Smoke Screen

IMG_5620

Here is a link to an article in the Atlantic, The Trouble With Satisfied Patients. The gist of the article is that often hospitals with the highest patient satisfaction demonstrated some of the worst patient outcomes. 

I first discussed the patient satisfaction issue a few months back in a post entitled How Satisfied Are You? In it I had linked to another article in JAMA that pointed out that patients who are more satisfied with their care spend more money on that care and are more likely to die.

How can this be?

Is it possible that we are emphasizing the wrong things when we are talking about and measuring patient satisfaction? 

Absolutely. 

Case in point: When my son was born I took him to the hospital to get his second newborn screen done, the one that checks for certain genetic and metabolic abnormalities and that is required by the state. I held him as the woman stuck his foot and squeezed it hard milking enough blood out of the wound to fill up the required bits of paper. He screamed bloody murder until he was hoarse and his face was beet red. It seemed to take an eternity, an eternity of having my own heart torn to shreds as I watched him suffer. I know how this works. I know it is necessary. Yet I experienced a very visceral hatred of that woman for hurting my baby, the depth of which shocked even me. Was she incompetent? No. But if you had sent me a survey to ask if I was satisfied with his care, I would have marked an unequivocal, very emphatic “NO” even though there was no way she could have done her job better.

Another example? I hear patients complain all of the time about not getting a response when they need assistance getting to the bathroom. One just a few days ago was telling me that he ended up soiling himself and the bed because after two whole hours no one responded to his pleas for help. This is from a hospital with an agressive PR campaign and a community perception of excellent care. If patients are happy with their care, they think they are getting better outcomes than they really are. Smoke and mirrors. This hospital has a cadre of employees that visit patients during their hospitalization in order to identify unsatisfied patients and give them coupons for discounts at the gift shop or cafeteria. Screw that, I say. Just help them to the dang bathroom for crying out loud! The hospital should not be intended as a resort. It is for healing and should in the process of that maintain dignity and humanity whenever possible.

When the push to start measuring patient satisfaction started a few years ago, I was totally behind it. I liked the shift from the perception that we were doing the patient a favor by deigning to see them to a more customer service oriented approach. At the time it seemed the focus was on providing quality care in a more humane way. I like that. I like that a lot. I am not afraid of being measured over it. But over the years the focus is slipping into something not quite so positive… I DO care when patient satisfaction is costing people their lives. So should you.

5% of my salary is tied to patient satisfaction. Right now in our organization there is an emphasis on patient wait times. Generally I run on time or pretty close, but there are days when I just cannot win no matter what I do. In fact, a couple of years ago the “random” survey was inexplicably sent out to a ton of patients who were seen the day after Christmas. We worked in a lot of people who needed to be seen that day and as a result we were running over an hour behind. The survey asked patients how long they had to wait, not whether or not they were happy about getting in to be seen. We took a huge hit on that time thing despite the fact that patients said they were overall very happy with their care. Should we have refused to see those patients in order to preserve our numbers? I have been told yes. I am certain that is not the right answer.

Have you received a survey in the mail about your visit to a physician or hospital before? There is a lot secrecy I think about how those things are scored. Did you know that for a score to count positively, you have to mark “exceeds expectations”? Anything less counts negatively. Even if you mark “good”. If you exceed expectation on everything isn’t that just average? Aren’t we setting ourselves up for failure? And in order to stave off that perceived failure is it possible that we are pouring resources into things that are not actually improving patient care?

Another consideration: Is it that patient satisfaction as it is currently measured is mutually exclusive of the most competent doctors? Can the two not mutually exist in the same person? Perhaps. Some of the most brilliant minds are just not capable of being hand holders or shoulder huggers. Do we want to exclude brilliant minds from practicing because of this? I am not sure that is in anyone’s best interest, either. I have seen and heard of more than one physician forced out of a hospital system because of low satisfaction scores. They were excellent physicians who had saved many lives. Will they be replaced by more personable doctors who are less competent? In some cases, yes. 

So, what do patients want? What do they need? Do they want to be seen within fifteen minutes of their appointment time every time? Or do they want a physician who feels free to take their time, listening to complaints, coordinating care collaboratively? Do they want someone to help them get to the bathroom or just someone at checkout who says they hope you will fill out the survey saying that they have provided you with “excellent care” because using the same verbiage that is on the survey results in higher scores? 

So do I care about patient satisfaction? Sure. But I am not going to be losing sleep over it. In the end I expect my patients to be treated as I would expect my own family to be treated. That does not mean handing them a cup of coffee at the door. That means making sure their referrals and procedures are scheduled in a timely fashion, that bloodwork and imaging results are communicated to the patient, that we minimize medication errors, and that we smile when we do all of this because it is a pleasure to serve our patients.

Advertisements

73 thoughts on “Smoke Screen

  1. I DID just get one of those surveys in the mail for a specialist I recently saw. He was great — by which I mean he did not do unnecessary tests and he listened to me — and so I marked him highly on everything.

    But every time you buy something, everytime you visit a place, everybody wants a damn survey. It’s maddening — normally I don’t even bther.

    Liked by 2 people

  2. You raise excellent points, and you’ll get no argument from me. The time thing is difficult. In primary care, there are always more patients than appointments. So, do we squeeze extra people in and thereby fall behind? (Which was my MO, because I hated to turn people away and I’m not a rusher.) Or do we tell them, “sorry, no more appointments today” and risk turning away someone who really needs to be seen? Neither bodes well on a patient satisfaction survey.

    Liked by 2 people

    • Exactly. Then they go to an acute care facility and pay more money to be treated by someone who may or may not be capable but who at the very least does not have the entire past medical history. But if you don’t see them then it does not trigger a survey to be sent out which is why I was told to turn them away. Make those people unhappy and not the ones who will for sure be getting the survey. But in my mind what is the point of having a PCP if you don’t have access to them?

      Like

  3. My first thought was of my very first driving lesson, right before I graduated law school. (I needed the license for my job in Japan.)

    The instructor immediately put me on the freeway. He was gruff and unfriendly and pissed me off. I called him a “real dick.” He said he didn’t care what I thought or called him as long as I was still alive to do so.

    I didn’t appreciate that so much before I became a parent. Now, I get it. I actually tend to prefer “real dicks” because … less pretense feels truer, somehow?

    I don’t usually complete surveys either way. An ex worked in tech support and told me he got docked for anything less than outstanding. I opt for silence, then, unless there is truly terrible OR truly outstanding troubleshooting/resolution.

    Liked by 1 person

  4. We get those surveys often since all four of us see the same family doctor. I usually send them back with the high marks checked, even for time. We usually aren’t seen until 30-60 minutes of appointment time, but I know that’s because our doctor is very thorough and doesn’t rush patients, which the survey certainly doesn’t account for.

    Liked by 1 person

  5. I recently had surgery. I liked my surgeon. He was personable, no nonsense yet funny. He asked me to use the patient portal because it affects the ratings of the team. He allowed me to chose a follow up schedule (which I did poorly because I minimized the recovery period). He was conscious of not wasting my time. One thing I really liked is that I was able to email him (through the portal) when my recovery didn’t go as I planned (notice I didn’t say as normal because I was delusional about how fast I would recover). He was able to get me in occupational therapy fast which helped a lot. I gave him high ratings. While I like the patient portal thingie, I know many people my age who are not so comfortable communicating by computer. I wasn’t sure why that would be tied into performance ratings.

    Liked by 2 people

  6. I hate surveys because I don’t believe I’ve heard afterward there has been an improvement. We now and again get a crackdown about long wait times in Emergency at the hospitals. All over the news you’ll hear there’s been a such and such percent improvement and then the complaints start again. My friend’s mother waited in Emergency for e.i.g.h.t. hour with a broken arm. She was 91 years old. Triage anyone?

    Like

  7. Reblogged this on Conversations I Wish I Had and commented:
    You make an excellent point. What are these surveys measuring. Often times, I have to work with surveys and let’s just say I’m not a huge fan… It’s not because you can measure something quantitatively that it means it’s valid or accurate. There’s also something to be said about the use of statistics in research… It’s not because you have a good p value that your research is good… A lot of people forget that it’s not about what result you obtain from a calculation that matters, but whether the question that was asked at the beginning can be calculated statistically, is calculated an appropriate way and that result reflects the question that’s investigated.

    Liked by 1 person

  8. The universities have also sort of gone in this direction. The mentality that students are customers and the professor is there to serve them. The result has been a major deterioration in the quality of a degree. For me, I want a doctor and hspital that treats me competently. I don’t need anyone to hold my hand.

    Liked by 1 person

      • Yes. To get enrollment higher (revenue) a consumer friendly apprach is taken. About half of students enrolled in school should not be there but so many allowances and dispensations are made even some forms of cheating are overlooked and the perfectly appropriate state of anxiety that every student ought to have is classed as a disability and so the student is given a shit ton accomodations. And that’s just scratching the surface.

        Liked by 1 person

  9. Aargh! This is a perfect example of statistics done wrong Victo. More likely than not, your surveys are design distributed and interpreted by administrative personnel. This is not a good thing. This should be done by a professional. I studied this type of statistical analysis in B-school quite extensively, as one of the driving forces behind everything from customer satisfaction to system analysis, to employee rewards and recognition. It is very very very tricky and can easily lead to huge problems when done wrong. My ex is a Director at Canada Post,our national mail carrier, and one day she came home very upset. She had given a training presentation (she was in retail customer service) to a roomful of high level management and they had completed an assessment form at the end to help her improve and to indicate the effectiveness of the training. Her score came back as being poor. There was little detail. I asked her for the raw data – the completed cards themselves (there were no names attached) and she brought them home the next day- along with the weighting. The analysis of the data had set attendees’ physical comfort as a major weight – the theory being that if they were not comfortable (which had been a common complaint in the past)the learning dropped to zero quickly. It actually turned out that the attendees were very favorable in their comments about the presentation. However, according to the summation, they all complained about the environment of the room. So i took the cards and manually sorted them (there were only about 200) into piles by comments. As in your case Victo, the assessment criteria only; allowed a positive if all was perfect- otherwise it was a fail. It turned out that exactly (almost to a person) half the attendees complained that the room was too cold and half complained that the room was too warm. So, my ex received, effectively a zero on her ability to make the attendees feel comfortable. Bullshit – the room temperature could not have been set more perfectly – precisely half complained each way.She took the revised interpretation back to her bosses and got her score upgraded as , like you, part of her pay was linked to effective presentations.

    We studied and discussed all kinds of statistical failures in history. For instance in the Vietnam war, the soldiers originally served fixed terms of deployment and so would avoid action trying to survive to the end of their deployment. This caused a problem and the Generals determined that the best way to engage the troops was to establish a body count. So, term of deployment then depended partially on the number of kills. Suddenly, the body count jumped and soldiers were going home earlier and earlier – until someone started looking on the body bags. The number of civilians being shot as enemy collaborators had increased hugely and the bags were full of villagers. There was no way to determine whether the troops were doing this deliberately or the new criteria had given them a different frame for interpreting what they saw and understood. But there was no denying that the deaths of so many non-combatants was a result of the change in rewards generated by the misuse of the statistics.

    In an hilarious case, the transit system in England was in shambles at the end of WW2. In London, the buses were always running behind when they showed up at all. Very many passengers and employers complained loudly that the lack of service was seriously impacting the recovery from the damage done by the war.. The London city council found a hired gun to solve their problem. They told him that his pay and bonus would be linked directly to whether the buses ran and ran on time. After one year he had that bus system humming along 100% and with a 99.9% on time record. He had set drivers’ pays based on running their buses on time. It was a brilliant piece of motivation using statistics. Until….the city council started getting huge numbers of complaints from the public. It turns out that there was no punishment for a bus driver passing a stop without stopping – so to stay on time, the drivers were driving right past the bus stops whenever they were running late. They were actually stopping less than 50% of the time. That was due completely to the statistics and which ones were being rewarded.

    In summation Victo, your company should be using a professional numbers person to generate, implement and interpret their statistics.And that person should be at least in part, informed by a panel doctors like yourself who understand what certain outcomes really mean -i.e. are happy customers less well?

    Liked by 1 person

    • We us a national organization named Press-Ganey. They interpret the data for the majority of healthcare providers and hospitals in the US…. (I enjoyed your examples here of how statistics don’t give the whole picture!)

      Like

      • After some thought Victo, i remembered some testing that Canada Post did on customer satisfaction. They were checking out customer satisfaction when .there were long line ups to get to a postal clerk in franchise outlets (happens during holiday seasons, especially Christmas) – similar to your waiting issue after Christmas. They found something very interesting. If the people in the line could see the clerks working their quickest serving the customers ahead, the satisfaction level remained high even if the wait was long. If the clerk was slow or incompetent or was out of sight (i.e.the line up went around a corner or down an aisle)the customer satisfaction was low, regardless of the wait. So a customer with say a 15 minute wait who was in a queue with line of sight to a busy clerk would have a much higher satisfaction rating than a customer who waited 5 minutes either out of sight of the clerk or who perceived the clerk to be slow or incompetent. Obviously in your business clients will never be able to see the doctor at work, but maybe, as old school as it is, a numbering system could be tried so a client always knew how many were ahead of them. That always bugs me. In fact I was at the hospital this morning to consult with a surgeon. Module K is large and when i arrived at 8:30 for my 9 am appt there were already about 30 people waiting. I didn’t realize it until after but there were 4 entrances to the corridors with 20 or so exam rooms – with 5 doctors working (all surgeons). I was upset that there were so many waiting so early – and resigned myself to a long wait when i broke out my book. Three minutes later the nurse called my name and assigned me a room. By the time I had gotten to the room, the nurse was standing waiting at the door, we went over medical history in about 10 minutes (all my e-records are there), and the doctor came in within a few minutes. 5 minutes later I was done – and it was 8:55am – my appt had been for 9am. I was happy – but when i had arrived, i was resigned seeing all the patients waiting. It is perception that makes us satisfied.

        Anyway, hope this gives some insight.

        Liked by 1 person

      • You are right about perception. No one was particularly unhappy about their experience. They were happy just to get seen. But if you are looking only at wait time we sucked. Patient satisfaction still remained high.

        Like

  10. How about the fact that there are as many expectations of “good care” as there are patients being cared for. Each person is coming to a physician as an individual who feels they are the only one undergoing whatever the issue is. They also bring their individual familial and environmental background as well. How do health care providers possibly satisfy everyone? They don’t, and as you say, you give the best care that you can on that day. The next day will be another story.

    Liked by 1 person

  11. I just got out of the hospital yesterday. Did I enjoy my stay? It was okay. I hated having someone take me to the bathroom though I understood their reasoning for doing so. While you are waiting for someone to come and take you to the bathroom, a few minutes can seem like a waited forever. Hospitals are suppose to be a place of getting rest and getting better What rest? Who can rest during the night when a nurse comes in when your ready to doze off around ten at night and the nurse comes in to give you meds. Not to mention the 3 or 4 o’clock in the morning visits to get your blood. My first day at the hospital I was in ICU. The bed was uncomfortable, My butt and one shoulder blade was hurting. I couldn’t move on my side for 24 hours because of catherization wounds at the groin. My mom and sister did laugh with me on the butt hurt and shoulder blade hurting. There was nothing else to do but bare it for a time and laugh about it.

    The highlight of my stay was a nurse who had a joyful spirit. It was a joy to be around her. The staff was nice. The food wasn’t bad. Between 1-10, I would give my hospital stay a 7. All and all I do expect ups and downs at the hospital but it was nothing I couldn’t bare.

    As for doctor visits I don’t expect to wait 2 hours or more to see the doctor. If the doctor has an emergency while I wait. I would like my appointment to be cancelled and scheduled for another time. I figure it saves the doctor time of having to rush and me a long waiting time. I do love the doctors I have. Both listen to my concerns and tell me I can do this and this to get to where I want.

    Liked by 1 person

  12. Hubby and I have had both ends of the scale with emergency services. They refused to send an ambulance to him when he was throwing up continually, rolling on the floor in agony (I couldn’t pick him up) and was incoherent. Luckily a friend rang and when I explained the situation, he was there in ten minutes and helped me get him in the car and down to A&E. Hubby was diagnosed with kidney stones and ended up in hospital overnight followed by a series of ultra sound treatments.
    I on the other hand had chest pain and following a discussion with a nurse on the phone, she had first responders, a paramedic and ambulance crew with me within 20 minutes. It turned out to be indigestion and I was allowed home (my post Scary Stuff refers).

    Liked by 1 person

  13. Right now there’s an election in the UK (stick with me here) You may have seen John Oliver’s take on the Labour (kind of soft Democrat) Party’s pink battlebus to attract women voters and to talk with them “around the kitchen table”. Yeah, that went down well.
    One of Labour’s avowed policies was to “weaponise the NHS”. The National Health Service (NHS) is a low-cost, universal healthcare programme (with admittedly poor outcomes, but you pays yer money). It is free at the point of use and has no insurance involvement.
    The ‘weaponise’ idea was to pretend that the governing Conservative Party (very moderate Republican) was planning to “privatise the NHS”. Though of course much is not so free — dentistry for example — and the Labour Party did much of the privatisation already in the system when it was in government — but that’s politics and I am straying from the point.
    It’s a strange amalgam of a system, with a Stalinist, centrist, command economy, inefficient hospital network of geographic fiefdoms. As a monopoly it has never had competition enough to make it better. Its idea of an appointment system is a pasteboard card in the mail saying that you will attend at 10:15am on Wednesday June 3 or whenever. When you arrive there is little chance you will be seen at a time remotely near. The national hospital network is bolted to primary care through doctors’ offices which are like architects, lawyers, or any other professionals in the private sector the epitome of private enterprise and profit.
    The conclusion I reached reading Smoke Screen is the healthcare model does not much affect the problems you describe, whether it’s nationally $9000 or $3500 per person spent on healthcare (yes, that is the difference between the US and UK). t happens here too. People drinking from flower vases when they could not get a simple glass of water, soiling themselves through lack of assistance, physical assaults on geriatrics, falsification of records to abide by target waiting times and needless deaths caused by people that should not have been within a hundred miles of a caring profession.
    My point? I don’t know if I really have one. I admire the American system for its aggressive diagnostic regime, don’t get me wrong. And I despair sometimes when I read letters to local newspapers in the UK reciting how great is the NHS, from folks who might not have had experience of any other better way of doing things.

    Liked by 1 person

    • How do you hardwire caring into such a system, I wonder? And how can people be so calloused and uncaring in the first place. I run it this with my own staff. Someone is visibly in pain? Help them, for crying out loud!!!! Gah! It makes me so frustrated. The whole measuring patient satisfaction addressed a much needed issue so it isn’t all bad but it must be balanced by outcomes.

      Like

      • I think that the care we nostalgically imagine from a bygone age depended on one thing above all — time. If economics demands that a nursing station with one person now manages six or eight patients, when in the fifties or sixties it was two or maybe three people looking after those patients, care suffers. Add to that 1001 rules about lifting, appropriate touching; rules about end of life care; rules about rules and bureaucrats to manage these rules — for their jobs depend on rules — and we are where we are.
        I get the feeling that there was a high watermark of “western” civilization around about 1960 and since that time, as the West has once again become a lifeboat for everybody’s huddled masses and at the same time just plain poorer, the tides of history are slipping back like they did with the Greeks and Romans — and the British — before them.
        As the Pythons sang: “Always look on the bright side of life…”

        Liked by 1 person

  14. I love your honesty & perspective in this post. I have high patient satisfaction scores, yet no matter how hard I try to have a “i don’t give a f*** about scores and would rather just focus on providing the best care possible,” I can’t help but hear a little voice in the back of my mind telling me my scores are gonna go down each time I decline an early refill of xanax, which is the type of pressure that I believe these surveys inflict upon us.

    Liked by 1 person

  15. Great photo by the way. Yes expectations are very deceiving for the average patient doens’t complain. It is the one that everobe avoids that write letters ask to see supervisors. Ect.
    Great article!

    Liked by 1 person

  16. Well, I already blogged my opinion about customer satisfaction. I do not think in reality we are far a part on this topic. I think the whole survey system is flawed beyond recovery. Statistics from it prove absolutely nothing. But patients do need a voice, but maybe not this instrument. And giving everyone a free cup of coffee does not counter poor treatment in any manner.
    I also agree that if the Dr. is running over an hour late, rebook people. Give them that choice. If I am running late, I can be turned away and yet charged for the visit. Be respectful of the patient’s time too. Again the system demands that we pass patients through at a record speed. There are just too few providers around for too many patients.
    The government is looking for the wrong things and under the wrong rocks which causes providers needless costs. Yes we need to treat people with empathy and compassion but I personally expect that from anyone who is providing me a service. I don’t go back there unless I feel it. What we have between this flawed survey tool and the OIG and DOH surveys is basically a witch hunt. Are there crappy providers out there? Most definitely. I went to one who almost ended up killing me because she disagreed with my gyno about a procedure. I do not think she is practicing anymore.(I hope)
    Truthfully, do I want to see someone who is brilliant yet so insulting and condescending that they are rude? Absolutely not….. No excuse for treating people like crap no matter the situation. And I truly believe in trauma informed care which leads to better outcomes.
    Maybe I am a bleeding heart on this, but we need people like me to counter the other version of care. Somewhere, there is a balance.

    Liked by 1 person

    • You and I are much alike on this. I worry that there will be a backlash from this data that will set the process back or that the data will be ignored completely and they will all keep going on as they are now. Striking that balance… there has to be a way to address patient satisfaction, caring for emotional and physical health, without sacrifice the one for the other.

      Liked by 1 person

  17. Yes I hate these surveys, not just for medicine, but in general (isn’t a student going to be more satisfied with a teacher that gives them an “A” for mediocre work than one who correctly gives them a “C”?). I was once asked at a medical office about my stress level, and I said 5 (out of 10). A social worker called me the next day! How can you be living and breathing and not have a stress level of 5? Yet the social worker said they call anyone who is above a 3!! I ended up hanging up on her; no one who is living and breathing has a stress level of 2 unless they are a Zen master. And now I always just say zero. And I won’t do rating surveys for anyone.

    Liked by 1 person

    • I loathe and detest depression scales for that same reason. A number like that does not tell you what you need know to treat someone effectively. Makes me think of how far off we are on body mass index. Since those with a BMI in overweight range (25-29) live longer than those in “normal” range, aren’t we doing something wrong? And how in earth did that medical office have the resources to have a social worker call everyone with a stress level of three? 😕

      Liked by 1 person

  18. This trend has started in India as well, at least in the bigger cities. I never cared that much about patient satisfaction, I always held that treating the properly and ethically and curing them or giving them relief was more important than doing things their way so they left smiling. I’ve had patients love me for that and not a few who hated me. But I was left with the satisfaction that I they got the best medical care I could provide.

    Liked by 1 person

  19. People so often perceive affability with good care. Tasty food gets good marks, not appropriate diets. They don’t know to watch for hand washing or to ask about meds. It’s like when I take my car to the shop. I hope for the best.

    Liked by 1 person

  20. Personally…..I am a patient not a customer….make me feel better….don’t worry about my feelings. My retired OB-GYN had a horrible bed side manner, but she didn’t mess around and got the job done. If she was still practicing I would recommend her in a heartbeat. Does that sound harsh? I feel for you and I hope that I didn’t sound to cranky. 🙂

    Liked by 1 person

  21. It’s connected to our “give 110 percent” society, Doc. Impossible, but people say it and start to believe it. The same holds true with “satisfied” suddenly becoming, somehow, less than satisfactory when being supplied as an answer in a healthy survey. When I say I’m satisfied with somebody, I’m saying they did everything to meet my needs. Otherwise, I would not have been satisfied. To me it’s more than semantics. It’s logical thinking. Satisfied can’t be negative!

    Liked by 1 person

  22. Sorry, Victo, I’m away so long I’ve skipped all the prior comments and thus may be repeating, but here’s my take: Those surveys are too politicized–either someone selling a service wanting low satisfaction ratings, or an institution designing its own survey wanting high ratings. Only a disinterested party with experience designing objective surveys could be trusted to do these right. So the info in the opening of your post, although I did not go to the sources, I would tend to discount as unreliable in terms of patients’ true opinions, and caregivers’ and facilities’ true qualities of service.

    Like

  23. I have been finding more and more that practicing “good medicine” usually means telling patients what they don’t want to hear… (or maybe I’ve just been spending too much time on internal medicine…)

    Liked by 1 person

  24. I think the whole survey thing is crazy. I don’t honestly believe people can extract how they feel about their health issues to the technical expertise of the care they receive. Yes, of course, an unprofessional employee lacking in the ability to show an empathetic nature will lower scores. What is just as likely to lower scores are the numbers of noncompliant patients who go home, are mad that the doctors and nurses didn’t wave their magic wands and make them feel 25 again! Then there’s the surgery patients who don’t understand why they don’t feel perfect 7 days after surgery- you know that’s when the survey arrives. They are feeling like crap when the survey comes.

    Liked by 1 person

  25. Pingback: The View From Here | Behind the White Coat

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s