Who should admit this??

[opr8n]

70 y/o demented lady with DM, HTN, Afib (on coumadin), GERD, OA, ect thousand other medical problems
Has a spontaneous retroperitoneal bleed from supratherapeutic INR of 9
No history of antecedent Trauma

Surgery or Medicine?

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[ESU_MD]

hospitalist. doesnt even really need a surgical consult to correct the INR, serial exams, etc.

 

[Buzz Me]

Medicine. Nothing to do besides serial H&H, correct coagulopathy, serial exams.

 

[Winged Scapula]

Yep, at my residency institution that would have gone to medicine (but surgery would have been consulted). At my current place that would also be the case.

 

[SLUser11]

70 y/o demented lady with DM, HTN, Afib (on coumadin), GERD, OA, ect thousand other medical problems
Has a spontaneous retroperitoneal bleed from supratherapeutic INR of 9
No history of antecedent Trauma

Surgery or Medicine?

I have to confess that I've admitted similar patients to the surgery service for similar problems. However, I've also seen them in consultation, which is how I prefer it.

A better question: If this patient was admitted to the surgery service, would you consult someone to manage the medical issues, or just take care of it yourself? I can't remember the last time I consulted a hospitalist for any reason other than trying to turf my patient to their service....

 

[maxheadroom]

Should go to Medicine with Surgery consult.

The corollary that I get is the call from the ED to admit a patient with hand cellulitis. I've taught my residents that cellulitis is a medical disease and that I will back them on telling the ED to call Medicine. We will follow as a consult, but I don't admit non-surgical patients. Period.

 

[Arcan57]

Should go to Medicine with Surgery consult.

The corollary that I get is the call from the ED to admit a patient with hand cellulitis. I've taught my residents that cellulitis is a medical disease and that I will back them on telling the ED to call Medicine. We will follow as a consult, but I don't admit non-surgical patients. Period.

From an ED perspective, I'd admit the patient to medicine +/- a surgery consult depending on the internist (if they insist I'd call, otherwise not).

Regarding the hand cellulitis (and cellulitis in general), I understand not wanting to have patients on your service that you aren't going to operate on. The flip side is that you are much better than IM at identifying when the patient needs to go to the OR for washout if a deep-space infection develops. If the only reason someone is being admitted is to watch for a potential complication, doesn't it make sense to admit the patient to a service that has the most experience in identifying and treating that complication? This of course assumes a situation where the service does admit.

Flame away...

 

[PMPMD]

70 y/o demented lady with DM, HTN, Afib (on coumadin), GERD, OA, ect thousand other medical problems
Has a spontaneous retroperitoneal bleed from supratherapeutic INR of 9
No history of antecedent Trauma

Surgery or Medicine?

Looks unanimous for medicine. Let me guess, you're a surgery resident who got stuck with this (inappropriate) admission?

 

[maxheadroom]

Regarding hand cellulitis, I'll see the patient as a consult. I just won't admit. They frequently have issues like diabetes and other comorbidities that I just don't treat. I'll see the patient and follow as a consult that almost never needs to go to the OR. And I appreciate the difficulty of being the ED doc and needing to find someone to admit, but it just ain't me.

 

[Winged Scapula]

From an ED perspective, I'd admit the patient to medicine +/- a surgery consult depending on the internist (if they insist I'd call, otherwise not).

Regarding the hand cellulitis (and cellulitis in general), I understand not wanting to have patients on your service that you aren't going to operate on. The flip side is that you are much better than IM at identifying when the patient needs to go to the OR for washout if a deep-space infection develops. If the only reason someone is being admitted is to watch for a potential complication, doesn't it make sense to admit the patient to a service that has the most experience in identifying and treating that complication? This of course assumes a situation where the service does admit.

Flame away...

I agree with max.

I don't see that it makes a difference that the surgeon is admitting to "identify and treat" any potential deep space spread as the surgeon is rounding on the patient daily, sometimes (depending on institution and surgeon preferenec) twice daily (ie, at least as much, if not more than IM), so any spread would be recognized anyway.

 

[maxheadroom]

This is similar to my approach for wound patients. I have a partner who has admitted all of those patients (to the despair of the residents) in the past. I won't admit those. I'll follow as a consult with the Hospitalist admitting. Reason: these are complex patients with multiple medical problems that I don't treat. Usually, the wound is a symptom of their larger problem and it requires someone who can approach all of their issues and not just debride a wound and apply a VAC.

 

[Arcan57]

I agree with max.

I don't see that it makes a difference that the surgeon is admitting to "identify and treat" any potential deep space spread as the surgeon is rounding on the patient daily, sometimes (depending on institution and surgeon preferenec) twice daily (ie, at least as much, if not more than IM), so any spread would be recognized anyway.

And that's why I don't generally have a problem with the admit to medicine with consult in the community. Where I practice, I can usually find someone to admit almost anything that needs hospitalization if the appropriate consultants are on board. In academics, I definitely felt like it made a difference who admitted the patient. The consults often didn't get the same level of care as service patients, because of the diffusion of responsibility and a tendency for inter-service bickering.

The question is going to be when bundled payments start becoming the norm, is having someone to answer that 1:00 am call for more pain meds or to do the d/c summary going to be worth having to share the payment?

 

[maxheadroom]

The question is going to be when bundled payments start becoming the norm, is having someone to answer that 1:00 am call for more pain meds or to do the d/c summary going to be worth having to share the payment?

True. The big problem in this whole scenario is that Plastic Surgeons (for the most part) have already fled the major hospitals in the community. The ones who remain are under more and more pressure to take call and give care to patients with minimal payor sources. Ultimately, more and more specialty surgeons will flee to ASCs and Surgical Specialty Hospitals where they don't have to deal with this type of issue.

 

[ESU_MD]

True. The big problem in this whole scenario is that Plastic Surgeons (for the most part) have already fled the major hospitals in the community. The ones who remain are under more and more pressure to take call and give care to patients with minimal payor sources. Ultimately, more and more specialty surgeons will flee to ASCs and Surgical Specialty Hospitals where they don't have to deal with this type of issue.

And I dont blame them. Thats the surgical dream- do great cases and not have to take calls from the er.

 

[maxheadroom]

It's just sad. Ultimately the patients suffer because of it. The sad truth is that if everybody took a small amount of call, it would be tolerable we wouldn't have the access issues that continue to grow.

 

[Arcan57]

It's just sad. Ultimately the patients suffer because of it. The sad truth is that if everybody took a small amount of call, it would be tolerable we wouldn't have the access issues that continue to grow.

Eventually the government will step in and issue some draconian mandates that at least provides the illusion of increasing access to subspecialty care. Some places are still trying the carrot approach, ie Ohio changing it's standard to willful negligence for malpractice in emergency care (great for ED docs, but actually done for our consultants). Or individual hospitals that pay for consultants to take call. But the stick will come.

 

[maxheadroom]

The trend of paying consultants to take call is coming along, especially in Hand surgery (following Neurosurgery). The stick will be harder -- how do you compel physicians to take call when they don't want to? In one town where I trained, it was a dirty secret that one of the hospitals in town had an ED that NEVER called a surgeon in an emergency -- it was a rinky-dink little hospital, but they had great outpatient and short-stay services. Where do you think a bunch of the private guys took all of their cases? They could do this by getting guest privileges at the bigger hospitals so they could do a few cases there per year without being on the call schedule.

 

[ESU_MD]

The sad thing is there is always a "bottom feeder" general surgeon who will admit all these nonoperative cases to their services.

 

[Arcan57]

The trend of paying consultants to take call is coming along, especially in Hand surgery (following Neurosurgery). The stick will be harder -- how do you compel physicians to take call when they don't want to? In one town where I trained, it was a dirty secret that one of the hospitals in town had an ED that NEVER called a surgeon in an emergency -- it was a rinky-dink little hospital, but they had great outpatient and short-stay services. Where do you think a bunch of the private guys took all of their cases? They could do this by getting guest privileges at the bigger hospitals so they could do a few cases there per year without being on the call schedule.

From a federal standpoint, the easiest way (in theory, probably a b*tch to implement in practice) to compel call would be to tie Medicare payments to taking call. That's not going to change the plastics/hand situation that much, but for most other surgical specialties that would be a significant hit financially.

On a more micro level, the bigger hospitals could decide they don't want surgeon X, who does 95% of his well-insured patients at the OSC, to have staff privileges. This would eliminate Dr. X's ability to transfer complications to a better equipped facility. Our hospital is already having issues trying to figure out how to handle reappointment for staff that is only admitting a handful of patients/year.

Of course, none of this stops the OSC from simply transferring a patient to the local ED. If I had a nickel for every block for a shoulder scope, that led to respiratory depression from diaphragmatic paralysis, that was transferred to us at ~5pm...

 

[maxheadroom]

Agree it is a mess. The problem is that surgeons who are primarily outpatient (Plastics, some Ortho, ENT, Ophtho) are pretty smart about making their main hospital the place where they don't get bothered much for call. If I were in private practice, I probably wouldn't get credentialed at the big non-academic Trauma center type hospital. Why would I? If my goal is a mix of outpatient Hand surgery and some general Plastics, all I'm doing is diluting my case-volume with low-pay and non-pay patients at the big Trauma center.

There's no way to compel those surgeons to have privileges there, you have to entice them with compensation for taking call (especially Hand call). There are also models where the surgeon who takes care of lots of under-funded patients gets a "Medical Director" title for something in the hospital, essentially giving him/her a kickback from the hospital for taking care of those patients.

 

[maxheadroom]

The sad thing is there is always a "bottom feeder" general surgeon who will admit all these nonoperative cases to their services.

That would only happen if the General Surgeons fail to take a stand for themselves. If you're being abused by Service X at your hospital (when you're out in practice), you either work out some sort of deal (who does what) or you quit your privileges at that hospital. When a hospital is threatened with losing a substantial number of surgical staff (and hospitals make most of their money on SURGERY), they'll take notice.

Several years ago, the Chair of Plastics at University X went to his hospital group and told them that his faculty were getting more and more unfunded hand trauma patients from a larger and larger geographic catchment area. The hospital received state funding, but the faculty were working for free. He told them that the faculty needed to receive an on-call stipend in order to make things more equitable and to keep the faculty willing to take call. The hospital CEO said, "No way."

A week later, the Chair returned to the CEO with a stack of papers. Every Plastic Surgeon with privileges at the hospitals had signed a letter of resignation that was to be turned in if they didn't get an on-call stipend. Guess what the CEO did?

Hospitals make money on under-funded patients -- Medicaid reimbursement rates for hospitals are significantly better than they are for physicians.

 

[ANCAdoc]

As a medicine resident, I think the patient should go to medicine. I would get a surgery consult.

You get bickering in academics only because there is no pay for performance, but in the community I don't think you will find any resistance. I'll ride the gravy train.

 

[Apollyon]

As a medicine resident, I think the patient should go to medicine. I would get a surgery consult.

You get bickering in academics only because there is no pay for performance, but in the community I don't think you will find any resistance. I'll ride the gravy train.

At a community hospital, I had a guy with a questionable infection vs gout vs infected gout in his hand. I spoke with the hand guy on call (these folks were great - they would see ANYONE - ANYONE - including people operated on by others - as long as you called them first), and he recommended IV antibiotics and he would see the pt the next day (this was a Sunday). The hospitalist - IM - balked at admitting the guy, stating "utilization review" would not cover him for a hand admission. Dude ended up getting a couple of big needles, had to come back in 12 hours, then 12 hours after that.

Resistance occurs everywhere.

 

[ANCAdoc]

Resistance occurs everywhere.

No doubt. My experience is that it occurs less in the community, though obviously can and does still occur.

I'm at a private hospital right now and haven't run into any of the hospitalists (and there are>20 in the group) where I've heard/seen them declining potential patients. They are generally happy for the business.

 

[45408]

At a community hospital, I had a guy with a questionable infection vs gout vs infected gout in his hand. I spoke with the hand guy on call (these folks were great - they would see ANYONE - ANYONE - including people operated on by others - as long as you called them first), and he recommended IV antibiotics and he would see the pt the next day (this was a Sunday). The hospitalist - IM - balked at admitting the guy, stating "utilization review" would not cover him for a hand admission. Dude ended up getting a couple of big needles, had to come back in 12 hours, then 12 hours after that.

Resistance occurs everywhere.

We've got a plastics guy (who also covers hand) who takes an obscene amount of call, to the extent where none of the other plastic surgeons are on call, at all. He shows up at a moment's notice, and he does a lot of his work right at the bedside. He doesn't have to wait for the OR to set up, anesthesia to do their thing, etc, but from what I heard, he can still get reimbursed well for the procedure. His surg tech just gets his cart, and he does it under local.

 

[maxheadroom]

I talked to a 2-3 surgeon Plastics/Hand group in the southwest last year. They do nothing but emergency Hand and some other emergency Plastics. They also do some inpatient consult type stuff for LE coverage (and get lots of free flaps out of that). They're in a major market that doesn't have much of an academic Plastics presence.

They're based out of a couple of major/Level 1 centers. They have block time that starts around 1700 and goes all night. As I understand it, they usually have three rooms. They do hand trauma and urgent free flaps all night long. They have a tiny follow up clinic that they run in the late afternoon a couple of days per week.

They have a couple of PAs who go all over their city to eval hand injuries in the ED and then transfer them to the hospital where they're working that night.

They make crazy money, mostly because they have no insurance contracts. Since they're dealing with emergency patients and operating right away, the patient's insurance can't turn down their U&C charges and they can't send the patient to another surgeon. It's a good deal if you don't mind living like a vampire.

 

[Winged Scapula]

Is that here in my town because I know some Hand guys here who have the same set-up?

I talked to a 2-3 surgeon Plastics/Hand group in the southwest last year. They do nothing but emergency Hand and some other emergency Plastics. They also do some inpatient consult type stuff for LE coverage (and get lots of free flaps out of that). They're in a major market that doesn't have much of an academic Plastics presence.

They're based out of a couple of major/Level 1 centers. They have block time that starts around 1700 and goes all night. As I understand it, they usually have three rooms. They do hand trauma and urgent free flaps all night long. They have a tiny follow up clinic that they run in the late afternoon a couple of days per week.

They have a couple of PAs who go all over their city to eval hand injuries in the ED and then transfer them to the hospital where they're working that night.

They make crazy money, mostly because they have no insurance contracts. Since they're dealing with emergency patients and operating right away, the patient's insurance can't turn down their U&C charges and they can't send the patient to another surgeon. It's a good deal if you don't mind living like a vampire.

 

[maxheadroom]

Yup. Talked to one of them at a meeting last year. It's not how I would like to practice, but it's a pretty smart approach.

 

[Winged Scapula]

Yup. Talked to one of them at a meeting last year. It's not how I would like to practice, but it's a pretty smart approach.

Yeah, those guys are crazy busy as I understand it.

 

[opr8n]

as a f/u ...

i refused to admit this pt from the ED because there is nothing surgical
what am i going to do as a surgeon to stop spont retropereitoneal bleeding from coumadin? My attending backed me up on this. I recieved alot of flack from the ER doc .. his reasoning was that thos is a sick patient with blood in their abdomen and a surgeon should be managing them. we had to agree to disagree.
We still consulted for a few days then signed off after doing nothing

 

[blue2000]

as a f/u ...

i refused to admit this pt from the ED because there is nothing surgical
what am i going to do as a surgeon to stop spont retropereitoneal bleeding from coumadin? My attending backed me up on this. I recieved alot of flack from the ER doc .. his reasoning was that thos is a sick patient with blood in their abdomen and a surgeon should be managing them. we had to agree to disagree.
We still consulted for a few days then signed off after doing nothing

I think the ER doc was misunderstanding WHERE the blood is; i.e. from my understanding NOT in the abdomen but in the retroperitoneum. MICU should be able to manage sick patients, including reversal of coagulopathy, and surgery can certainly be involved. In my institution, surgery tends to have a better and closer relationship with IR, in that we can have better luck pushing IR to embo if it were to ever get to that point (which most dont).

 

[opr8n]

I think the ER doc was misunderstanding WHERE the blood is; i.e. from my understanding NOT in the abdomen but in the retroperitoneum. MICU should be able to manage sick patients, including reversal of coagulopathy, and surgery can certainly be involved. In my institution, surgery tends to have a better and closer relationship with IR, in that we can have better luck pushing IR to embo if it were to ever get to that point (which most dont).

this is not even someone you would embolize, they didnt have a trauma injury, there is no lacerated or injured vessel

i tried raising that point about where the blood was

 

[45408]

i tried raising that point about where the blood was

Not the first time. We had a patient die after a huge retroperitoneal bleed, and the death summary said "Intra-abdominal hemorrhage" until our attending e-mailed the author and said that was completely inaccurate.

 

[droliver]

They make crazy money, mostly because they have no insurance contracts. Since they're dealing with emergency patients and operating right away, the patient's insurance can't turn down their U&C charges and they can't send the patient to another surgeon.

That whole end-around they're doing with the U&C (usual and customary charge) is going to disappear over time via legislative maneuvers. It's already happened in California and some other states where high out of network (OON) charges and balance billing have been restricted on ER/trauma patients. For elective surgeries your also going to see a ceiling on U&C charges by insurers for this in areas with lots of OON providers (like NYC). The carriers are just going to refuse to play along on ridiculous OON charges and patients aren't going to be able to afford high balances. When the frustration gets high enough, the states will drop the hammer on this. You don't have to be a genius to know that at some point your U&C charges will limited to some % of Medicare's fee schedule for your region.

 

[maxheadroom]

True, insurance companies and their well-paid lobbyists will always try to find ways to decrease their payments. I think the bigger lesson here is that a group of surgeons identified a major need in their community (this metro area in particular was literally in crisis for lack of Hand coverage) and found a way to structure their practice to offer patients the care that they need while taking care of their own bottom line.

I'm sure that they will have to adjust their practice as the regulatory environment and payors change, but their ability to meet a need (and not just waste their lives and training injecting Botox and stuffing implants into boobs) and generate a good income is worthy of note.

 

[europeman]

Hi. For me, it depends on the institution and patient.

Right now I'm doing my trauma/gen surg rotation at a new york city hospital where the medicine and micu services suck. the medicine residents are from god knows where, and so are the attendings. SO if i'm really concerned about a patient (i.e. the sicker they are) with a retroperitoneal bleed, the more likely I am to take the patient to my service or SICU.

I've seen patients get compartment syndrome from SEVERE (granted this is very rare) retroperitoneal bleeds. That's surgical.

Surgeons tend to be much more expeditious about getting stuff done (i.e. GETTING the FFP hanging within 20 minutes, not 4 hours from now), etc.

Now, at my home institution, the patient would be just as well served on a medical/micu service and I would prefer it that way, I agree.

As far as cellulitis... again, for me, it depends how bad. If really really bad, I don't mind taking them.

Diverticulitis is another example. Run of the mill.. i dont care. Sick... i take. i guess that's a more obvious one though 'cuz if they are sick, they prolly need IR or oR.

Pancreatitis the same. if gallstone pancreatitis i PREFER them on my service especially when they are sick. alcoholic i try and avoid.

 

[filter07]

What do you guys do for constipation or ileus? I have had the ED try to convince me that it is standard for surgery to admit these patients. I'm not talking about post op ileus or constipation, I'm talking about pediatrics and geriatrics.

 

[Winged Scapula]

What do you guys do for constipation or ileus? I have had the ED try to convince me that it is standard for surgery to admit these patients. I'm not talking about post op ileus or constipation, I'm talking about pediatrics and geriatrics.

Surgery? For a non-post op patient with a non-surgical problem?

NO...that does not go to Surgery, but rather the appropriate medical service.

 

[Arcan57]

What do you guys do for constipation or ileus? I have had the ED try to convince me that it is standard for surgery to admit these patients. I'm not talking about post op ileus or constipation, I'm talking about pediatrics and geriatrics.

That's medicine with a GI consult if they've already failed a bowel regimen as outpatient.

 

[Buzz Me]

Why are all these non-surgical patients going to surgical services?

Many non-surgical people just don't quite understand what the retroperitoneum is. They think it's part of the abdominal cavity, or that it's an actual "space."

 

[45408]

What do you guys do for constipation or ileus? I have had the ED try to convince me that it is standard for surgery to admit these patients. I'm not talking about post op ileus or constipation, I'm talking about pediatrics and geriatrics.

Medicine, all the way. I get annoyed when they consult us, as if they can't figure out laxatives and enemas on their own. If there's concern for a surgical issue, then by all means call us, but this isn't rocket science. We saw (and signed off) on a LOL with constipation due to an ileus from her L1 compression fracture, and they called us back to give "additional recommendations." She'd had 9 BMs in 4 days, the radiology read on her films was that she was improving, belly was 100% benign, and GI had just signed off saying "continue aggressive bowel regimen, no new recommendations." Ugh. I left a concise note that summed up with "Agree with GI."

 

[Socrates25]

70 y/o demented lady with DM, HTN, Afib (on coumadin), GERD, OA, ect thousand other medical problems
Has a spontaneous retroperitoneal bleed from supratherapeutic INR of 9
No history of antecedent Trauma

Surgery or Medicine?

Maybe I'm being obtuse here, but I dont understand why these decisions are so hard.

Rule #1: If the patient is going to surgery, they get admitted to surgery. If not, they go elsewhere.

Rule #2: If the patient has a post-op issue that could cause them to go to the OR, then they get admitted to surgery.

WTF?

I cant believe there are that many ER attendings who use the logic of "yeah I understand they dont need surgery but a surgeon should manage this." That makes absolutely ZERO sense to me. I'm not in surgery though.

 

[Socrates25]

That's medicine with a GI consult if they've already failed a bowel regimen as outpatient.

You really need a GI consult for that? I'm in peds and they'd be pissed if we consulted them for every single 3 y/o w/ constipation who was already on miralax at home and is still constipated.

IMHO, GI doesnt get involved until the pt fails a 24 hour golytely drip and several enemas.

 

[Socrates25]

What do you guys do for constipation or ileus? I have had the ED try to convince me that it is standard for surgery to admit these patients. I'm not talking about post op ileus or constipation, I'm talking about pediatrics and geriatrics.

From the pediatrics perspective thats outrageous and somebody is lying to you. There's no way in hell those kids go to the surgery service at 99% of the hospitals in the country.

 

[Socrates25]

That whole end-around they're doing with the U&C (usual and customary charge) is going to disappear over time via legislative maneuvers. It's already happened in California and some other states where high out of network (OON) charges and balance billing have been restricted on ER/trauma patients. For elective surgeries your also going to see a ceiling on U&C charges by insurers for this in areas with lots of OON providers (like NYC). The carriers are just going to refuse to play along on ridiculous OON charges and patients aren't going to be able to afford high balances. When the frustration gets high enough, the states will drop the hammer on this. You don't have to be a genius to know that at some point your U&C charges will limited to some % of Medicare's fee schedule for your region.

Oh it gets a lot worse than that. Some idiot in Massachusetts legislature is floating a bill out there right now which would make accepting the state medicaid program a CONDITION OF LICENSURE in the state.

Yeah it probably wont pass, but still.

 

[Arcan57]

You really need a GI consult for that? I'm in peds and they'd be pissed if we consulted them for every single 3 y/o w/ constipation who was already on miralax at home and is still constipated.

IMHO, GI doesnt get involved until the pt fails a 24 hour golytely drip and several enemas.

Where are you practicing? In Cinci, the peds hospital had an entire service that was essentially bowel clean-outs. In the community (where I'm not seeing kids currently), 90% of the time I'm admitting a geriatric patient with obstipation the primary requests a GI consult (n~10).

 

[Lucid Intervals]

I stumble through some primitive Spanish convos with patients in the early morning. Just make sure you get the interpreter for important talks.

Spanish ROS
Ha tenido problemas con la vista?
(Have you had vision problems?)


Se ha sentido mareado?
(Have you felt dizzy?)


Ha dolor de cabeza?
(Headache?)


Ha perdido peso recientemente?
(Have you lost weight recently?)


¿ha tenido fiebre?
(have you had a fever)


¿ha tenido escalofríos?
Have you had chills?


Ha tenido vómitos o diarreas frecuentemente?
(Have you been vomiting or having diarrhea frequently?)
Note: In Spanish, it is said literally, "Have you had vomits or diarrheas frequently?"


Le ha dolido la cabeza últimamente?
(Has your head hurt you recently?)
Note: Note the use of present perfect tense, "ha dolido," or "has hurt."


Tienes dolor de cabeza?
(Headache)


Tienes Falta de aliento?
(shortness of breath)


Tienes dolor de pecho?
(chest Pain)


durante los últimos veinticuatro horas
(over the last 24 hours)



Cuándo fue su último período?
(When was your last period?)


Su período viene todos los meses?
(Your period comes every month?)


Presenta alguna molestia antes o durante el período?
(Occurs any symptom before or during the period?)

 

[ESU_MD]

Oh it gets a lot worse than that. Some idiot in Massachusetts legislature is floating a bill out there right now which would make accepting the state medicaid program a CONDITION OF LICENSURE in the state.

Yeah it probably wont pass, but still.

Even those liberals in mass know better.. They gave dead teddy kennedys seat to someone that derailed the whole health bill ( temporarily at least)