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Nurse Practitioners, Part 2 – Are They the Answer for Primary Care?

December 29, 2010
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Most observers of the American healthcare system conclude there is a primary care shortage, though opinion varies on what to do about it. Nurse practitioners and other mid-levels such as physician assistants have been suggested to fill the gap. Could they become the primary care providers of the future? I think the most accurate answer is: It depends.

First, let’s acknowledge there is good evidence that nurse practitioners and other nurses with advanced training provide excellent care for single chronic diseases such as diabetes, asthma, and high blood pressure, and focused procedures such as anesthesia in low-risk patients. The quality of their care is essentially identical to physicians, and some studies conclude that patients are just as satisfied with NP visits.

The problem with all this evidence is that it doesn’t represent the real world of primary care, where patients have multiple chronic diseases, new symptoms, family difficulties, and financial struggles. Nurses in general are comfortable following treatment algorithms for straightforward situations. In many types of patients, especially those middle-aged and older, and those with several chronic diseases, issues raised in the office don’t fit into neat boxes with clear definitions and boundaries.

U.S. organizations have already tried giving nurse practitioners completely independent practices. Roger Merrill, M.D., the chief medical officer at Perdue Farms Inc., spoke at the AAFP Annual Scientific Assembly in 2009 of their experience with this experiment. After the NPs were given independent practice, referrals to ologists climbed, hospitalizations increased, and overall costs increased. (I can’t find written confirmation of this, but several people who heard the speech told me the same thing.) Perdue Farms abandoned this approach.

My institution had a similar experience 15 years ago. A NP clinic was set up and even had a full time internist available for consultation. Compared to our family medicine resident clinic patients, the NP patients were less sick, had three times as many referrals, twice the hospitalizations, and the NPs saw half the patients per day as our 2nd-year family medicine residents. That experiment was also abandoned after many years of it being propped up by sympathetic high-level nurse administrators.

Let’s also acknowledge that there are family physicians in practice, and probably internists, who don’t embody the full potential of primary care. They practice scared and refer patients they shouldn’t. One example is a family physician who refers skin tags to dermatologists for removal. These physicians commonly practice band-aid primary care: prescribing medicines for symptoms without spending the time and energy, nor taking the responsibility, to diagnose the underlying cause. I’m not suggesting they should order more tests, but I am saying these physicians should use their brains more and take full responsibility for their patients without pawning them off to a parade of ologists.

Could NPs replace family physicians? If your view of family medicine is that they are merely medical traffic cops – “You have a nose problem, I’ll refer you to a nose doctor. You’ve had diarrhea for a few days, I’ll send you to an intestine doctor,” then yes, nurse practitioners can do that as well as any physician. If your view of family medicine is that they only deal with colds and well person care, then yes, nurse practitioners can do that as well as any physician.

On the other hand, nurse practitioners and other mid-levels could be part of the answer to the primary care shortage if they work in teams with physicians who can closely supervise them. Many general practices in Britain have hired nurses to do the chronic disease checklist care to meet pay-for-performance targets, freeing the general practitioners to focus on acute care. An example of an unacceptable approach is when a colleague of mine agreed to supervise a NP in a rural health clinic 20 miles from his office, but was unsuccessful in getting her to stop giving antibiotic shots (ceftriaxone, or Rocephin) to every patient with a runny nose.

However, if you’re idea of a family physician is someone who cares for 100% of the patients and 90+% of the issues that walk through the clinic door, there is no way a nurse practitioner, physician’s assistant, or even a “nurse doctor” can do an adequate job. The breadth of knowledge is too great. The expectation of the final accountability for the total patient is beyond most NP’s comfort levels.

If we’re going to launch into a major reform of physician/nurse roles, instead of expecting NPs to handle the complexity and uncertainty of primary care, it makes much more sense to teach them how to do heart caths.

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21 Responses to Nurse Practitioners, Part 2 – Are They the Answer for Primary Care?

  1. Dave Mittman on December 30, 2010 at 9:22 am

    Obviously the god doctor does not know that NPs and PAs have the knowledge to DO primary care and they are already doing it all over the country. PAs and NPs run primary care clinics acrosss America and the outcomes are comparable. PAs are flight surgeons and medical battalion surgeons in the Army and also doing ADVANCED trauma care. I guess those ear aches, abdominal pain and dermatitis will just throw us all for a loop.
    You have not worked with a PA or NP with 15-30 years experience, have you?
    In any case, your comments are not only made with only anecdotal evidence, not evidenced based, you also threw in that old arrogance for show.
    Now, we can debate the “nurse doctorate issue, or what kind of relationships between physicians and NPs/PAs are best, but again show me the evidence.
    Dave

    • Richard Young MD on December 30, 2010 at 11:30 pm

      Mr. Mittman,

      Thank you for your comments. I have worked with nurse practitioners directly in family medicine clinics and urgent care centers. My department supervises about 25 nurse practitioners in school-based clinics, though I’m currently not one of their direct supervisors.

      I love your request for good evidence on this issue. I would broaden the request to other innovations in healthcare delivery. Unfortunately, the NIH does not have the mission of sponsoring research in healthcare systems. Maybe the Comparative Effectiveness Research initiative will shed some light on this issue, but I’m not optimistic. It would be a massive and expensive undertaking and I’m afraid the general lack of primary care research in Washington will make this a low priority.

      Richard Young

  2. Frank on December 30, 2010 at 10:22 am

    Dr Young.

    First a comment on a specific statement in your article, “Many general practices in Britain have hired nurses to do the chronic disease checklist care to meet pay-for-performance targets, freeing the general practitioners to focus on acute care.” During my two years of practice in the UK (introducing physician assistant concept in that country, 2005, 2007), the Royal College of Nursing handbook stated that until guidelines were rewritten, any nurse could declare themselves a nurse practitioner, something that is unlikely to happen in this country. Even in the 2010 update, it reads “The RCN recommends that would-be advanced nurse practitioners should undertake a specific course of study to at least honours degree level.” Note the word, recommends!

    Your entire article is based upon the NP, but appears to only throw in the physician assistant as a comparison, without addressing our unique training and the training differences between the PA and Nurse Practitioner. You are obviously not aware that even the President has two White House Physician Assistants that travel with him and his family.

    AS far as your last comment about heart caths, “A physician assistant or cardiovascular fellow,who is a physician in training and will assist the
    doctor during your procedure.” (Brigham and Women’s brochure on cardiac catheterization, http://www.brighamandwomens.org/Patients_Visitors/patientresources/patienteducation/patientguides/cardiac_cath.pdf)

    Frank

    REFERENCES
    Nurse practitioners—an RCN guide to the nurse practitioner role, competencies and programme approval. Available at: http://www.nursepractitioner.org.uk (updated RCN document on nurse practitioners under RCN NPA link). Accessed November 27, 2006.

    Advanced nurse practitioners
    – an RCN guide to the advanced nurse practitioner role, competences and programme accreditation. (2010). Page 3. Retrieved from http://www.rcn.org.uk/__data/assets/pdf_file/0003/146478/003207.pdf

    • Richard Young MD on December 30, 2010 at 11:39 pm

      Frank,

      Thank you for your thoughts and taking the time to include the references. I was careful to use only the term “nurse” when I mentioned how some are used in the GP surgeries in Britain, because I realized their level of formal training was variable.

      I focused on nurse practitioners because I have had more exposure to them and because the inspiration for this and the previous blog was a comment from a reader about nurse practitioners in an older blog. I find the training, experience, and practice capabilities of physician assistants and nurse practitioners to be similar. I suggest that if you feel there are important differences, the physician assistant community has not done a good job making those differences clear.

      As for my last comment, I suggested that nurse practitioners or physician assistants could be trained to DO heart caths, not merely assist.

      Richard Young

  3. Stephen Ferrara, NP on December 30, 2010 at 10:27 am

    So let me get this straight, you are partly basing your argument on an “experiment” by Perdue Farms Inc (the chicken company)? Yes, they operate many on-site employee health clinics but nurse practitioner practice is authorized at the state level. How exactly were they able to overcome many state laws to have autonomous practice for those NPs? They weren’t. I can only assume that they relaxed their own self-imposed collaboration/supervision model of NP delivered care. It’s hardly a good example without knowing the details of this experiment and unfortunately the anecdotal evidence provided doesn’t suffice. Since they abandoned their experiment, how is NP care delivered now? Does every encounter that an NP sees need to be reviewed by a physician? That doesn’t sound like a particularly good allocation of resources. I also tried to find a transcript of this speech but this (http://www.aafp.org/online/en/home/publications/news/news-now/2009assembly/20091016assembly-keynote.html) mentioned nothing of the experiment.

    Anecdotal evidence aside, NPs deliver high-quality and cost effective care. NPs are not looking to supplant physicians. Should NPs see 100% of patients and handle 90+% of their problems? That never was the intention. NPs can and do manage chronic & episodic illnesses. Our physician colleagues are available for consultation/referral when the level of acuity increases. And please don’t patronize us with the “they don’t know what they don’t know” or the “they can miss something subtle” arguments. That can happen to any clinician and no published evidence suggests that NPs have a higher rate of misdiagnosis than any other discipline.

    • Richard Young MD on December 30, 2010 at 11:52 pm

      Mr. Ferrara,

      Thank you for your thoughtful comments. I previously viewed the AAFP website you referenced and agree that the nurse practitioner comments were not mentioned. A few months ago, I emailed Perdue Farms asking for a transcript of the speech or any other documentation of Dr. Merrill’s comments so I could be sure I got my facts straight. Unfortunately they never answered. Three people who were at the AAFP meeting told me the same thing about the nurse practitioner experiment. However, if anyone could send me documentation that I mistated the Perdue Farms experience I will post the correction.

      I believe you misrepresent my comments in your second paragraph. All physicians and midlevels are human and will therefore at some time in their career feel they know something they don’t, and miss subtle information. I made no statement about misdiagnosis rates. My comments were focused on efficient care, complex care, and taking full responsibility for all services that can be provided in the primary care setting.

      Richard Young

  4. Robert M. Blumm, MA, PA-C, DFAAPA on December 30, 2010 at 12:22 pm

    A nice article if you are trying to perpetuate a scare but filled with postulations on a group of clinicians that you have not obviously supervisd, collaborted with or plain, have no personal or little personal general knowledge of. I have been a PA for forty years which makes me fairly senior or old and have seen through my career a depth of educational equivilancy, life experience and multituds of multiple syndrome and symptom and disease care , which not unlike a shoe that was once new, became comfortable. Doctors of Medicine have been no different in that I have taught various resident classses ans they too learn through the halls of universities, residencies and then through their own personal disasters and triumphs. Yes, medicine is a dificult and demanding profession where the true practitioner has never stopped learning and will continuue to learn even after completing their practices and retiring.
    As Mr. Mittman so eloquently stated, one needs to take an educated , evidenced based observation at the profession and then make judgements. Better still, “Judge not , less you be judged.”
    Much of my time has been in a surgical group of sub-specialties and I have seen many CRNA’s giving anesthesis on ASA 3-4 cases. Start thinking of one of he most dangerous surgical procedures, a tonsilectomy, look at the potential problems and vever say minor procedures.
    Like it or not, NPs and PAs are on the health landscape to stay and newer clinicians will refer more often, which remainsa good practice as turfing saves patients lives. Stand with us and help us to become all that we can become and perhaps look at the Colombia NP group who recieved the scrutiny of medicine and came up with excellent grades.
    Respectfully, A PA who is proud of both the NP and PA professions.

    • Richard Young MD on December 31, 2010 at 12:08 am

      Mr. Blumm,

      Thank your for your passionate and thoughtful comments. My reaction to the first parts of your comments are similar to the others and I won’t repeat them here. The only thing I’d add is that I’ve worked with two family medicine residents who worked as PAs prior to going to medical school. Their views on the limits of physician assistants were an important contributor to my views I expressed in my last 2 posts.

      Kudos to the Columbia NP group that has led the efforts to provide what evidence there is on important outcomes in care provided by NPs. I know that kind of research takes a ton of work, and they should rightfully be proud of their efforts.

      Finally, I am prepared to stand by anyone who wants to work towards a more affordable U.S. healthcare system, and NPs and PAs will probably be a part of that effort.

      Respectfully,
      Richard Young

  5. jennifer on December 31, 2010 at 9:36 am

    Dr. Young,
    An interesting if not entirely subjective perspective. The AANP site has an entire link devoted to the literature/studies published regarding outcomes with NP’s in both primary care and in specialty. These references may assist your next editorial on the topic and will provide you with the ability to reference your claims.
    Jen

    • Richard Young MD on January 1, 2011 at 11:31 pm

      Jennifer,

      The AANP site is an excellent resource for people interested in 4 decades of research in care provided by nurse practitioners and physician assistants. I’ll go ahead and provide the link for the quality review document here: http://www.aanp.org/NR/rdonlyres/34E7FF57-E071-4014-B554-FF02B82FF2F2/0/QualityofNPPractice4pages.pdf. There is also a cost-effectiveness review.

      I was already aware of much of this research, but I thought I’d take a look at the more recent studies and reviews on undifferentiated patients. I didn’t have access to all the studies I wanted, but I have some observations on the ones I did.

      Cooper MA, et al. RCT in an Accident and Emergency department.

      ANNP summary: “. . . patients randomly assigned to emergency NP-led care or physician-led care . . .” (No description of the patients included).

      Article: This was a “. . . convenience sample of [patients] with specific minor injuries . . . randomized to ENP-led care or Senior House Officer-led care.” (in other words, residents still in training).

      Ettner SL, et al. Controlled trial of multi-disciplinary doctor-nurse practitioner model in an inpatient medical unit.

      ANNP summary: “Significant cost savings were documented when 1207 patients in an academic medical center were randomized to either standard treatment or to a physician-NP model.” This was the only comment.

      Article: “The authors examined the net cost savings associated with care management by teams of physicians and nurse practitioners, along with daily multi-disciplinary rounds and postdischarge patient follow-up.” This study was basically a comparison between one hospital wing where doctors had no extra help and another wing where doctors had help both in day-to-day care during the hospitalization and follow up care after discharge.

      Horrocks S. Systematic review of nurse practitioners in primary care.

      AANP summary: “The health status data and quality of care indicators were too heterogeneous to allow for meta-analysis, although qualitative comparisons of the results reported showed comparable outcomes between NPs and physicians.”

      Article: “Although all of the randomised trials found no significant differences between doctors and nurse practitioners in health outcomes, the research has important limitations. The studies used many different outcome measures, reflecting the difficulty in measuring changes in health outcomes after single consultations predominantly about minor illnesses. None of the studies in our review was adequately powered to detect rare but serious adverse outcomes.”
      “Our review lends support to an increased involvement of nurse practitioners in primary care. However, most recent research has been based on nurse practitioners providing care for patients requesting same day appointments predominantly for acute minor illness and working in a team supported by doctors. It cannot be assumed that similar results would be obtained by nurse practitioners working in different settings or with different groups of patients, nor that they could substitute entirely for general practitioners.”

      Laurant M. Cochrane review of substitution of doctors by nurses in primary care.

      AANP summary: “The quality of care provided by nurses was as high as that of the physicians. Overall, health outcomes and outcomes such as resource utilization and cost were equivalent for nurses and physicians. The satisfaction level was higher for nurses. Studies included a range of care delivery models, with nurses providing first contact, ongoing care, and urgent care for many of the patient cohorts.”

      Article: “The findings suggest that appropriately trained nursed can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.”
      “While doctor-nurse substitution has the potential to reduce doctors’ workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors’ workload may remain unchanged either because nurses are deployed to meet previously unmet need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.”

      Mundinger MO. Randomized trial of primary care outcomes after an ER or urgent care visit.

      AANP summary: This summary is straightforward and on target.

      Article: My primary concern with this article is there is absolutely no description of the physicians.

      After this exercise, I’m left with these impressions:

      The AANP described the results of the studies in a manner expected of an advocacy organization.

      Several of the AANP summaries did not mention the fact the NPs did not have independent practices, but were supervised by physicians.

      There is good evidence mid-levels provide equivalent care to physicians for uncomplicated patients with minor illnesses and injuries.

      Family physicians who believe they primarily add value to the world by providing prevention, health education, counseling and minor illness care to mostly well patients are on shaky ground. Lots of non-physicians provide those services well for lower costs, including mid-levels, dieticians, diabetic educators, and counselors. The drivers of costs in any healthcare system are severe illnesses in patients with multiple or severe single chronic diseases. There are no studies showing mid-levels can pull this off independently.

      Practically all the listed studies compared mid-levels to primary care physicians. This means there is a large unmet potential to explore areas where the mid-level–physician fee differential is larger: common procedures performed by ologists.

      • jennifer on January 3, 2011 at 10:14 pm

        Most of these, if not all as i believe they had to be to make it onto the site, were published in peer reviewed journals, such as JAMA. But then that would be your peers who reviewed the studies.
        Here is a 2010 study, published in a peer reviewed journal, 1.6 millions patients in the VHA responded.
        Comparing Care: Nurse Practitioner, Physician’s Assistant, and Physician
        http://www.medscape.com

        Implications for practice. This study shows that most primary care clinic patients would rather see NPs than PAs or physicians. Besides clinical care, NPs focus on health promotion, disease prevention, health education, attentiveness, and counseling. These findings have implications for the hiring of more NPs in the VHA system.

        The bigger point here, despite your opinion, this already is. Your are talking to the backs of Health care administrators, policy makers and hospital board members, you know the people hiring the ‘you’s and me’s’ of the world.
        With all due respect, I suggest we (you and I) dig in and create great teams that will do awesome things, much better spent energy. We (you and I) have way too much talent to waste it on this sort of thing.
        Jen

  6. Steven Gilles on December 31, 2010 at 12:33 pm

    Dr. Young

    With respect, your article is a rehashing of sadly overused arguments based on little more than conjecture, a few case reports and personal anecdotes. Because I am trained as a PA in a medical model, I generally don’t rely on anecdotes or case reports to make decisions on items of importance.

    Your comment:
    “doesn’t represent the real world of primary care, where patients have multiple chronic diseases, new symptoms, family difficulties, and financial struggles”

    What does this mean exactly? If a patient with hypertension who cannot afford his brand name ARB (the ACE caused a cough, luckily my supervising MD was around to hand hold me through the change over to an ARB) do I automatically fall apart as a provider?

    Has it been by shear luck then that my patients with hypertension, type II diabetes, ischemic vascular disease and CKD happen to be doing better than they ever have? Perhaps it has only been through the careful guidance and direction from my MD supervisor that these patients have managed to leave the office alive.

    The reality Dr. Young is that NP and PA providers are providing top notch complex primary care to young, old, multi-problem patients with outcomes on par of MD providers. My MD colleagues will back me up 100% on this. When I see one of their patients for a flare or recheck of their chronic issues, I return those patients to their MD PCPs with cleaned up problem lists, clearer medical histories and a patient with a clearer understanding of their medical problems and medications.

    I can easily juggle the complexities of their CKD needs, their IVD needs, their medication adjustments, their finacial and social problems without blinking. I will, when needed grab an MD colleague and say “is this okay?” and will receive a positive response. I will, when needed say to a patient “I want an MD to look you over”. This is rare.

    With respect Dr Young, just stop. Stop the old, sad, “old school” argument that PA and NP providers cannot provide care for complex patients. We fill a gap in primary care. The market and administrators need us. We are not going away. We can provider similar quality of care and get paid a fraction of what an MD gets paid for providing the same care and generating the same (often more) revenue. We have proven this. We have data to support it.

    Steven Gilles, MPAS, PA-C
    Family medicine and proud!

    • Richard Young MD on January 1, 2011 at 9:50 pm

      Mr. Gilles,

      It sounds like you have a great relationship with your physician colleagues. Surmising what I can from your comments, your practice’s blend of physicians and PAs is a perfectly acceptable approach. If you really are juggling multiple chronic diseases, medications, symptoms, and social challenges in patients with little supervision from physicians, then all I can say is way to go. I’m sure you are the exception not the rule. I’m also sure mid-levels fill gaps and are not going away.

      By the way, I couldn’t help noticing that you criticized my use of personal anecdotes, then rattled off several paragraphs of nothing but your personal anecdotes, then mentioned there are data to support your positions, then didn’t provide those data. See my reply to Jennifer.

    • jennifer on January 6, 2011 at 9:40 pm

      Steven,
      You make a great point here. There really is no such thing as simple patients, everyone we see (the Dr. Young’s, if he is in practice, and the Steven’s) has complex overlapping issues that may compromise their ability to heal, be compliant or avoid complications. With a proper PMH and psycho social evaluation we would see family stressors and financial strains in everyone. Thank you for pointing this out.
      Jen

  7. southern pcp on January 3, 2011 at 11:35 am

    “One example is a family physician who refers skin tags to dermatologists for removal.”

    I would guess that this hypothetical family physician knows that he won’t be paid enough (or anything at all if it’s conjunction with a sick visit) for removing the skin tags to cover his overhead, and reluctantly refers them to the derm who has negociated a higher fee schedule.

  8. Bob Blumm on January 4, 2011 at 7:49 am

    Where have you folks b een? PAs have been DOING Heart Catheterizations for almost fifteen years in many institutions and there was a study on their results, Contact the Association of PAs in Cardio-vascular Surgery.

  9. jennifer on January 6, 2011 at 9:42 pm

    Amen, I have been doing them for 10, like i previously said this is a subjective situation and “we see things as we want to see them” sort of perspective. Jen

  10. medstud on April 8, 2011 at 10:17 am

    I can’t help but wonder if NPs as a profession have a mission to go to every single physician blog with an article on NPs and start bashing the author for not equating NPs=doctors. Maybe it is nurse union driven, who knows.
    I have worked with NPs on my 3rd year rotations and I think they’re great. For the most part, they know their limits in terms of training- When I asked, no one wanted to play ‘doctor’, but become a ‘provider’ instead.
    I think NPs are great supplements to the practice by seeing the common quick visits, but I am hoping that the physician still becomes the captain of the ship when the patient centered medical homes/ACOs come to us soon.

  11. Rebecca Coelius on June 28, 2011 at 11:25 pm

    Does anybody have data comparing outcomes and COST/referral levels of NP managed versus MD managed clinics, for anything other than single chronic disease patients and focused procedures? I ask this not to be provocative, but because these are the only studies I can find, and I do not feel that this represents the average primary care practice.

    I don’t doubt that there are some amazing NPs on this message board who are absolutely capable of handling complex patients after their decades of experience, but I don’t think these anecdotes prove anything, and vice versa for the other side of the argument.

    These are the most important question to ask about both the new grads and the average NP and MD when determining policy around what the minimun licensure requirements should be to run a practice, (because we do not start with those decades of experience but must rely on our training), and what the most efficient and cost-effective method is in the long run.

    For those NPs being paid so much less than a generalist MDs: if you really are performing the same services, you are getting abused financially by whatever institution you belong to. The hospital or group does not get paid less just because you are an NP, that is not the way coding for reimbursement works in this country. This is one of the reasons that private NP practices will NOT save the health system money, though it does of course improve access to medical care.

    • Richard Young MD on June 30, 2011 at 9:12 pm

      Rebecca,

      I’ve never seen a study like that, which is a huge hole in the literature, especially for those who support the notion that the primary care shortage can be alleviated by deploying an army of mid-levels. The closest thing I’ve heard of was the Perdue Farms experience, though it was spoken of at a national meeting and I haven’t seen it in print. I talked about it in the original post. This is also an important issue, because the way family physicians care for their complex patients is what drives their cost-effective care. I have no doubt a mid-level can do just as good a job caring for diabetes as well as a physician, as measured by metrics such as frequency of hemoglobin A1C measurements and documented dietary education, but that won’t fix our unaffordable healthcare system.

      Thanks for your thoughts,
      Richard Young, MD

  12. John Casey on March 17, 2012 at 10:12 am

    This is America and not a third world country.
    Every Amercan deserves first class medical care.
    One can not get top medical care from a nurse practioner. All these Nurse Practioners are a ( Want To Be Doctor )There not as good as a REAL Dr and why should Americans settle for 2nd best care.
    Only reason Drs office use these type people is the $$$$. Its cheaper to use these type people to treat patients than to hire a REAL DR.
    And who gets short change yep the patient….
    The goverment needs to produce more real drs and out law these want to be Drs.

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