Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard. Today we're going to discuss a topic that is really near and dear to my heart as a family physician, the role
of primary care. There's often a misconception by legislators and even the public that primary care is somehow easy, and so therefore, it can be relegated to allied health professionals, especially nurse practitioners. Today I'm joined by two special guests who are experts in the role of primary care and health care. Dr. Emily O'Rourke is a family physician in Virginia, and she's the owner of Fountain
Direct Primary Care. We're also joined by Dr. Meghan Galer, she is a Board Certified emergency physician who opened her own direct primary care practice as well in Georgia. So welcome both of you to the podcast. Thank you so much for joining me. So let's talk about primary care. What does that term even mean? So just to get some more information, I just googled it to see basically what the
universe thinks about it. And the first response was from Oxford Dictionary, and it said, healthcare at a basic rather than specialized level for people making initial and initial approach to a doctor or nurse for treatment. And I guess if that's what you think primary care is, then maybe it does sound like it's easy. Emily, what are your thoughts when you hear that definition?
So unfortunately, I think that that is pretty accurate when you're describing most insurance based primary care practices, because even the most knowledgeable physician really can't give quality care in a seven minute visit. I know when I was an employed insurance based physician, I would sometimes have to refer out something that I knew that I could easily do myself, but I just didn't have time to do on that visit if I was already running an hour and
a half behind. And so I think these practices sort of turn physicians into less trained providers. And there's actually a huge spectrum of primary care. So you can have it practiced really poorly, either due to lack of time or lack of training, or you can have it practiced really well. So I'm from Nebraska, I trained there.
And my first exposure to primary care was being trained by these rural country doctors who did everything for their patients, you know, these were people that were afraid to drive in the city. And so really, if it wasn't done by their country doctor, it wasn't going to be done at all. And so these doctors, they delivered babies, both vaginally, and by C sections, they did, EGDs and colonoscopies, they saw patients in the hospital, they really did everything for their patients.
And that's how I saw primary care. And in fact, that's why I started a direct primary care practice, so that I could be that type of physician and do more for my patients and save them both time and money.
So I think what I hear you saying is, there's sort of this idea of primary care, which could be very basic care not done very well or can be incredibly comprehensive, super high
quality care. And I think when you look at the definition from the American Academy of Family Physicians, they say that they define primary care as 'integrated, accessible health care services by physicians and their health care teams who are accountable for addressing a large majority of personal health care needs,' just like you said, for the patient being available for a broad spectrum of whatever that patient might need, and really having to know a whole heck of a lot about
medicine. And one of the things they also say is that 'primary care physicians are specifically trained in comprehensive first contact in continuing care for persons with any undiagnosed sign symptom or health concern, the undifferentiated patient,' and we're going to get into why that's so important in our training. Before we get into that, Meghan, can you weigh in you actually trained as an emergency physician, and now you're practicing primary care.
So tell us what your thoughts are about the role of primary care.
I'm going to do my best with this dog crying in the background, but yeah, so my background is I'm a board certified emergency physician. I've been involved in emergency medicine in some way, shape or form since I was a teenager basically started as a paramedic in a fire station for a while throughout college and emergency medicine is really, you know, where my heart is that joined during the military, did my training, went to Fort Benning,
Georgia. After my deployment in 2016-2017, I came back to Columbus, Georgia and started doing a little bit of moonlighting in one of the local emergency rooms. Really was just disheartened beyond repair, the mid level situation was completely out of control, you know, 300 patients per day emergency room with, you know, maybe two doctors on it at any given point and then just sort of an army of mid levels. And these were mid levels of various
skill sets. And being just a PRN contractor, I didn't really I wasn't really afforded the opportunity to get to know any of their strengths and weaknesses. And so after doing a few shifts at this hospital, I realized I couldn't participate in the system as it was set up at that time. So I brought my concerns to the medical executive committee very professionally and they essentially fell on deaf ears.
And at that point, I said, 'Look, this is not a system that I can ethically participate in.' And I went, I went ahead and put my resignation and and I was very explicit in my resignation, about the reasons that I was leaving, and the fact that I thought this was a social justice issue, and that they were getting away with things they wouldn't be able to get away with in a more medically sophisticated population. And,
again, crickets. So I walked away and proceeded to get ready to finish my military service, but really had sort of lost my way for a little while, I didn't know what I was going to do when I got out of the military now, because that civilian sector, easy peasy, just transition your PRN job to full time was definitely no longer an option for me. So that was when a friend of mine store sort of introduced me to the direct care
concept. And, you know, at first I had a lot of trepidation about it, because as an emergency physician, transitioning to general practice is is not at the forefront of a lot of people's thought planning process, I think maybe a little bit more, more. So for myself, since coming from the military background, we're always sort of prepared to fill whatever role needs to be filled. But anyway, that's when I started looking into looking into the direct
primary care movement. And then it really spoke to me, I went to a conference in 2019. And I was like, these are my people. And I really started to embrace the idea of sort of the old fashioned general practitioner, recognizing that I'm not trained in, you know, a classic primary care specialty, I do think there's definitely a role for general practitioners.
So you know, you're actually the second emergency physician that I know that has converted to direct primary care. And I applaud you for that, because I just don't know how our ER colleagues are managing with the way corporate healthcare has gone and private equity. But tell me, did you have to do any extra training to get that kind of bone up on your primary care? Or are you just kind of looking things up? As you go reaching out to resources? How are you handling that?
Oh, yeah, primary care is daunting. I think I was always fairly respectful of my colleagues in primary care, but I have a whole new appreciation for what you guys do. And my tack is, you know, I've never pretended to be a perfect person or a perfect
doctor. So I'm very upfront with my patients that, you know, hey, this is my background, I'm emergency medicine trained, you know, and there's some things that, you know, might seem simple that I'm going to take a little bit longer to try to make sure I'm doing things properly. But rest assured, you know, when I come up with a care plan, it's going to be well thought out and up to date, and we're going to
be very diligent about it. And I really sort of try to preach the virtue of slow medicine and slow is smooth, smooth is fast. That's one thing we definitely preach in the emergency room. And I think what I actually bring to the table, in addition, is, you know, I'm really good at keeping patients out of the emergency room around here. But yeah, things that are probably super basic to you guys, like like vaccination schedules, and blood pressure medicine, like JNC seven, not a thing anymore.
I didn't know that. All the diabetes medicines have changed. But I'm really relishing the opportunity to sort of deep dive into these things and go back to like the basic pathophysiology. Because in the emergency department, you're just running that hamster wheel, non stop. And whether you admit it or not, most of us after 10 years of practice, are still practicing, like, you know, we were in training, which, regardless of your specialty, is is not ideal.
Yeah, you know, I, as I'm listening to you talk and I'm thinking about how I've been doing family medicine for 18 years, but yet every single day, I'm going on to Up To Date to make sure there's not something new or something that hasn't changed. So actually, I think your patients are probably getting a really fantastic experience because first of all,
you're a physician. So you've gone through medical school, you have the the foundations, of course, you are an ER doctor, so you know, a heck of a lot of medicine, and especially about serious things, and then you know where to look. And you're going to be very conscientious. And so it sounds to me, like actually patients are going to be really happy with the care that you're given. So I'm
excited to hear about that. So Emily, I want to read to you this statement that someone wrote on Facebook, they said, 'if you think primary care is easy, you're doing it wrong.' So what does that mean?
That's sort of what I was saying before that end of the spectrum where you're you're not doing primary care well. And so it may be that you're doing it poorly because you're not educated. And you're just trying to mimic things that you've seen other people do, and you're literally doing it wrong.
It may also be that you're you're just taking shortcuts, you're doing things like like ordering extra tests, because you don't have time to do a thorough history and physical, or you may be referring out because, you know, at the end of a patient's visit, they say, Oh, hey, can you look at this spot on my arm, and you know that it is suspicious for skin cancer, and that it needs to be biopsied, but you can't take the time to gather the materials and do it right then and the easiest
thing to do is click a few buttons on your computer and refer them to a dermatologist.
And what I see happen a lot of times in primary care, of course, this sometimes happens with physicians that are working in very ridiculously busy RVU generating systems where they're referring patients left and right. But it's a lot more common when it's happening with nurse practitioners and sometimes physician assistants as well. The patient comes in
and it looks easy. If you send them to endocrinology for their diabetes, you send them to rheumatology for their Fibromyalgia or osteoarthritis, which are things that a primary care physician can certainly handle, you send them to cardiology for their hyperlipidemia, you send them to urology for their prostate enlargement, I mean, and basically at the end of the day, you have 10 referrals for a patient for basically problems that a well trained primary care physician could handle with
time, of course, it's you're not going to get all that done in one office visit. But over time, the relationship you'll be able to handle all of that rather than sending the patient to all these different specialists, which is expensive, it's time consuming, there's more risk of
polypharmacy that way. And you know, I think this comes down to why primary care done well is so important, because studies show that it lowers mortality, there was a study in the British Medical Journal published in 2018, showing that continuity of care with the same doctor over time, decreased mortality. We also see another study from BMJ in 2019. That United States patients live longer in areas with more primary care physicians. And then another
review in 2020. Again, mortality rates are lower with more continuity of care. So what are your thoughts, Emily, when you hear about, you know, why do you think it's so important that patients have that same doctor over time? What do you think it is that lowers that mortality?
Well, part of it is, let's say you have a primary care doctor who has their schedule booked in advance for months, and so you can never go and see them when you get sick. So you end up in an urgent care with someone who's never seen you before. Even if you're seeing a physician in that urgent care, and they're a good physician, they may not ask all the questions, they may miss things about your history.
Whereas for my patients, if they shoot me a text, I can handle that Urgent Care complaint within a couple of minutes, because I know them I know their whole history. I know what they're allergic to. I know what's worked for them in the past, plus someone you trust, you're going to be more likely to trust them on things like should I get a COVID vaccine?
I know that studies have shown a decrease in cardiovascular mortality, because patients with the same doctor over time are getting better blood pressure control, better lipid management, they're also seeing a decrease in some common cancers, again, because patients are getting those screening tests. Now, Meghan, when you worked in the emergency room, I'm guessing you probably saw patients with pretty serious end stage consequences of diseases that weren't picked up early enough or by screening.
Was that an experience that you had often?
Oh, yeah, every day, I mean, we're not checking like lipids in the emergency room, but uncontrolled hypertension, uncontrolled diabetes, you know, we see the end stage of all of that. So I think maybe I'm extra motivated to sort of jump on the the preventive care and the early management, things like that diabetes and hypertension.
I mean, I think back to my residency, admitting a patient with advanced colon cancer, and just like, I'll never forget that patient that and whenever I'm talking to patients about colon cancer screening and why it's so important, it's from that hospital experience that I had with seeing a patient that basically was going to die from colon cancer because she had never had screening for whatever
reason. So I think, you know, when you see those consequences of things that can be prevented, you realize that it's just so important that patients get those opportunities and that's what happens in primary care. It doesn't happen if you're popping into an urgent care or a minute clinic or going to the ER when you've had you know, have a
catastrophic situation. And in fact, one of the things that that someone posted on Facebook that I really liked so much it was an ER doctor and he was talking about how much he respects primary care doctors because He says he can tell the quality of the primary care doctor based on when the patients come into the emergency room. Like he says, The good doctors basically if their patients come in, it's because it was something that absolutely could not have been avoided.
They're not just sending patients willy nilly to the
emergency room. And what he wrote was, 'this is a big contrast opposed to the new nurse practitioner who sends patients to him in the ER, without having even asked the right questions or started the evaluation.' And he says that, 'no offense folks, but for the past few years, the average standalone practice full practice authority nurse practitioner referral to the emergency room is based almost exclusively on lack of knowledge by brand new nurse practitioners whose schooling and personal
commitment to knowledge did not prepare them to avoid unnecessary ER and specialist referrals to their patients.' Meghan, did you experience any of those types of referrals when you were working in the ER?
oh my god, absolutely. And I can only speak from my own experience, but it's so bad out there that whoever posted that is spot on, right, like we know who the good primary care doctors are. And we know you know who the with the primary care doctors are, and they are our primary care doctors out again, I was in the military system. So pretty close system knew most of the PCPs.
But you know, there were folks that would dump the same patients every afternoon at you know, three, four o'clock on the emergency room just just lazy and the patients are poorly managed and they don't make take any initiative at follow up, you know, and then there were the patient that the PCPs were you know, we'd see one of their patients once every couple of
years. And they always called ahead and did you know really good closed loop communication and I've got I'll give those doctors whatever they want on a silver platter when they're in the emergency room, because I know they work really hard to keep their patients out of the ER, but it was so bad with particularly the nurse practitioners less so with the PA is that I don't even care what they say when they call the emergency room, like their reports are so unreliable that
once I realize it's an NP on the phone, I just want them to send their patient to me, like I don't even care what it is because I would just rather start over then take the word of, you know, one of these more poorly trained nurse practitioners, I have lots of conversations about this sort of thing, actually in the ER because, you know, my activism in this realm is I don't keep it
a secret. And I was lucky enough to work with actually a couple of excellent PAs and one particularly excellent, old school brick and mortar nurse practitioner, and even she was just completely appalled with some of the things that these these new grad NPs would send to the emergency department.
Well, you know, just speak to your point of just not being able to trust what you're hearing. You know, we I think about the case of Alexis Ochoa, who we wrote about in our book, The patient was had a serious pulmonary embolism, the nurse practitioner failed to note that Instead, she assumed the patient was using drugs because of a false report. And so she called a consulting cardiologist, and she told the cardiologist some of the patient's symptoms, but left out almost all of the important
information. So the consultant was giving her advice, but based only upon partial information and so not able to finally actually he did figure it out even just based on this limited information that the nurse practitioner gave, but it's so important to be able to trust the people that are giving you a report otherwise, you just sort of have to just do it all
yourself. Yeah, you know, it's it's more than anecdotal to and I want to talk about why you know, primary care when it's done, right, it reduces mortality, but primary care and any medical care when it's done wrong, it increases mortality. And this is really important, because we always hear that we need to allow full practice authority because patients need
access. But my counter argument is that studies show that just access to care that is not high quality, it actually kills more people across the world, then just plain lack of access. In fact, they say this Lancet study said, 5 million people die worldwide due to poor quality care. In other words, they get the wrong diagnosis, the wrong treatment, the wrong medication that causes them to die, versus 3.6 million people that die because of lack of access to
care. And the authors of this study said we cannot just send in just anybody to offer care. It has to be highly trained professionals. So what do you think when you hear about that, Emily, you did you see that study?
I haven't seen that study. But that makes really good sense to me, because if somebody let's say they're out in a rural area, and there are no doctors in that town, and let you know, maybe no clinic, no hospital, nothing, but if they have a severe enough medical issue, they are going to get themselves to the nearest
city and see a doctor. But if you suddenly set up a little clinic there with an online trained nurse practitioner, now those people think that they're getting care, they don't know any better and so they're going to see this person and They're getting the wrong diagnosis, the wrong treatment. And so now they're now they're not just suffering from their illness, now they're suffering from the effects of the wrong treatment
as well. And their care, their true care for the actual conditions that they have is going to be delayed. Whereas if there was nobody in that town, they would have at least had the opportunity to see a physician.
And that's exactly what happened with Betty Wattenbarger who died at seven years old, when the nurse practitioner at the urgent care she visited, told her parents just take her home, she's fine. They thought they were being seen by a physician, and that his dad told me if he had known it was a nurse practitioner, he said, you know, his daughter looked really bad to him. But because he had gotten that advice, and he said, Well, you know, I don't want to take her to the ER, if I was told she's
okay. And if he had known that things might have been different, or if we didn't have these urgent cares on every corner, staffed by nurses, you know, maybe when your child looks really, really sick, you take her to the emergency room and work she's hopefully seen by a physician. And it's interesting that you haven't read the article, because what you've just said, is exactly what the expert said. They said, they're popping up all these
little rural clinics. And what's happening is the patients are going to those places, but they're not getting the right diagnosis and the right care. And so they recommend, just like ending that, and instead, transporting patients to the big city to the hospitals, it's a little more inconvenient for the patient. But in the long run, it's way more convenient, because the patient's going to get the right diagnosis and treatment and potentially not
die. So you know, despite knowing this, what we hear is that nurse practitioners and advocates often argue that they can do the same thing and all the extra training for that doctors go through like what's the point we really don't need that. And that same doctor that ER doctor, one of the things he wrote on Facebook that I loved, he said that he blames the poorly regulated profit above all educational system for nurse
practitioners. And he says that 'these nurse practitioner students are being brainwashed, they're being told that they can come out and practice at a high quality, and that they will be quote better than a doctor coming straight out of nurse practitioner school.' And they're, you know, attending these diploma mills, of course, they think that they know what they're doing, and they don't. And so here's the question, does
the training really matter? And it's, it's kind of like, is the onus really on us to say, yes, more training matters? Shouldn't it be, no, you can get away with less training? Well, here's a study that I thought was very interesting. It was published by the British Medical Journal just this year in 2021. And it was called association between primary care physician diagnostic knowledge and death, hospitalization and emergency department visits after an
outpatient visit. And what they did was they took doctors and they rank them based on their score of how much they knew basically, on their exam scores. And they found this is going to
the more the doctor knew, the better the patients did. I know it sounds absolutely crazy. But sure enough, the doctors that were in the top versus the bottom third, and diagnostic knowledge was associated with much less diagnostic errors. So if this is true for physicians, how can it not be true for someone that gets just a fraction of the training? Megan, what do you think when you hear about that?
I think it's obvious. I think probably the the worst place for somebody with minimal training is in any of the sort of generalist lanes, right? Like, what emergency medicine and general practice both sort of have in common is, you know, our patients come to us completely undifferentiated.
And if you don't have sort of that, that ability to start with sort of a comprehensive unbiased history and physical and develop that broad differential diagnosis, there's a high likelihood that you're going to miss something and you're going to inappropriately pigeonhole that patient down one path of care without regard for what the what the actual issue issue may
be. Furthermore, I think once a patient is referred in there, and they're pigeonholed if the person who's actually seeing them in specialty, so I guess I'm trying to phrase I'm trying to say, okay, even even our specialists have completed a broad base of training because they've all been through medical
school, right? So you know, in my head, I kind of have this pipe dream where specialists start to conceive of themselves not just as I'm a specialist in whatever but but I'm a physician who also specializes in you know, this, that or the other thing, because our esteemed physician colleagues in these specialties still recognize when something doesn't fit their
little lane, right? Like you send somebody to a cardiologist and they're like, you know, I'm not quite sure what this is, but I know that it doesn't fit my lien, and they know enough to then take what was perhaps mistakenly made into a narrow differential and re broaden it again and sort of bring back in the general store refer to other specialists, I think you just don't see that, that flexibility of thinking with folks that don't have that strong general practice, or medical school
basis of their their education and experience.
I think you hit the nail on the head when you use the term undifferentiated. And this is such an important point in that all of the studies ever done evaluating nurse practitioners, and physician assistants. First of all, they've all been done involving physician supervision or following physician protocols. They always exclude high risk patients. But the most important thing is they pretty much never evaluate undifferentiated patients, they always have patients with a
defined problem. Here's a patient with diabetes, let's see how you do taking care of the diabetes. Here's a patient with high blood pressure. And by the way, we're not talking about the usual primary care, which is diabetes, hypertension, high cholesterol, depression, anxiety, you know, etc, etc, etc. They're looking at very targeted, very focused problems.
And the undifferentiated situation is what really is the point of all of the extensive medical school and residency and critical thinking skills that we have to learn.
I think that's a really good point. And in fact, I'm seeing this with
Dr. Galer. And the fact that he can do direct primary care, nd I would be more than happy o have her as my own direct rimary care physician, not only ecause she'd be great in an mergency, but also because I now that she has that that road fund of knowledge, and hat she knows how to find the nswers to the questions for hings that she does not know, he would also know when omething is too much for her nd when she needs to refer out. o I would absolutely trust her
n that. And I have that same rust for all physicians across pecialties, that they went hrough the same kind of raining in medical school that did, they went through the ame type of basic internship hat I did, and that they have xtra knowledge that I don't ave, but that they're going to e able to differentiate between hat they know and what they
on't know. And to make sure hat if it's something that they on't know that they get that nswer, whether they're going to ook that up or whether they're oing to consult with another hysician, I don't have that ame trust. If I in fact, I orry when I send a patient to he emergency room, are they ven going to see a physician here? I worry if one of my atients is in the hospital? Are hey going to go days without eeing a physician while they're ospitalized? If I refer a atient that I've already done
n extensive workup on? Are they oing to see a physician, when hey when they go to that pecialist office? Are they oing to have a completely asted visit? Oh, it's really rustrating.
You know, it's interesting when you say that it makes me think about I was talking to my friend who's a financial advisor, and he was explaining to me about how he doesn't trust most financial advisors and on and on. And I said, 'Really?', and he goes, 'W ll, let me put it this to you
his way. If you're in a room wi h a whole bunch of doctors that are all different specialties, are you just going to trust an of them?' And I said, 'Yes, of ourse I would.' And he said 'O ,' and I said 'because we al have the same standard trainin and some might be a little bett r and you know, than others. ome are a little more fine sed than others. But I trust th m' and he said, 'Oh, wow.' He sa d 'because I don't trust a single other financial advisor.' And I thought that was reall
Well, first of all, Emily, thank you, that's a
huge compliment. But I absolutely share the sentiment, you know, there's this certain sort of baseline level of training that that you know, other physicians have that you can trust and sort of rest assured when you refer patients, unfortunately, you know, working in in the town that I work at and, and having you know a little bit of familiarity with how there's only really like two big emergency rooms in this town of about 200,000 people and I know that most of them are
somewhat overrun with with mid levels. Very second day I was open I was sort of forced into an epiphany because I had a patient so I opened my practice on June 1 on June 2, I had a 64 year old patient come in to see me her Medicare just kicked in on June 1 and she was basically explained to me all the symptoms of what was obviously a big stroke that she had on May 15.
Complete with right upper extremity weakness right lower extremity weakness, to the extent that she actually was using her dead husband's Walker at work for a couple of weeks but was just despairing because she didn't have coverage and knew it would be way too expensive to go to the emergency
room. So here I am seeing her two weeks after the fact she's definitely outside of the acute treatment windows she qualifies for like a subacute CVA at this point, and I've got my work cut out for me because her blood pressure is like 220 over 110 she hasn't seen a doctor in 20
years. I know she needs imaging but I'm I was basically left with the decision between do I send this patient to the emergency room knowing that there's a very big chance not being acute that she won't a tually see an emergency p ysician versus keeping her my l ttle clinic where I can do m nitoring where I can draw her b ood where I can get her, you k ow, imaging within 24 hours. B t it raises an interesting q estion, right? Like, what's t e most valuable resource? In w
ich situation? Do you need a n n physician in a real ER? Or a e you better off with a real E doctor in a not real ER, and i her case, we talked about we d d some shared decision making a d she said, No, I want to s ick with you. And we were able t get her an MRI the next day a d confirm exactly what we t ought and get her started on d al antiplatelet and lipid l wering agents and started w rking on getting your blood p essure under control. And it w s a lot for day two of being o
en in my DPC practice. And I'm s re I will have to continue to t ke these on a case by case b sis. But it's really i teresting that we are and s mewhat shameful that we're at t e point in this frickin c rporate medicine quagmire w ere that's a legitimate q estion that has to be asked, A e you better off in a real ER w th a fake doctor or with a r al doctor in a fake ER?
Wow, that is so profound. And it's what you have said really just blew my mind because you're so right. And what I love about I do direct primary care as well is the fact that you do have the time for that shared decision making. Think about how much money you save that patient, now she had Medicare, she had no insurance you it would have been out of her pocket, but you save the healthcare system money by being able to keep her out of
the ER. And it sounds like you were able to give her just the highest quality of care, and then follow up with her to make sure she doesn't have another stroke in the future. So what a great story, thank you so much. You know, another big aspect of this is the fact that primary care, as important as it is, is undervalued and under rewarded in our current healthcare system. And I think that's probably why the three of us have chosen the direct primary
care route. And I'd love to bring you back to talk about that, because I do think that that is probably the way for most primary care physicians to really provide the type of care that they want to do, and it's the right way for patients. So I'd love to bring you back for that. Unfortunately, we're out of time for tonight. And so I want to thank my guest, Dr. Emily O'Rourke and Dr. Megan Gaylor, thank you so much for
joining me. If you'd like to learn more about this topic, I would love for you to get my book that I co wrote with Dr. Niran Al-Agba. It's called 'pat ents at risk the rise of the nur e practitioner and physician ass stant in healthcare.' It's av ilable@amazon.com and at Ba nes and Noble calm, and pl ase subscribe to our podcasts an our YouTube channel. It's ca
led patients at risk. And if yo 're a physician, we would lo e for you to join our group th t advocates for physician led ca e and truth and transparency am ng healthcare practitioners we e called physicians for pa ient protection. You can find us at our website physicians for pa ient protection.org Thanks so mu h and we'll see you on the ne t podcast.