Re: patient centered care

[Guest guest]

“I receive exactly the care I want and need exactly when and how I want

and need it.”

The phrase seems to imply that we give up our professionalism so

patients get anything they want. In so doing we give up any

reasonable boundaries and limits, leading to an unsustainable work

life.

The phrase is “want AND need”

It is part of our work to articulate the gap between wants and needs when

it arises, and to help explain why some things patients want would be

things that they not only don’t need but may be contrary to their best

interest. [Antibiotics for viral infections, annual EKGs, executive

physicals all come to mind.]

We must also be aware that the pendulum has swung so far from what

patients want and need that we have a long way to go before we cross

lines.

The phrase might imply to some (“exactly when and how…”) that there will

be no boundaries. This is also not the case, but we have erected

such boundaries of “protection” around physicians that we have become

inaccessible. The result of these boundaries is to create

unnecessary demand, waits and delays that degrade patient outcomes, cost

us more in terms of work effort, and ultimately lead to a degraded

physician-patient relationship.

The way I give patients care “exactly when and how” is by being open

during normal business hours, giving patients access to excellent

information through handouts, web portals, after visit summaries, and by

making myself accessible 24/7. This last seemingly outrageous offer

has resulted in the most dramatic reduction in call volume and pressure

that I have ever experienced – an experience shared by many if not all

who take their own call.

I have boundaries and limits, but I have also made myself accessible in

ways that give patients what they want and need most of the time.

There are certainly times when I am not available and there are certainly

patients who want from me what I am unwilling to give. I strive for

ideal, but I will maintain balance and a sustainable work

environment.

Gordon

At 02:35 PM 9/17/2006, you wrote:

nice article.

i was struck by the underlying operator at the apex of the pyramid,

" i receive exactly the care i want and need exactly when and how i

want and need it " . as a matter of fact, i take issue with

it.

if the IMP chooses to deliver care to that standard, which i contend is

unrealistic and unprofessional, if not impossible, it is also a setup for

failure.

it begs the question what are the limits of one's training and

facilities? what are the limits of one's physical and emotional

capabilities? where is the practice of evidence-based

medicine? where are the professional standards by which we govern

ourselves?

if one provides services to a standard defined by the patient, one has

effectively transferred control of one's practice to the patient. any

business which does not clearly define what and how it performs it's

services, and leaves the definition of the services provided to the

consumer, is quite frankly foolish, not only in terms of expectations and

one's ability to meet them, but also from a risk management

standpoint. " i wanted and expected you to provide this for me,

and you didn't " .

those of us who are practicing a style of medicine which focusses on the

kernel of health care, the doctor-patient relationship, must maintain

appropriate boundaries, be clear about what we do and don't do, our

limitations, and of course, our obligation to educate and discuss our

patient's expectations, and whether they are reasonable.

i am concerned that we not revert to the " superdoctor " who

supposedly could do everything. we cannot right all the wrongs of

the current health care system, and make up for those doctors who don't

take the time with patients, to get to the bottom of their worries and

concerns.

" i receive exactly the care i want and need exactly when and how i

want and need it " is the basis of the boutique practice. i

suppose if we lived in utopia, or if one were a multibillionaire, we

might all have that. but would it still be appropriate?

many of us complain that we don't get compensated for the time and effort

in providing care management and telephone calls. many patients

don't want to be seen, just be provided a prescription over the

phone. now there's a patient expectation that fits right into

" i receive exactly the care i want and need exactly when and how i

want and need it " . is that good medical practice? is

that an appropriate standard of care? " i receive exactly the

care i want and need exactly when and how i want and need it " will

not solve this problem, only exacerbate it. even with

" membership fees " , it does not resolve patient expectations,

professional standards, nor address risk management.

i depend on my history-taking and physical examination skills to

determine what's medically appropriate and necessary for my patients, at

a time when i can bring those skills to bear, within the context of my

professional abilities and training, meeting professional standards.

i agree that patients receive the care they need when they need it,

however we must separate want from need. the IMP cannot be the

be-all, do-all, however we can educate patients on the difference between

the two. otherwise, want=need is a formula for disaster, which

ultimately will not help us or our patients.

we don't exist in a vacuum. we work in a health care system, which

implies that there are a number of different entities which provide for

patients-- ambulatory care, emergent/urgent care, hospitalization,

rehabilitation, and specialty consultation. to be sure, family

doctors, internists, pediatricians and other generalists play a key role

in helping patients navigate that maze. let us at the same time

clearly define our role, our abilities and limitations, our professional

standards, and our patient's expectations in a realistic fashion.

some patients believe that they get to come into the office and tell me

what to do, and have me sign off on what they want, merely because i have

the medical license, and they are the patient. we can all agree how

ridiculous that is. " i receive exactly the care i want and

need exactly when and how i want and need it " is merely that in

another form.

we've already given up control of the practice of medicine to insurance

companies. it is irresponsible to give up our professional

responsibilities and standards to patients, or anyone else.

certainly, to work collaboratively with patients, to improve access to

care, to meet standards of preventive care, to intervene aggressively in

chronic disease and to educate patients, are all critically important in

guiding patients toward a path of good health rather than just

maintaining a state of non-disease, or focussing on cure after the

fact. we can all do a better job, and an ounce of prevention these

days is worth far more than a pound of cure. we have better tools

available, especially in the form of electronic relational databases,

transfer of medical records and access to the internet, and evolving

research and guidelines for the maintenance of good health.

rather than define the doctor-patient relationship in a pyramid, with

patient expectation at the top of the hierarchy, i would define it as a

ven diagram, with overlapping areas of the doctor and patient,

professional standards and responsibility, evidence-based medicine, and

patient expectation. i believe that's a more realistic approach to

patient care.

LL

Stay in the know. Pulse on the new Yahoo.com.

Check it out.

[Guest guest]

thank you for the clarification. with that, i don't think there's any disagreement in what's been said. my concern is how others may interpret want vs need, and that it's not a swing of pendulum, rather a paradigm shift in the practice of medicine. certainly, when appropriately educated, and ideally, patients will come to equivalency between want and need. and i completely agree with you, that equivalency will only come through the development of our professional relationships with our patients. i still think a ven diagram is a better representation. LL "L. Gordon " wrote: “I receive exactly the care I want and need exactly when and how I want and need it.” The phrase seems to imply that we give up our professionalism so patients get anything they want. In so doing we give up any reasonable boundaries and limits, leading to an unsustainable work life. The phrase is “want AND need” It is part of our work to articulate the gap between wants and needs when it arises, and to help explain why some things patients want would be things that they not only don’t need but may be contrary to their best interest. [Antibiotics for viral infections, annual EKGs, executive physicals all come to mind.] We must also be aware that the pendulum has swung so far from what patients want and need

that we have a long way to go before we cross lines. The phrase might imply to some (“exactly when and how…”) that there will be no boundaries. This is also not the case, but we have erected such boundaries of “protection” around physicians that we have become inaccessible. The result of these boundaries is to create unnecessary demand, waits and delays that degrade patient outcomes, cost us more in terms of work effort, and ultimately lead to a degraded physician-patient relationship. The way I give patients care “exactly when and how” is by being open during normal business hours, giving patients access to excellent information through handouts, web portals, after visit summaries, and by making myself accessible 24/7. This last seemingly outrageous offer has resulted in the most dramatic reduction in call volume and pressure that I have ever experienced – an experience shared by many if not all who take their own

call. I have boundaries and limits, but I have also made myself accessible in ways that give patients what they want and need most of the time. There are certainly times when I am not available and there are certainly patients who want from me what I am unwilling to give. I strive for ideal, but I will maintain balance and a sustainable work environment.GordonAt 02:35 PM 9/17/2006, you wrote: nice article.i was struck by the underlying operator at the apex of the pyramid, "i receive exactly the care i want and need exactly when and how i want and need it". as a matter of fact, i take issue with it.if the IMP chooses to deliver care to that standard, which i contend is unrealistic and unprofessional, if not impossible, it is also a setup for failure. it begs the question what are the limits of one's training and facilities? what are the limits of one's

physical and emotional capabilities? where is the practice of evidence-based medicine? where are the professional standards by which we govern ourselves? if one provides services to a standard defined by the patient, one has effectively transferred control of one's practice to the patient. any business which does not clearly define what and how it performs it's services, and leaves the definition of the services provided to the consumer, is quite frankly foolish, not only in terms of expectations and one's ability to meet them, but also from a risk management standpoint. "i wanted and expected you to provide this for me, and you didn't".those of us who are practicing a style of medicine which focusses on the kernel of health care, the doctor-patient relationship, must maintain appropriate boundaries, be clear about what we do and don't do, our limitations, and of course, our obligation to educate and discuss our patient's expectations,

and whether they are reasonable. i am concerned that we not revert to the "superdoctor" who supposedly could do everything. we cannot right all the wrongs of the current health care system, and make up for those doctors who don't take the time with patients, to get to the bottom of their worries and concerns. "i receive exactly the care i want and need exactly when and how i want and need it" is the basis of the boutique practice. i suppose if we lived in utopia, or if one were a multibillionaire, we might all have that. but would it still be appropriate?many of us complain that we don't get compensated for the time and effort in providing care management and telephone calls. many patients don't want to be seen, just be provided a prescription over the phone. now there's a patient expectation that fits right into "i receive exactly the care i want and need exactly when and how i want and need it". is that good

medical practice? is that an appropriate standard of care? "i receive exactly the care i want and need exactly when and how i want and need it" will not solve this problem, only exacerbate it. even with "membership fees", it does not resolve patient expectations, professional standards, nor address risk management. i depend on my history-taking and physical examination skills to determine what's medically appropriate and necessary for my patients, at a time when i can bring those skills to bear, within the context of my professional abilities and training, meeting professional standards.i agree that patients receive the care they need when they need it, however we must separate want from need. the IMP cannot be the be-all, do-all, however we can educate patients on the difference between the two. otherwise, want=need is a formula for disaster, which ultimately will not help us or our patients. we don't exist in a

vacuum. we work in a health care system, which implies that there are a number of different entities which provide for patients-- ambulatory care, emergent/urgent care, hospitalization, rehabilitation, and specialty consultation. to be sure, family doctors, internists, pediatricians and other generalists play a key role in helping patients navigate that maze. let us at the same time clearly define our role, our abilities and limitations, our professional standards, and our patient's expectations in a realistic fashion.some patients believe that they get to come into the office and tell me what to do, and have me sign off on what they want, merely because i have the medical license, and they are the patient. we can all agree how ridiculous that is. "i receive exactly the care i want and need exactly when and how i want and need it" is merely that in another form.we've already given up control of the practice of medicine to

insurance companies. it is irresponsible to give up our professional responsibilities and standards to patients, or anyone else.certainly, to work collaboratively with patients, to improve access to care, to meet standards of preventive care, to intervene aggressively in chronic disease and to educate patients, are all critically important in guiding patients toward a path of good health rather than just maintaining a state of non-disease, or focussing on cure after the fact. we can all do a better job, and an ounce of prevention these days is worth far more than a pound of cure. we have better tools available, especially in the form of electronic relational databases, transfer of medical records and access to the internet, and evolving research and guidelines for the maintenance of good health. rather than define the doctor-patient relationship in a pyramid, with patient expectation at the top of the hierarchy, i would define it as a ven

diagram, with overlapping areas of the doctor and patient, professional standards and responsibility, evidence-based medicine, and patient expectation. i believe that's a more realistic approach to patient care. LL Stay in the know. Pulse on the new Yahoo.com. Check it out.

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[Guest guest]

Larry and I are in complete agreement in philosophy.

One point that came up in a side conversation he and I had:

The after hours work burden is dramatically lower in a practice that

reliably delivers excellent care during the day.

While I talk about 24/7 access, the burden of after hours work is

very low for me, so it is easy to open myself up. If I felt the

after hours work was intrusive, I don't know if I'd be able to do

it. It works because it is not intrusive.

It is not intrusive because I take the time in the day to do all that

I can for patients.

Gordon

At 11:58 PM 9/17/2006, you wrote:

>thank you for the clarification.

>with that, i don't think there's any disagreement in what's been said.

>my concern is how others may interpret want vs need, and that it's

>not a swing of pendulum, rather a paradigm shift in the practice of

>medicine. certainly, when appropriately educated, and ideally,

>patients will come to equivalency between want and need. and i

>completely agree with you, that equivalency will only come through

>the development of our professional relationships with our patients.

>i still think a ven diagram is a better representation.

>LL

[Guest guest]

Larry and I are in complete agreement in philosophy.

One point that came up in a side conversation he and I had:

The after hours work burden is dramatically lower in a practice that

reliably delivers excellent care during the day.

While I talk about 24/7 access, the burden of after hours work is

very low for me, so it is easy to open myself up. If I felt the

after hours work was intrusive, I don't know if I'd be able to do

it. It works because it is not intrusive.

It is not intrusive because I take the time in the day to do all that

I can for patients.

Gordon

At 11:58 PM 9/17/2006, you wrote:

>thank you for the clarification.

>with that, i don't think there's any disagreement in what's been said.

>my concern is how others may interpret want vs need, and that it's

>not a swing of pendulum, rather a paradigm shift in the practice of

>medicine. certainly, when appropriately educated, and ideally,

>patients will come to equivalency between want and need. and i

>completely agree with you, that equivalency will only come through

>the development of our professional relationships with our patients.

>i still think a ven diagram is a better representation.

>LL

[Guest guest]

One thing that I have been struggling with is my desire to be available to my my patients who need evening and weekend hours but balance this with my own families needs. My evening and weekend hours are booked sometimes 1 month in advance. I work 1 evening a week and 1 Saturday a month. I tried more weekend days but I am just unwilling to miss any more of my kids soccer games or events. Larry Lindeman MDLarry and I are in complete agreement in philosophy.One point that came up in a side conversation he and I had:The after hours work burden is dramatically lower in a practice that reliably delivers excellent care during the day.While I talk about 24/7 access, the burden of after hours work is very low for me, so it is easy to open myself up. If I felt the after hours work was intrusive, I don't know if I'd be able to do it. It works because it is not intrusive.It is not intrusive because I take the time in the day to do all that I can for patients.GordonAt 11:58 PM 9/17/2006, you wrote:>thank you for the clarification.>with that, i don't think there's any disagreement in what's been said.>my concern is how others may interpret want vs need, and that it's >not a swing of pendulum, rather a paradigm shift in the practice of >medicine. certainly, when appropriately educated, and ideally, >patients will come to equivalency between want and need. and i >completely agree with you, that equivalency will only come through >the development of our professional relationships with our patients.>i still think a ven diagram is a better representation.>LL

[Guest guest]

One thing that I have been struggling with is my desire to be available to my my patients who need evening and weekend hours but balance this with my own families needs. My evening and weekend hours are booked sometimes 1 month in advance. I work 1 evening a week and 1 Saturday a month. I tried more weekend days but I am just unwilling to miss any more of my kids soccer games or events. Larry Lindeman MDLarry and I are in complete agreement in philosophy.One point that came up in a side conversation he and I had:The after hours work burden is dramatically lower in a practice that reliably delivers excellent care during the day.While I talk about 24/7 access, the burden of after hours work is very low for me, so it is easy to open myself up. If I felt the after hours work was intrusive, I don't know if I'd be able to do it. It works because it is not intrusive.It is not intrusive because I take the time in the day to do all that I can for patients.GordonAt 11:58 PM 9/17/2006, you wrote:>thank you for the clarification.>with that, i don't think there's any disagreement in what's been said.>my concern is how others may interpret want vs need, and that it's >not a swing of pendulum, rather a paradigm shift in the practice of >medicine. certainly, when appropriately educated, and ideally, >patients will come to equivalency between want and need. and i >completely agree with you, that equivalency will only come through >the development of our professional relationships with our patients.>i still think a ven diagram is a better representation.>LL

[Guest guest]

I agree. I average 2-4 calls per

month after hours.

From: [mailto: ] On Behalf Of L. Gordon

Sent: Monday, September 18, 2006

7:08 PM

To:

Subject: Re:

patient centered care

Larry and I are in complete agreement in philosophy.

One point that came up in a side conversation he and I had:

The after hours work burden is dramatically lower in a practice that

reliably delivers excellent care during the day.

While I talk about 24/7 access, the burden of after hours work is

very low for me, so it is easy to open myself up. If I felt the

after hours work was intrusive, I don't know if I'd be able to do

it. It works because it is not intrusive.

It is not intrusive because I take the time in the day to do all that

I can for patients.

Gordon

At 11:58 PM 9/17/2006, you wrote:

>thank you for the clarification.

>with that, i don't think there's any disagreement in what's been said.

>my concern is how others may interpret want vs need, and that it's

>not a swing of pendulum, rather a paradigm shift in the practice of

>medicine. certainly, when appropriately educated, and ideally,

>patients will come to equivalency between want and need. and i

>completely agree with you, that equivalency will only come through

>the development of our professional relationships with our patients.

>i still think a ven diagram is a better representation.

>LL

[Guest guest]

I agree. I average 2-4 calls per

month after hours.

From: [mailto: ] On Behalf Of L. Gordon

Sent: Monday, September 18, 2006

7:08 PM

To:

Subject: Re:

patient centered care

Larry and I are in complete agreement in philosophy.

One point that came up in a side conversation he and I had:

The after hours work burden is dramatically lower in a practice that

reliably delivers excellent care during the day.

While I talk about 24/7 access, the burden of after hours work is

very low for me, so it is easy to open myself up. If I felt the

after hours work was intrusive, I don't know if I'd be able to do

it. It works because it is not intrusive.

It is not intrusive because I take the time in the day to do all that

I can for patients.

Gordon

At 11:58 PM 9/17/2006, you wrote:

>thank you for the clarification.

>with that, i don't think there's any disagreement in what's been said.

>my concern is how others may interpret want vs need, and that it's

>not a swing of pendulum, rather a paradigm shift in the practice of

>medicine. certainly, when appropriately educated, and ideally,

>patients will come to equivalency between want and need. and i

>completely agree with you, that equivalency will only come through

>the development of our professional relationships with our patients.

>i still think a ven diagram is a better representation.

>LL

[Guest guest]

I average less than that - I think in 11 months of

practice I have been called after 9 PM 3 times total -

all were very appropriate - panic value lab result and

moms worried about their febrile kid.

I find that my patients respect what I am doing and

value our relationship, so they don't want to bug me.

They routinely apologize for calling me with questions

even during office hours!

, MD

Rancho Mirage, CA

--- Ellsworth wrote:

> I agree. I average 2-4 calls per month after hours.

>

>

>

>

>

>

> _____

>

> From:

> [mailto: ] On

> Behalf Of L. Gordon

> Sent: Monday, September 18, 2006 7:08 PM

> To:

> Subject: Re: patient centered

> care

>

>

>

> Larry and I are in complete agreement in philosophy.

> One point that came up in a side conversation he and

> I had:

> The after hours work burden is dramatically lower in

> a practice that

> reliably delivers excellent care during the day.

> While I talk about 24/7 access, the burden of after

> hours work is

> very low for me, so it is easy to open myself up. If

> I felt the

> after hours work was intrusive, I don't know if I'd

> be able to do

> it. It works because it is not intrusive.

> It is not intrusive because I take the time in the

> day to do all that

> I can for patients.

> Gordon

> At 11:58 PM 9/17/2006, you wrote:

>

> >thank you for the clarification.

> >with that, i don't think there's any disagreement

> in what's been said.

> >my concern is how others may interpret want vs

> need, and that it's

> >not a swing of pendulum, rather a paradigm shift in

> the practice of

> >medicine. certainly, when appropriately educated,

> and ideally,

> >patients will come to equivalency between want and

> need. and i

> >completely agree with you, that equivalency will

> only come through

> >the development of our professional relationships

> with our patients.

> >i still think a ven diagram is a better

> representation.

> >LL

>

>

>

>

__________________________________________________

[Guest guest]

I noticed the same thing. Plus I had 5 no-show incidents in one year, 3

from the same patient. In my case, the main thing is that I don't

accept Medicaid patients, which generate most of the phone calls and

no-show problems.

> I average less than that - I think in 11 months of

> practice I have been called after 9 PM 3 times total -

> all were very appropriate - panic value lab result and

> moms worried about their febrile kid.

>

> I find that my patients respect what I am doing and

> value our relationship, so they don't want to bug me.

> They routinely apologize for calling me with questions

> even during office hours!

>

> , MD

> Rancho Mirage, CA

>

> --- Ellsworth wrote:

>

> > I agree. I average 2-4 calls per month after hours.

> >

> >

> >

> >

> >

> >

> > _____

> >

> > From:

> > [mailto: ] On

> > Behalf Of L. Gordon

> > Sent: Monday, September 18, 2006 7:08 PM

> > To:

> > Subject: Re: patient centered

> > care

> >

> >

> >

> > Larry and I are in complete agreement in philosophy.

> > One point that came up in a side conversation he and

> > I had:

> > The after hours work burden is dramatically lower in

> > a practice that

> > reliably delivers excellent care during the day.

> > While I talk about 24/7 access, the burden of after

> > hours work is

> > very low for me, so it is easy to open myself up. If

> > I felt the

> > after hours work was intrusive, I don't know if I'd

> > be able to do

> > it. It works because it is not intrusive.

> > It is not intrusive because I take the time in the

> > day to do all that

> > I can for patients.

> > Gordon

> > At 11:58 PM 9/17/2006, you wrote:

> >

> > >thank you for the clarification.

> > >with that, i don't think there's any disagreement

> > in what's been said.

> > >my concern is how others may interpret want vs

> > need, and that it's

> > >not a swing of pendulum, rather a paradigm shift in

> > the practice of

> > >medicine. certainly, when appropriately educated,

> > and ideally,

> > >patients will come to equivalency between want and

> > need. and i

> > >completely agree with you, that equivalency will

> > only come through

> > >the development of our professional relationships

> > with our patients.

> > >i still think a ven diagram is a better

> > representation.

> > >LL

> >

> >

> >

> >

>

> __________________________________________________

>

[Guest guest]

Oh yes, at least 90% of my no call-no

shows & after hours calls are from Medicaid patients. I dismiss after

3 no call-no shows or after one no call-no show to a specialist I have referred

them to.

Re: patient centered

>

care

>

>

>

>

Larry and I are in complete agreement in philosophy.

>

One point that came up in a side conversation he and

>

I had:

>

The after hours work burden is dramatically lower in

>

a practice that

>

reliably delivers excellent care during the day.

>

While I talk about 24/7 access, the burden of after

>

hours work is

>

very low for me, so it is easy to open myself up. If

>

I felt the

>

after hours work was intrusive, I don't know if I'd

>

be able to do

>

it. It works because it is not intrusive.

>

It is not intrusive because I take the time in the

>

day to do all that

>

I can for patients.

>

Gordon

>

At 11:58 PM 9/17/2006, you wrote:

>

>

>thank you for the clarification.

>

>with that, i don't think there's any disagreement

>

in what's been said.

>

>my concern is how others may interpret want vs

>

need, and that it's

>

>not a swing of pendulum, rather a paradigm shift in

> the

practice of

>

>medicine. certainly, when appropriately educated,

>

and ideally,

>

>patients will come to equivalency between want and

>

need. and i

>

>completely agree with you, that equivalency will

>

only come through

>

>the development of our professional relationships

>

with our patients.

>

>i still think a ven diagram is a better

>

representation.

>

>LL

>

>

>

>

__________________________________________________

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[Guest guest]

Larry, My husband and I have our own youth track team(ages 6-13), which completed its first year. This year at AAU Nationals our team garnered 6 medals...3 from my daughter, 2 from my son and 1 from another athlete. I tell you Larry, I wouldn't miss it for the world. I think about it this way. Three years ago, I have came to realize how miserable I was was I was trying to do it all aka burnout. I had to rethink what was important to me. To my surprise, my patients are soooo supportive of me and my family. My philosophical goal is Faith, Family, Finances..in that order. Once, I changed my way of thinking, which was probably the reverse order, I was a much more happy person and able to start my IMP. At my practice, I am willing to see patients AFTER my kids game. I am flexible and willing to accommodate reasonable requests. I have even gone to the office after I put my kids to bed,

because it is that important to me to tuck my kids in. DON'T MISS ANY MORE SOCCER GAMES. Those moments cannot be made up. n Bobb-McKoyLarry Lindeman wrote: One thing that I have been struggling with is my desire to be available to my my patients who need evening and weekend hours but balance this with my own families needs. My evening and weekend hours are booked sometimes 1 month in advance. I work 1 evening a week and 1 Saturday a month. I tried more weekend days but I am just

unwilling to miss any more of my kids soccer games or events. Larry Lindeman MD Larry and I are in complete agreement in philosophy.One point that came up in a side conversation he and I had:The after hours work burden is dramatically lower in a practice that reliably delivers excellent care during the day.While I talk about 24/7 access, the burden of after hours work is very low for me, so it is easy to open myself up. If I felt the after hours work was intrusive, I don't know if I'd be able to do it. It works because it is not intrusive.It is not intrusive because I take the time in the day to do all that I can for patients.GordonAt 11:58 PM 9/17/2006, you wrote:>thank you for the

clarification.>with that, i don't think there's any disagreement in what's been said.>my concern is how others may interpret want vs need, and that it's >not a swing of pendulum, rather a paradigm shift in the practice of >medicine. certainly, when appropriately educated, and ideally, >patients will come to

equivalency between want and need. and i >completely agree with you, that equivalency will only come through >the development of our professional relationships with our patients.>i still think a ven diagram is a better representation.>LL

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