to cut the patient's foot off about a month down the road! Sure it isn't the funnest or most glorified procedure in the world but it has its indications and every medical specialty has it's equivalent.

 

[Feli]

...I would rather cut old people's toe nails and calluses than perform rectal exams in the ER.

Good point. Every specialty has its cases which are not the best. Orthos fix no pay femurs at 4am. Plastics does long, demanding burn cases that pay nowhere near what they should. Gastro and many gen surgeons do rectals and colonoscopies ad nauseum. Not every OB/gyn patient is 20 years old (probably twice that on avg). A lot of int med or ER docs take nursing home call or work malignant inner city hospitals/clinics while cutting their chops, paying off loans, and building their patient/referral base after residency. The grass is always greener...

"The whole pattern of medical education is backwards: by the time we realize we're not going to be TV docs undressing ripe-titted beauties, but rather House docs disempacting gomers, we've invested too much to quit, and we wind up like you poor slobs: stuck. The sequence of training should be reversed: on day one, bring in the puking BMSs right into the House of God and rub their noses in Olive O. Turn off potential surgeons with her humps, potential internal medicine red-hots with her numbers incompatible with life and her inability to be cured or dead. Even potential gynecologists will take one look at the terrain of their future specialty and transfer into dentistry. And then - only then - let the ones who still have the stomach for it start on the preclinical years."
-the Fat Man, from Shem's novel, House of God (a hilarious must read for any pre-med/pod/etc)

 

[PADPM]

You don't always simply "choose" what type of practice you'd like. Otherwise the majority of DPM's out there would all be performing surgery. In REALITY, the overwhelming, yes the overwhelming majority of DPM's don't have wound care practices, and don't have surgical practices and don't have biomechanical practices.

By FAR, the overwhelming majority of DPM's have a "general" practice, encompassing all of the above. I've been around the business for over 20 years, I've run a surgical residency, I've been an oral examiner for the ABPS, I've been involved with all levels of the APMA, etc., and I know of very few practices that are strictly surgical or strictly wound care. That's despite the fact that the doctor may have performed a 36 month residency.

Many times that "routine"/palliative patient is who ends up referring you the next surgical patient. Or many times that palliative patient ends up becoming a surgical patient.

So realistically, even those that do high power 36 month residency programs often end up in general practices doing a little of everything. Very few DPM's I know do a "couple of surgeries every day". Most docs have 1 or 2 days a week dedicated to surgery or one or two mornings or afternoons a week dedicated to surgery.

There are always exceptions, but as usual I'm talking amount the vast majority of our profession. Just like sticking your finger up someone's ass everyday is part of being a primary care doc, a urologist or even a general surgeon (and I'm sure most of them don't enjoy that part of the job), trimming toenails is a "part" of our job, but so is performing major surgical procedures. Variety is the spice of life.

 

[dyk343]

You don't always simply "choose" what type of practice you'd like. Otherwise the majority of DPM's out there would all be performing surgery. In REALITY, the overwhelming, yes the overwhelming majority of DPM's don't have wound care practices, and don't have surgical practices and don't have biomechanical practices.

By FAR, the overwhelming majority of DPM's have a "general" practice, encompassing all of the above. I've been around the business for over 20 years, I've run a surgical residency, I've been an oral examiner for the ABPS, I've been involved with all levels of the APMA, etc., and I know of very few practices that are strictly surgical or strictly wound care. That's despite the fact that the doctor may have performed a 36 month residency.

Many times that "routine"/palliative patient is who ends up referring you the next surgical patient. Or many times that palliative patient ends up becoming a surgical patient.

So realistically, even those that do high power 36 month residency programs often end up in general practices doing a little of everything. Very few DPM's I know do a "couple of surgeries every day". Most docs have 1 or 2 days a week dedicated to surgery or one or two mornings or afternoons a week dedicated to surgery.

There are always exceptions, but as usual I'm talking amount the vast majority of our profession. Just like sticking your finger up someone's ass everyday is part of being a primary care doc, a urologist or even a general surgeon (and I'm sure most of them don't enjoy that part of the job), trimming toenails is a "part" of our job, but so is performing major surgical procedures. Variety is the spice of life.

I don't want to "burn bridges" but don't you constantly tell people to speak like a "professional" on this board since its all professionals? I've read alot of posts of you dogging others choices of words...

I would like to add that you do however provide very useful info on this forum

 

[PADPM]

I was simply trying to make a point, but I guess you just didn't get it.....

In the past, when I spoke of members on this forum speaking like professionals, I was referring to the grammar that was being utilized, the slang terms, the constant spelling errors, using the term "your" instead of "you're", using "there" instead of "their", calling attendings "cuz" or "bro", etc.

But once again, if I have to explain myself, than you apparently missed the point.

This is now completely off topic, so if you have a problem with me, send me a PM.

 

[rom3o]

I don't want to "burn bridges" but don't you constantly tell people to speak like a "professional" on this board since its all professionals? I've read alot of posts of you dogging others choices of words...

I would like to add that you do however provide very useful info on this forum

Serioulsy? Gimme a break

 

[dyk343]

I was simply trying to make a point, but I guess you just didn't get it.....

In the past, when I spoke of members on this forum speaking like professionals, I was referring to the grammar that was being utilized, the slang terms, the constant spelling errors, using the term "your" instead of "you're", using "there" instead of "their", calling attendings "cuz" or "bro", etc.

But once again, if I have to explain myself, than you apparently missed the point.

This is now completely off topic, so if you have a problem with me, send me a PM.

lol Sorry, I had to.

No I really don't have a problem with you, I just put it out there. I do respect the info you provide because you have had so much experience in the field. Thanks and I'm sorry

 

[PADPM]

dyk343,

Why don't you do us all a favor and keep your sarcastic, wise ass comments to yourself.

I already told you that your comments were off-topic and if you had a problem you should "PM" me. You can't keep insulting someone and simply say "I'm sorry" and keep insulting that person. It's not quite that simple.

While you were sitting behind your keyboard "giggling" and proud of yourself with the irony of finding an error in MY grammar when I accidentally wrote "than" instead of "then", did you ever consider the fact that I may have simply had a VERY long day (look at the time of my post) and written the post very quickly without proofing what had been written?

Believe me, with the total lack of respect you've shown at this stage of your education, you have proven your immaturity.

If you learn ANYTHING.....learn when to quit and when enough is enough.

 

[Podmeister]

Palliative care is not that bad especially when you have seen one too many infected wound or toe amputation from patients cutting themselves inadvertently.

 

[Feli]

Palliative care is not that bad especially when you have seen one too many infected wound or toe amputation from patients cutting themselves inadvertently.

Exactly.^ A lot of patients with comorbidities reach their feet and/or can't see them very well. Prevention, education, and regular doc visits are undoubtedly the best ways for those patients to avoid disaster.

"Simple" stuff like diabetic foot care education, fasciitis relief for construction workers, or ingrown nail treatment for an athlete really mean a lot to the pts in both the short and long term. It seems "boring" to some pods, but it's all stuff patients need yet don't understand... yet we can usually fix in a snap.

 

[PADPM]

Additionally, "simple stuff" isn't always "simple stuff". The beauty of what we do and the extent of our education is that we are NOT simply pedicurists. Often our strong academic background does play a significant role in understanding that the ordinary is not always a simple problem.

That is exactly what separates us from other doctors that often dismiss patients as having an everyday problem, when in fact it is something relatively unique.

This week I had a patient that was dismissed by several doctors as "just having" a painful mycotic nail on 3 toes on her right foot. However, she also complained of some pain and swelling in those toes that the doctors also brushed aside as irritation secondary to the trophic nails. However, I didn't like the fact that the toes were edematous, painful and had an almost "sausage" appearance.

Radiographs showed a classic appearance of bone destruction at the IP joint indicative of psoriatic arthritis, which was also consistent with the nail deformity (psoriatic nails). Lo and behold when examined she had psoriatic plaques on her elbows, etc.

So while others were too busy to listen to her complaints since she "only" had mycotic nails, in fact her condition was not caused by mycotic nails but was psoriatic arthritis.

Therefore, listen to your patients, be thorough in your examination and history and always give your patients the benefit of the doubt. And check your ego at the door and you'll be a much better and comprehensive doctor that will offer your patients the FULL spectrum of services we were trained to provide.

 

[jonwill]

This is a good discussion. Let's keep it civil.

 

[ThetaChiNAU]

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[podpod]

i think a big thing is that patients dont just walk in your office and want their foot cut off. Building relationships that last with patients is EXTREMELY important so if (hopefully not) they require surgery, they are more open to your suggestion.

IF you are cutting their nails forever, then great, they will refer their friends/family and that means more patients. When that old person says to you, my grandson isnt wearing his shoes outside and got something on his foot, there's ur next referral. pod work is very nice bc its not like the dentist. kids dont come in to the office screaming bc your not busting in the room with a whining drill.

also as one poster said, cutting nails give u a time to learn ur patients and perform COMPLETE podiatric evaluations that an family doc cant. who knows, that could save their life.

 

[air bud]

when I followed my pod, cutting nails was a great way to be working and still being able to talk to his patients. I think getting to kno your patients on a personal level and developing rapport and trust with them is more beneficial than being an awesome technical surgeon

 

[Darklord]

I think this is the best thread to post the below.

I am attending a wedding, and I talked to my uncle from Detroit who is a podiatrist. He discouraged me from pursuing podiatry as: "people don't walk into podiatrists' offices when they have foot problems, they go to their family practitioner. Then they get referred to you. Thus, you have to work hard to build relationships with patients and internists/family practitioners".

His son said: yeah, my dad had to work ridiculously hard-going from nursing homes to house calls to clinics to make good money. I originally planned on becoming a podiatrist, but my dad discouraged me (even though I could have taken over his practice!). Thus, I went into dentistry and I'm happy.

Well that funny thing about all of the above is: this happens in any specialty in private practice. Patients just don't walk in, and you have to work hard.

 

[NatCh]

I think this is the best thread to post the below.

I am attending a wedding, and I talked to my uncle from Detroit who is a podiatrist. He discouraged me from pursuing podiatry as: "people don't walk into podiatrists' offices when they have foot problems, they go to their family practitioner. Then they get referred to you. Thus, you have to work hard to build relationships with patients and internists/family practitioners".

His son said: yeah, my dad had to work ridiculously hard-going from nursing homes to house calls to clinics to make good money. I originally planned on becoming a podiatrist, but my dad discouraged me (even though I could have taken over his practice!). Thus, I went into dentistry and I'm happy.

Well that funny thing about all of the above is: this happens in any specialty in private practice. Patients just don't walk in, and you have to work hard.

People go see their primary care physician, from whom they get a referral, but they also seek out a podiatrist on their own. It happens both ways, but either way you still need to build relationships. This is where having strong interpersonal skills comes into play. Patients for the most part don't know or care which podiatry school you went to, who you trained under, or how many papers you've authored (or how rapidly you got through school -- ahem, Darklord). They do know whether they like and trust you, and that doesn't happen on paper.

Primary Care Physicians don't give a hoot what your podiatric credentials are. PSR-12, PM&S 36, NYCPM, DMU, ABPS, ABPOPPM -- they don't care! They do know and care if their patients give good feedback and are satisfied with your treatment though.

 

[Podmeister]

I think this is the best thread to post the below.

I am attending a wedding, and I talked to my uncle from Detroit who is a podiatrist. He discouraged me from pursuing podiatry as: "people don't walk into podiatrists' offices when they have foot problems, they go to their family practitioner. Then they get referred to you. Thus, you have to work hard to build relationships with patients and internists/family practitioners".

His son said: yeah, my dad had to work ridiculously hard-going from nursing homes to house calls to clinics to make good money. I originally planned on becoming a podiatrist, but my dad discouraged me (even though I could have taken over his practice!). Thus, I went into dentistry and I'm happy.

Well that funny thing about all of the above is: this happens in any specialty in private practice. Patients just don't walk in, and you have to work hard.

Unlike primary care practices (family practice, internal medicine, pediatric and ob-gyn) most medical specialties require referrals for cardiology,pulmonology,rheumatology,endocrinology,nephrology, orthopedics, general surgery, vascular surgery, urology, oncology, allergy/immunology, etc...and podiatry is no different.

As a podiatrist, you have to build interpersonal relationships with primary care physicians, and also with the orthopedic surgeons, endocrinologists, nephrologists, vascular surgeons, and infectious disease docs...and work along side them at hospitals, medical clinics or just hanging out in the doctor's lounge or operating room. Can you say the same about other allied professionals?

Nursing home work is easy money but hard work physically and not suitable for everyone. If you don't like it, then don't do it.

A friend of mine is making a killing with nursing home work and he's quite happy. He goes in from 6-9 AM and has the rest of the day off. He spends 2 days in the office, and the rest of the time at the Indian casinos.

 

[SportPOD]

Another benefit of taking care of toenail clipping patients is the patient referral system that has just been instituted. All it takes is a good first impression for one of your patients to start referring you to their friends. Before you know it, you will also have family members and potential surgical candidates. So, it might seem meaningless, but those few minutes that you are performing palliative care can lead to bigger and better things down the road.

 

[Podmeister]

I had an elderly Russian speaking patient whom I provided palliative care for 5 yrs. One day, I performed bunion surgery on her and post-operatively, she claimed that some other doctor performed her surgery at the hospital. I kept telling her that it was ME...but she kept arguing saying that it was someone else. I guess she thought all I did was cut her nails and calluses. Maybe I forgot to take off my surgical mask at the hospital...

 

[Darklord]

Yes, I am beginning to learn what you all have mentioned about building patient relationships (in addition to internist/FP relationships).

This reminds me of the neurologist whom I am currently shadowing. None of his epilepsy patients know that he completed a one year epilepsy fellowship. They just know that he is a brain and nerve doctor and they trust him as he treats them well and is kind and courteous.

NatCh pointed out that most patients don't care about where you went to school, what degrees you posses, and what kind of certifications you have-I have found this to be true as none of the neurologists patients noticed he was a DO (I don't think his staff knows what a DO is either )

A friend of mine is making a killing with nursing home work and he's quite happy. He goes in from 6-9 AM and has the rest of the day off. He spends 2 days in the office, and the rest of the time at the Indian casinos.

Now that is funny. Is he at *****go or San Manuel?

Okay, so what is the verdict on my podiatrist of an uncle who doesn't want his sons/neices to go into podiatry: Is he lazy? Does he not realize that this happens in every specialty in private practice? Is he a disgruntled podiatrist?

 

[diabeticfootdr]

Unlike primary care practices (family practice, internal medicine, pediatric and ob-gyn) most medical specialties require referrals for cardiology,pulmonology,rheumatology,endocrinology,nephrology, orthopedics, general surgery, vascular surgery, urology, oncology, allergy/immunology, etc...and podiatry is no different.

As a podiatrist, you have to build interpersonal relationships with primary care physicians, and also with the orthopedic surgeons, endocrinologists, nephrologists, vascular surgeons, and infectious disease docs...and work along side them at hospitals, medical clinics or just hanging out in the doctor's lounge or operating room. Can you say the same about other allied professionals?

Exactly right, and good thoughts to keep in mind!

 

[whiskers]

Cutting toe nails is low stress social time for most.

It pays pretty well and if the patient has an inch thick nail, how the hell are they going to cut it in the 1st place without hacking up their feet and legs?

Tell grandma not to worry, you will cut her nails too if she's nicer to you.

If not, she can continue to cut her own nails when she's elderly and can't reach them or has diabetes.

That's all you have to say./

 

[Shireiqiang]

If we don't do it who will? These people really need help. Those of you who have seen patients with neuropathy have probably seen some pretty bad wounds. This is a real issue. We aren't doing pedicures, these are procedures. The patients only need one wound to develope, let it fester for a little while, and before long their whole foot is at risk. We are not above trimming toenails and calluses.

 

[tkim]

A lot of int med or ER docs take nursing home call or work malignant inner city hospitals/clinics while cutting their chops, paying off loans, and building their patient/referral base after residency.

A small point. ER docs don't take nursing home call to build their patient base. People just come or get sent.

 

[ThetaChiNAU]

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