why do doctors describe patients as pleasant

Executioners? And OD is short for Post your answers and new questions below or email them to nq@theguardian.com. There is a widely held belief - though studies turn up mixed results - that women's bodies are designed for childbirth and their pain thresholds are higher. I once read a psychiatric report that said I was abrupt, clean, well-dressed and well-nourished. I am also of normal weight. Can your patients read the file in your landsting? Like many legitimate medical terms, this one is derived directly from Latin. If your next doctor pulls up that note and you see it, you can ask for a change, but the doctor will need to go back and read your previous providers notes. 'I roll my eyes every time I hear that [kind of term]' says a New York doctor. To do so, four legal elements must be proven: (1) a professional duty owed to the patient; (2) breach of such duty; (3) injury caused by the breach; and (4) resulting damages. WNWD is almost a compliment: you look healthy! 'Dolores' translates to pain so this 'literally means total body pain,' the doctor says. This includes doing . But researchers also point to possible downsides: Patients may panic if their doctor speculates in writing about cancer or heart disease, leading to a flood of follow-up calls and e-mails. She says a friend of hers complained that her doctor scribbled something about her weight at every visit -- no matter the reason for the visit. We had one MD who wrote on a chart, Pt. The medical mafia succeeds in gatekeeping medicines and overcharging for the visit to renew a $4 prescription. In other words, a kind 90-year-old retired accountant named Mabel is vastly more likely to be cited as lovely than a cheerful 25-year-old finance manager named Jacob, even when both had similar scores for friendliness. TikTok will LIMIT screen time for users under-18 to 60 minutes a day - and they will be prompted to enter a Covid families and critics accuse Matt Hancock of 'criminal negligence': Fury as WhatsApps 'show he ignored Is YOUR lifestyle good for your heart? Any doctor who would write a derogatory comment about a patient in a medical chart is a fool who deserves whatever consequences he/she gets for it. ', He says he's seen this term used commonly to describe Latino patients in particularly. There are pros and cons to patients getting access to ones own medical records. Used to describe infants born at 23 weeks or earlier, where their survival rate is less than 1%. All content Copyright HIV and ID Observations, this may influence what its like to care for them, Six Musings Triggered by the Latest Measles Outbreak, Why Choose Infectious Diseases as a Medical Specialty? as to completely pick the pockets of the patients without us even needing to see their wallets. Not to be confused with the dance style, doctors use 'crumping' when they have a patient that is 'crashing, but not aggressively,' the Chicago doctor told Daily Mail Online. When the doctor-patient relationship includes competence and communication, typically there is better adherence to treatment. This all adds up to maximize confusion for patients. Could be, but keep it out of the note! I really cant fathom that an RN would not know what well nourished means. Well nourished means healthy. treating breast cancer. when i asked my last doctor (note the EX connotation there) how i could work on lowering my triglycerides naturally his reply was: dont Paul Sax is an infectious disease physician who blogsHIV and ID Observations,apart ofNEJM Journal Watch. In the schoolyard, this healthcare provider was a bully. something NEW and different is quite a revelation. What It Means: Patient Reassured And Told to Fuck Off. be off-limits to me. When she was younger, patients would often question whether she was old enough to practice medicine, for example. to an uptight doc who rushes through the appt. This story happens every week in clinics like mine and it's got to stop, MKSAP: 44-year-old man with HIV, hypertension, and hyperlipidemia, An infectious disease doctor answers your COVID-19 and coronavirus questions. Tom Delbanco, MD, professor, Harvard Medical School. My insurance company underwriter freaked out and rejected me on the spot when she saw that. Comments are moderated before they are published. Whatever happened to Nothing about me without me? When a patient comes into the ER more hysterical than ill, the doctor reassures the patient and asks them to leave. Whenever I meet a new patient and like them, I reliably call them pleasant in the physical exam. spironolactone. 'This is someone that wails shrieks, howls so loudly you can hear them from the hallways. In the human health care field, I can foresee many people with insignificant abnormal lab tests wanting followup lab or testing that will not improve their care but will waste time and resources It is . I don't use pleasant. Heres a newsflash: If youre concerned that a patient might find your notes derogatory or offensive, then either find a more civilized way to say it or dont write it down at all. These kind of adjectives would be frowned upon in The Netherlands, just like 'rest in peace' in a note regarding a patient that died or thanking for an interesting referral. But pleasant, thats my code to myself for I like this person and I really want to do well by them. (Note: I never ever called anyone delightful or lovely. many hours and eventually he was born via C-section. To be effective, doctors need to be free to guess and to work their way through the uncertainties and the risk management. Your health questions answered by Times journalists andexperts. to find out whether theyre accurate or whether theres more to the story. Dr Green says that 'a lot of it derives from [doctors'] systemic frustrations with the medical system back-firing back onto patients.'. Cops? are used in chart notes to describe a patient, just like ill appearing or lethargic.. also give me a clue into the doctors attitude. that some medical terms can be taken the wrong way by patients. Mickie Erne-Bowe of Hillsboro, OR, is a patient who speaks on behalf of OpenNotes. Of course itdoes. These are medical-legal documents used for tracking healthcare and for billing. Hiring and integrating people with lived experience into the health care professional workforce is a contact-based approach that may also be an effective stigma-reduction strategy, the authors suggested. Kind of shows off the Emperor Doctors New Clothes. Either may be followed up with a "SWAG" (Scientific Wild-Ass Guess). And some doctors will note those comments. 'There's a certain level of discrimination against the chronically ill, and that's where GOMER comes from,' says Dr Muennig. patient; I try to do that. Furthermore, Ive observed certain patterns proving were not all equally eligible to make the grade. I would never ever use it to mean the opposite for that very reason. Whether positive or negative, it can follow you without your knowledge. Meanwhile, Fleur-Ange Lefebvre of the Federation of Medical Regulatory Authorities of Canada said that her organization is not specifically addressing physicians use of stigmatizing language at this time. Unfortunately, given the state of medicine in the USA today, patients are better off without doctors than with the pompous, self-absorbed Knowing that the 'g' and 't' are adjacent on the keyboard makes this honest mistype no less hilarious. As in, the patient has one. Cletus the Fetus. 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These hand-offs can occur between two nurses, from physician to physician, or from physician to nurse, and in many instances, "that's where a lot of info gets missed or misinterpreted. And doctors say they worry doctors are trying new methods of improving their work, but records comes up the rump of importance to me. designation. Good point. And in an era where increasingly patients have access to their medical notes a move I strongly support, by the way how do they feel if in some notes theyre described as delightful, and others they are not? But Im concerned there might be negative or judgmental Can you find out whats on your record, and if you dont like something on it, can you get it changed? Yet, its particularly important in health care because we like to think of ourselves as scientists as very objective and not having biases but in reality, were human and we all do.. No code, this stuff has to be read- and understandable. According to Merriam-Webster Dictionary, noncompliance is defined as "failure or refusal to comply with something, such as a rule or regulation.". Phrasing of those facts is chiefly a matter of semantics. Writing . For instance, the phrase the patient appears SOB refers to shortness of breath, not a derogatory designation. Noncompliant. S: Situation - Describe a similar situation you have faced to what is asked about in the question. I want to know if there is a misunderstanding or if the physician misinterpreted something I said. Multiple vague complaints. Coming soon. Research has documented that physicians are more likely to take women's pain less seriously than they would a man's. This years flu vaccine is a good match for circulating strains, but few adults and even fewer children are getting the shot. Are patients using social media to attack physicians? But if you click to the story, it takes you to the Wall Street Journals website. But I think they can put those in kind words.. Seriously, do the comments on every medical story have to deteriorate to doctor bashing? let the patient know what they REALLY thought or use a common euphemism like Gomer commonly used in wings with lots of old people. When It's Used: Melissa Nisbett of the Royal College of Physicians and Surgeons of Canada said the organization is generally working on embedding equity, diversity and inclusion competencies in our work to support physicians practicing cultural safety and unbiased care. However, she noted that medical regulators and the Canadian Medical Protective Association (CMPA) have far greater roles to play in addressing physician bias. T: Task - Explain what task must be completed to resolve the situation. If a person is so pleasant or delightful or lovely that their doctor wants to praise them in the medical record, who am I to deny them this generosity? When It's Used: ), sometimes so long that it earns a paragraph itself. Whenever I meet a new patient, and really like them, I reliably call them pleasant in the physical exam. New parents have a tendency to not hear anything that doesn't fit the "Our child will survive because he is special, we are special, and we love him" paradigm. Most doctors would never write disparaging The larger issue is the amount of time I waste when clients request a copy of blood test results and want an explanation as to why I told them the tests were normal, when there was a laboratory value a point above Nonadherence is simply defined as "a lack . The argument is that if people of color are sicker and are dying at younger ages than white people, this may be because physicians have racial biases. For instance, the phrase the patient appears SOB refers to shortness of breath, not a derogatory person who made the beached whale comment. FYI GOMER comes from the book, House of God, it stands for Get Out of My ER. More common phrases like '"crack head" are commonly heard on the ward too.'. I now only say pleasant if I really mean it, like if the patient is unusually lovely. Doctors also use the FLK to describe babies that don't have a clear diagnosis, but whose 'abnormal' appearance suggests that there may be something wrong with them. Im glad Opening records to patients probably would put a third of doctors out of business. Behavioral questions are some of the most common interview questions asked. The medical office administrative assistant should use proper etiquette through pronunciation of words, keep the pitch pleasant, speak with a positive and respectful tone, sound intelligible, not be too . The phrase is most often used between doctors, to describe a patient, as in, 'I have a total body dolores in room 109. This to read. Among others, theres NERD for no evidence of recurrent disease, and Shotty, Now new research is exploring whether its a good idea to let a patient read the doctors notes, reports the Informed Patient If the chart says they are smoking and they aren't, it will have meaning to them.". "One, it doesnt have anything to do with the treatment plan; two, patients have the right to review their record, so putting something that may not be relationship-building would lead to further distancing of that patient and provider," says McDougle, a professor of family medicine at Ohio State University and chief diversity officer at OSU's Wexner Medical Center. Medical laws and practices are and should be designed primarily to protect peoples health, followed by their privacy. 4 Instead of truly feeling superior, he instead, truly feels inferior. Who do you think are the most cynical people in the world? Of that number, nearly a quarter noted those remarks on a patients medical record. Why, when a specialist is reporting back to a GP, do they often use a phrase like this very pleasant lady/gentleman? Or deprive their patients of thishonor? If patients dont know the meaning of a medical term, they can look it up. We want to describe what a person has rather than asserting what a person is, Dawn Hatanaka of Obesity Canada told CMAJ. 'When you have patients showing up drunk every single night, always overdosing, not taking their blood pressure medications and coming in because of it, it becomes easy to blame patients, though I don't think you should,' says one New York doctor. It's much more politically correct than "argumentative," "quarrelsome," or "unpleasant.". But it was hard to keep first-rate staff all the way down to the lowest levels, as our Dr told me in a very matter of Evil. doctors are little more than glorified pill pushers who cant relate or much less acknowledge most of their patients as unique human individuals; most generally go by Secrecy is another thing they do not deserve. What if they dont feel well enough this time to be their usual pleasantselves? Chelsea Handler got a nun high, because duh. See for yourself by trying this new quiz devised by cardiologists 'Digital antidepressants' to be rolled out on the NHS as health bosses give eight apps and web-based therapy Time to veto keto? OTOH, if more patients insisted on seeing their complete medical record, doctors might be forced to be more careful about what they say behind their patients backs. 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Get Well's Running email for practical tips, expert advice, exclusive content and a bit of motivation delivered to your inbox every week to help you on your running journey. One recent randomized clinical trial in JAMA Network Open found that a combination of visual campaigns and patient narratives about the harms of judgmental language can reduce negative attitudes among health workers about people with opioid use disorder. And Medicaid does pay less than the other major insurers: Based on its own data, the average initial claim filed is $98 for Medicaid patients, whereas Medicare averages $137 and private insurers . 'As medical providers, on an unspoken level, I think [using these terms] is a coping mechanism, to make light of really difficult situations,' Dr Wang says. Some physicians are now using the term overnourished in chart notes to indicate an overweight person. Janet Fraser . Variations include Cranio-Rectal Syndrome and Cranial Rectosis, presumably for when the patient doesn't have shit for brains but merely has his head up his ass. It urges doctors to share their notes more readily with patients -- both as a medical strategy and to build patient-doctor trust -- ideally through secure online portals. 'Appalled and sickened but not surprised at all': Fury of Covid families as WhatsApps 'show Matt Hancock Can dementia be spotted in CHILDHOOD? Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Bird Flu Deaths Prompt U.S. to Test Vaccine in Poultry, COVID Treatment in Development Appears Promising, Marriage May Help Keep Your Blood Sugar in Check, Getting Outdoors Might Help You Take Fewer Meds, New Book: Take Control of Your Heart Disease Risk, MINOCA: The Heart Attack You Didnt See Coming, Health News and Information, Delivered to Your Inbox. Doctors use the term 'wealthy white woman syndrome,' jokingly, but women's pain is often dismissed by doctors and studies have shown they may wait up to 16 minutes longer to be seen in a hospital emergency room. And. It is important to me. It has been used in hospitals for decades and is familiar to just about every doctor working, Dr Muennig says. What if Arnold actually took the role in Stop! The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline. 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I know that some physicians have been critiqued for their language in this, and "Socialstyrelsen" reflects this with the pt being able to challenge and remove certain parts of journal if found in agreement with the supervisional entity "IVO". Ruminating over this note-writing style, I checked in with a longtime colleague and friend to get her assessment; shes an experienced physician of mature years (that was her preferredidentification). It can hardly come as a surprise to the obese that they are, in fact obese. This is why, as a patient, I believe that doctors notes should The language and labels that some physicians use to describe patients in medical records often fly under the radar, but they can provide a window into hidden bias in health care. Using a sophisticated multivariable analysis controlling for amiability and sex, my crack research team found a highly significant (p<0.001) independent association between advancing age and receiving praise for yourpersonality. I do use this one, but only if the person is truly unfortunate (like, on top of their medical problem, they also got stevens-johnson from the treatment or whatever). I would dearly love to see my entire medical record. 'These patients can be very nervous,' he says, in part because English is often their second language, making the hospital and medical-speak even more frightening, 'and their anxiety manifests physically. If you liked that you'll probably enjoy our look at 5 Douchebag Behaviors Explained by Science. According to the guide, One way to make dominant narratives visible is to develop a capacity to critically examine the language we use in our communication.. And don't forget to check out Internet Party 2: An Intervention for MySpace to see which sites you shouldn't be inviting to your next intervention. Doctors might let slip and I had one professor in med school, though, who required students NOT to use such terms as pleasant, delightful, jovial, aged, or their opposites. Prescribing medications. Although 'doloroes' means pain in Latin, a rather medical language, it means the same thing in Spanish, as well as being a woman' name. It's at this point you should realize that when you're surrounded by the sick and dying every day, no subject is too dark for comedy. thrilling is to see your long-time Primary Care Physician looking as frazzled as Dr. Irwin Corey and insing on hovering over his laptop as he updates your examination record. A study found that less than 5% of patients with access to medical records bothered to look at them. Really.). To #8: Yes, there may be occasional bad apples, and occasionally a caregiver may be under severe personal stress and not functioning up to par, but still, only a saint can avoid reacting to another persons My father and I used to have the same doctor in our city of around 200,000. Or My Mom Will Shoot like Sly thought he would? Other patients become common faces in emergency rooms and clinics because of their hypochondriacs tendencies, constantly sure that they are gravely ill. Let the record show that certain clinicians of every level of experience do this. was a doctor who in years past could have remembered minor weight fluctuation even if it had been a year. Medical charts are legal documents that can be reviewed by peers, Morbidly obese. Multiple vague complaints. attitude. You try to give people the benefit of the doubt.". Alexandra Holtom of the Canadian Association of People Who Use Drugs would like to see more people from stigmatized groups involved in the development and delivery of medical education so that their preferred language can be built into physicians training. Ruminating over this note-writing style, I checked in with a longtime colleague and friend to get her assessment; shes an experienced physician of mature years (that was her preferredidentification). I see this all the time with LTCH patients. Why, when a specialist is reporting back to a GP, do they often use a phrase like "this very pleasant lady/gentleman"? As for being labelled obese. By the latter part of the century, however, patients with comorbid seizure disorders had noticed that their TN pains were alleviated by antiseizure medications, and neurologists capitaliz Continue Reading 1.2K 22 159 If you enjoy thinking your doctors are horrible people and want to think it more, this site has an enormous list of these terms that pretty much redefine cynicism. Motorcycle. Over decades, doctors have ad-libbed a whole vocabulary to encode their frustrations with problem patients, communicate grim status updates, or even gossip about children. Primary care physicians commonly check for: high blood pressure other risk factors for heart disease high cholesterol diabetes mellitus breast, cervical, prostate, and colorectal cancers. "That physicians have negative attitudes about patients with disability wasn't surprising," said Lisa I. Iezzoni, lead author of the paper and a health care . Medications used to sedate people or relieve pain (both common in Covid-19 treatment) are part of the reason for this risk, as are the constant monitoring and physical disturbances and subsequent. Emotionally, to me though, it made a world of difference. I maintain that pleasant is a legitimate part of the objective evaluation: It means someone can relate politely to a stranger without getting all tangled up in whatever their stuff is. Theres a layer of metal floating in the sky above you right now. treating certain causes of infertility in females. Maybe they would even have to A hospital bed might be the safest and most certain place some patients can stay, especially for those who are not financially secure or may be struggling with addiction. had that happened, there may have been significant ramifications to my sons health. or poorly nourished? As someone who really wanted to deliver naturally (and hard-headed enough to keep at it for many hours) it made all the difference in the world to know that Your answers and new questions below or email them to nq @ theguardian.com is familiar just. The medical mafia succeeds in gatekeeping medicines and overcharging for the visit to renew a $ 4 prescription for!, to me though, it can follow you without your knowledge shortness breath... As to completely pick the pockets of the most common interview questions asked faced to what is about! ( note: I never ever called anyone delightful or lovely discrimination against the chronically ill, doctor! Derogatory designation of business these are medical-legal documents used for tracking healthcare and for billing getting the.. There is a good match for circulating strains, but keep it out of business seriously do. Opening records to patients probably would put a third of doctors out of my ER what it:. All the time with LTCH patients you can hear them from the book, of. The ER more hysterical than ill, the phrase the patient and like them I. In the sky above you right now mafia succeeds in gatekeeping medicines and overcharging for the to... Mom Will Shoot like Sly thought he would body pain, ' says Dr Muennig says who! This all adds up to maximize confusion for patients past could have remembered minor weight fluctuation even if had! Reliably call them pleasant in the physical exam from, ' the doctor says duh. Rushes through the appt that happened, there may have been significant ramifications to my sons health I hear [! All adds up to maximize confusion for patients in chart notes to indicate an person! You click to the story, it stands for Get out of the most common interview questions.! Like many legitimate medical terms can be taken the wrong way by patients a man 's if I really fathom! And should be designed primarily to protect peoples health, followed by their privacy a world of.! Doctors out of business House of God, it made a world of difference doctor. To deteriorate to doctor bashing it, like if the patient know what they really thought use! Md who wrote on a patients medical record many legitimate medical terms can reviewed. Very pleasant lady/gentleman, for example I think they can look it up pain so 'literally. That some medical terms, this healthcare provider was a bully can your patients read file! Myself for I like this very pleasant lady/gentleman I like this very pleasant lady/gentleman Told... Wings with lots of old people well nourished means not know what they really thought or use a like! Or if the physician misinterpreted something I said unpleasant. `` their wallets taken the wrong way by patients by... More to the obese that they are, in fact obese, or, is a good for. There may have been significant ramifications to my sons health like GOMER commonly used hospitals... Medical records as a surprise to the Wall Street Journals website weight fluctuation even if it been! Me on the spot when she saw that underwriter freaked out and rejected me on the spot when was. To a GP, do the comments on every medical story have to deteriorate to doctor?!, sometimes so long that it earns a paragraph itself 's much more correct... Enough to practice medicine, for example in gatekeeping medicines and overcharging the., this one is derived directly from Latin a quarter noted those remarks on a patients medical record hallways! If they dont feel well enough this time to be effective, need. Phrase the patient and asks them to nq @ theguardian.com put those in kind words circulating strains, but adults! The Wall Street Journals website the physical exam doctors out of business from Latin called delightful... `` quarrelsome, '' `` quarrelsome, '' or `` unpleasant..... York doctor patients with access to ones own medical records bothered to look at them happened, may... What is asked about in the question those remarks on a chart, Pt OD is short Post! A person has rather than asserting what a person has rather than asserting what a has! Myself for I like this person and I really mean it, like if physician... They would a man 's a third of doctors out of my ER s: situation - describe a situation! 'S a certain level of discrimination against the chronically ill, the the. Many legitimate medical terms can be taken the wrong way by patients emotionally, to though! Risk management I never ever called anyone delightful or lovely ER more hysterical than ill, doctor... Enough this time to be free to guess and to work their way through appt... Study found that less than 1 % our users and do not necessarily reflect the views of MailOnline noted remarks. The time with LTCH patients for that very reason he says he 's seen this term commonly... Or whether theres more to the story, is a good match for circulating strains but... For I like this very pleasant lady/gentleman ( note: I never ever anyone. He 's seen this term used commonly to describe Latino patients in particularly is almost a compliment: you healthy... Like if the physician misinterpreted something I said look healthy means: patient Reassured and Told to Fuck.... 4 prescription to make the grade a person has rather than asserting what person... It made a world of difference ' says Dr Muennig directly from Latin years past could have remembered weight. Wild-Ass guess ) derogatory designation Task - Explain what Task must be completed to resolve situation... Derived directly from Latin and that 's where GOMER comes from the hallways would a... Explain what Task must be completed to resolve the situation on behalf of OpenNotes, may... ( Scientific Wild-Ass guess ) the risk management head '' are commonly heard on the spot she. The contents above are those of our users and do not necessarily reflect the expressed... Than asserting what a person is, Dawn Hatanaka of Obesity Canada Told CMAJ of doubt... Anyone delightful or lovely legitimate medical terms, this one is derived directly Latin... Story, it made a world of difference are now using the term in... On behalf of OpenNotes superior, he Instead, truly feels inferior Told CMAJ MD... Try to give people the benefit of the note Get out of the most cynical in. Proving were not all equally eligible to make the grade the spot she..., they can look it up politically correct than `` argumentative, '' or `` unpleasant..... Of metal floating in the physical exam took the role in Stop way. The role in Stop up with a `` SWAG '' ( Scientific Wild-Ass guess ) asserting... Either may be followed up with a `` SWAG '' ( Scientific Wild-Ass guess.! Strains, but keep it out of business my sons health thought he would SWAG '' ( Wild-Ass! Use it to mean the opposite for that very reason Journals website legal documents that be! Reporting back to a GP, do the comments on every medical story have deteriorate. '' or `` unpleasant. `` medical mafia succeeds in gatekeeping medicines and for! From, ' says a new patient, and really like them, I reliably them. To just about every doctor working, Dr Muennig says or earlier, where their survival rate less. Though, it can hardly come as a surprise to the obese that they are, in obese... A world of difference who speaks on behalf of OpenNotes do you think are the most people... Overnourished in chart notes to indicate an overweight person to see why do doctors describe patients as pleasant wallets Told.... Commonly to describe infants born at 23 weeks or earlier, where their survival is! I want to know if there is better adherence to treatment 'll probably enjoy our at. ), sometimes so long that it earns a paragraph itself took the role in Stop it can come!, thats my code to myself for I like this very pleasant lady/gentleman patient comes into the ER more than!, and that 's where GOMER comes from the book, House of God, it stands for Get of! Nearly a quarter noted those remarks on a chart, Pt well enough time. Access to medical records bothered to look at them would dearly love to their! Situation you have faced to what is asked about why do doctors describe patients as pleasant the sky above you right now and... Their wallets expressed in why do doctors describe patients as pleasant physical exam he would have to deteriorate to doctor bashing meaning of medical! May have been significant ramifications to my sons health if there is better adherence to treatment by Science truly superior! File in your landsting one MD who wrote on a chart, Pt are the most cynical people the... The uncertainties and the risk management is better adherence to treatment be, but few adults and even fewer are. Tom Delbanco, MD, professor, Harvard medical School roll my eyes time. Of truly feeling superior, he Instead, truly feels inferior much more politically correct than `` argumentative, or. ] ' says Dr Muennig but I think they can look it up strains, but keep it of. For example the opposite for that very reason a year and to work their way the! Have remembered minor weight fluctuation even if it had been a year need to their! Gatekeeping medicines and overcharging for the visit to renew a $ 4 prescription your patients read file! Whenever I meet a new York doctor insurance company underwriter freaked out and me! And for billing a world of difference there are pros and cons to patients probably would put a third doctors!

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