Dead subspecialists walking--Enough with the reprieves, already!

It's really getting to be habit, you know—this end-of-year pilgrimage that subspecialists make down the long hall. We begin our final ambulation with the booming announcement decried by a few anxious hangmen politicians, "Dead subspecialists walking!" We are shackled Django-like from about mid-December while politicians haggle for the best deal possible until they shut down for a few hours of Christian holiday merriment. Washington awakens just before the dawn of the New Year to reactivate our march toward our final destination. Other physicians clang their cups on their bars as we pass by, keenly aware that at any moment their number may also come up. We walk hoping upon hope that a miraculous reprieve from the looming employee-salary, benefit-busting, private-practice-gutting plan for a 20-something percent cut in Medicare reimbursement might disappear. Several times now, we've won that welcome reprieve from Congress, but one of these days, we'll be strapped into the big chair and asked if we have any final words, then the gas will come pouring into the world of subspecialists. Our crime? Simply desiring to continue to deliver good care to our communities from our well-established offices. This time, though, the big machines of medicine didn't get that reprieve, as hospitals suffered a massive reduction in reimbursement, and our friends who are those Rubik's cubes of relative value units (RVUs) didn't get the governor's call either.

What exactly do politicians hope to gain by the mass execution of American subspecialists? Reducing Medicare reimbursement is akin to removing a corner piece from a massive house of care delivery cards? As we walk toward our public execution, we carry our patients on our backs, patients who already have difficulty accessing outpatient services and who cannot afford their medications. Politicians don't understand or seem to care enough that families of our employees who depend upon us for their livelihoods and healthcare coverage dangle precariously at our side. The greater question is this: Why excise a metastatic cancer from the surface of a damaged and broken system and do nothing to stop the terminal processes that drive it?

Reductions in Medicare reimbursement are a lazy and uninformed legislator's ineffective and very temporary way out. There are tons of opportunities for savings that would be immediate and broad sweeping if we just implemented a few solid changes early this year:

1. President Obama—Declare war today on smoking in our nation. The carnage from first- and secondhand smoke exposure is one of the oldest Benghazi stories in the US, although it's not a cover-up—it's malignant neglect. Listen closely—can you not hear our continuing cries for help? Driving legislation state by state would result in massive reductions in heart-attack occurrence and visits to emergency departments for asthma, COPD, and bronchitis therapies within just six months of implementation. The rising cost of healthcare in the US is unsustainable. The long-term benefits of these legislative changes would be immeasurable and immediate.
2. Provide tax incentives to hospitals that implement programs that reduce medical errors and hospital-acquired infection. It's entirely possible to increase transparency and promote mediation instead of litigation. According to Dr Roger Stark of the Washington Policy Center, in 2011 "the country spent $2.4 trillion, or nearly 18% of our gross domestic product (GDP), on healthcare." Frivolous lawsuits against doctors and hospitals contribute significantly to these rising costs and by some estimates are responsible for up to 10% of the cost of healthcare. Fifty-four cents of every dollar awarded goes to the litigation process. I know most men don't like to talk on the phone but First Lady Michelle, please ask the president to be bold and pick up the phone! Tell him to call the University of Michigan and ask for Richard Boothman. He can tell him everything he needs to know about this monstrous issue that does have a fairly easy, straightforward solution. Make your man be the first man in public office to change the world of US patients and practitioners forever—and you don't even have to breathe the words "tort reform."
3. Start rolling the wagon wheel of prevention. The hub of that most important wheel is the massively expensive DRG known as heart failure. The spokes are hypertension, diabetes, obesity, sedentary lifestyle, poor diet, and smoking, all of which drive coronary heart disease, diastolic dysfunction, systolic dysfunction, obstructive sleep apnea, atrial fibrillation, and stroke. Incentives to improve access to simple blood-pressure checks in places where US citizens congregate are one simple step—put them in grocery stores, beauty salons, and barber shops. Asking schools to restructure their health programs by teaching our kids the difference between a carb and a fat and how to read labels for sodium content are key. Making phys-ed programs a daily mandatory activity is also essential as the ultimate prevention measure. Incentivizing with tax breaks to large US employers for not only providing access to dietary and exercise programs but implementing the actual utilization of these services will work!
4. Instead of penalizing hospitals with 30-day readmit issues, incentivize them to provide adequate follow-up. Fellow blogger Dr Ileana Pina from Montefiore Medical center's brown-bag clinic is a great place to start. Other studies with nurse-driven simple phone calls following discharge have shown impact on readmit rates. Seems to me another phone call might be in order here from our legislators to those folks with proven success to push these out to their constituents state by state.

One of the most impactful movies for me as a child was the Susan Hayworth film I Want to Live. I'll never forget seeing it with my mother on our old black-and-white television that just received one or two stations. The tension was palpable every time she was forced to walk the walk toward the execution chamber, but on her final walk, the one where they picked up the phone line just to make sure the governor couldn't get through, one could see the terror in her eyes. I'll never forget her hands tensed against leather straps as a blend of sulfuric acid, distilled water, and cyanide crystals generated a cloud of smoke that encircled her head. One of these days, subspecialists will not get that much-needed reprieve, and access to decent subspecialty medical care will diminish forever in the US, an irreparable foray into the worship of mediocrity.

Next year, let's not do this again. Let's not leave everyone dangling, hoping and wondering as we sit in the glow of our festively decorated trees trying to pretend we aren't just a little bit distracted. Enough already. Start now, legislators! It's the dawn of a New Year. If we work together and avoid trying to reinvent the wheel, a reprieve this time around 2014 won't be necessary at all.

Your comments

	Dead subspecialists walking--Enough with the reprieves, already!
	# 1 of 24	January 7, 2013 03:39 (EST)
	becky christianson	Dear Melissa. When, my dear sister, will you ever learn? To say "government" and "common sense" in the same sentence is contradictory! You and I along with many other colleagues on this forum have offered up so many ways to decrease the cost of healthcare over the last 6-7 years--I even sent a copy of one of our threads to the 2008 presidential candidates....I never even got an acknowledgement of receipt! No, Medicare was canibalized (sp?) many years ago and instead of being a voluntaray place to put money for our retirement it is now being touted as an ENTITLEMENT! Money is given to those who never put a penny in there. The govt has decided that rather than cut back on who is "eligible" to recieve the money you and I put in there, it's just better to cut reimbursements and Marketbasket Updates.....Value Based Purchasing and all that! WeALL in healthcare will soon be those dead men Walking.....from all avenues of healthcare. Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 2 of 24	January 7, 2013 07:55 (EST)
	Melissa Walton-Shirley	Hey Becky!!! I know....as I was writing this I realized we've all reinvented our same recommendations in so many ways, I feel like a high school gal trying to get the attention of that special guy in the lunch line!!! (who is now my husband I might add!);Different outfits, make-up, perfume.....maybe pretend to ignore? It worked for him for seems that nothing gets the attention of our congressmen! (well except a few perks!) Since I eventually nabbed my guy, I guess I think if I just NEVER give up, someone might just listen! Thanks for posting! Great to hear from you again!!! Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 3 of 24	January 7, 2013 10:23 (EST)
	Espinoza Andrey	Bravo Melissa, but truly where do we go from here?..we have no voice...at least no voice that anyone will ever listen to or implement to changes you suggested...a week doesnt go by where I dont ask our Family medicine residents how we can truly impact the care for our patients and at the same time reduce healthcare costs overnight....their answers are always geared to some complex app they are currently creating to change the world...I tell them if the government and our country were SERIOUS about doing what was best for our society in the long run we would outlaw fast food and shut down the nicotine industry ASAP...put a fresh fruit and vegetable market on every corner ...I really believe if people are given the option of making the right decision they will....but alas its a pipedream because it flies in the face of...dare I say...CAPITALISM.. Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 4 of 24	January 8, 2013 09:43 (EST)
	Melissa Walton-Shirley	How about Washington D.C? Wouldn't it be nice if we could all march down Pennsylvania Avenue holding up signs that would outline multiple opportunities to cut medical cost and save lives? Since we can't seem to jump our own representative through hoop that land them in the oval office for a few minutes, maybe we could attract attention that way! I'd be game-take a few months to organize but would LOVE To do it! Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 5 of 24	January 8, 2013 10:53 (EST)
	James J. King	How about Washington D.C?? 1. Al Jazeera bought Current TV. 2. Al Jazeera is a front for the America GOP, Republican Party. This organization is owned by the International Oil Interests. 3. Mid-Eastern oil interests also has controlling interest in Fox News. 4. There will be an attempt by the controlling American Media to end Social Security and Medicare. Author's disclosure (Jan 8, 2013) I have no relevant disclosures to make in connection with this topic.
	# 6 of 24	January 8, 2013 12:01 (EST)
	becky christianson	Walk on DC! The Prez had those drs there in their white coats when Obamacare was announced......I think it would be GREAT for a walk down the avenue!!!! And set up tents/MASH units along the water area in between the monuments (my fibro's kicking in and I forgot the name of it!). Occupy DC til we can "knock" some sense into some heads.... (oh, and James, I'm one of those "Republican people who watches Fox News......Not sure how you figure that Al Jazeera was a front for "us"......why would the GOP buy something from Al Gore, and why would he sell it to the GOP--he wouldn't sell it to Glen Beck, for pity's sake! get a life, James.....nothing you said here makes sense in the context of the thread.) I'd like to go when the cherry blossoms bloom.... Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 7 of 24	January 11, 2013 10:20 (EST)
	Kathleen Lynch	Prevention? I hate to sound cynical, but I truly believe that there is WAY too much money being made (and not by medical professionals!)in the diagnosis and treatment of disease to devote any meaningful attention or resources to prevention. Author's disclosure (Jan 11, 2013) I have no relevant disclosures to make in connection with this topic.
	# 8 of 24	January 11, 2013 10:37 (EST)
	Glen Brizendine	From an industry point of view Dr Melissa W-S>> I love reading your commentary on all things, but as has been said before, you're never going to get anywhere with Congress using a message that includes logical, well constructed and well meaning solution based thinking. If you think the Cardiologists are in a bad spot you should talk to an Endocrinologist about CMS cuts. In the face of a Diabetic / Obesity epidemic in the US, Medicare has basically chosen to make the sub-specialty needed most in that fight a financial losing pursuit. When will they learn? Never I suspect. Author's disclosure (Jan 11, 2013) I have no relevant disclosures to make in connection with this topic.
	# 9 of 24	January 11, 2013 11:24 (EST)
	Rick Seip	curb driving to public schools Public schools train our youth in many ways, including fostering the entitlement to drive a car. Many juniors and seniors in suburbs and rural school districts drive to school alone in their own car. This is inefficient and unhealthy. It reduces bicycle riding, walking, caloric expenditure and stimulates a psychology that increases driving behavior thereafter into adult life. This massive learned phenomenon I have observed for 40 years of adult life. Aimless car driving is insidious in its effects on more pollution and less physical activity, and develops in Americans the psychology that automobile transportation is a deserved entitlement. It is costly. We should curb single driver commutes to public schools. Author's disclosure (Jan 11, 2013) I have no relevant disclosures to make in connection with this topic.
	# 10 of 24	January 11, 2013 11:56 (EST)
	Jeffrey Young	Agreed Eloquent as usual!!! PREVENTION!!! What a novel concept!!! At a cost of $56 million dollars an hour CVD and its related complications should have a bullseye on it as big as the states of TX!! JY2 www.preventevents.com Author's disclosure (Jan 11, 2013) I have no relevant disclosures to make in connection with this topic.
	# 11 of 24	January 11, 2013 12:22 (EST)
	Joel Reginelli	Prevention may raise costs I am a proponent of prevention; however, many cost analyses have suggested that effective prevention may actually raise the cost of health care, lending more credence to the maxim: "Death is cheap". The sad truth is that the government coffers benefit from the insane taxation on tobacco. In addition, it may be more cost effective to pay for acute illnesses in a patient who will die before the age of 65, as opposed to paying for a healthy individual to live into their 90s. I would not look to the government to champion prevention. Author's disclosure (Jan 11, 2013) I have no relevant disclosures to make in connection with this topic.
	# 12 of 24	January 11, 2013 12:48 (EST)
	Timothy  McKeever	Malpractrice I must take issue with your assertions about malpractice. Malpractice insurance and governance are typically regulated by the individual states and not the federal government even though the Supreme Court ruled in 1944 that the Fed could regulate the industry under the statutes of Interstate Commerce. Because of "state sovereignty" there isn't any real federal "fix" to be had. The assertion that "malpractice contributes to an estimated 10% of the cost of healthcare" (my paraphrasing) is unsupported by the statistics. Figures that provide an overview may be found in National Practitioner Data Bank. Approximately between 180,000 and 225,000 deaths occur annually from "preventable" medical errors. Of that number, barely 2% result in malpractice filings. Less than 2% of THAT number ever result in any form of compensation. The estimates are as follows" 12,000 deaths due to unnecessary surgery 7,000 due to medication errors 20,000 due to errors in hospitals 80,000 due to nosocomial infections 106,000 due to adverse effects from medication Obviously, many of these deaths cannot be attributed directly to the physicians, so that makes the number somewhat smaller with regard to individual physician cost of care. But having said that, no deaths should be discounted that are preventable. Let's put a little perspective on this. A 747-400 Jumbo Jet airliner seats 460 people. Lets use the lower end of the malpractice estimate and say that 180,000 people died in crashes of 747 passenger jets annually. That would equate to 7 jumbo jet crashes every week where there were no survivors. Without doubt the government would intervene. Air travel changed significantly after the Value Jet crash of the 80's in Florida if you recall. Unlike air transportation, the practice of medicine in this country is decentralized and largely regulated by the individual state. As stated, that includes malpractice insurance. No other industry utilized by the general public pays such a small price for such a significant rate of mortality among those who utilize the system. Of the middling few malpractice suits that do pay, the time from incident to payout is roughly 4 years. The Alliance for Specialty Medicine would like to implement a three year statute of limitations that would effectively eliminate most malpractice payouts entirely. Think about that and count your blessings that you belong to one of the most lightly accountable professions with regard to financial liability for deaths. Finally, those of you who firmly believe in the power of the market force will be happy to know that the malpractice insurance industry typically raises premiums when the economy destabilizes and investment revenues become anemic. Increases in your policy premiums are directly linked to those forces, even though the insurance industry would like everyone to believe that those increases are due to malpractice payouts. If that were true, as I have pointed out, many physicians would be driven completely out of business and nobody would be able to afford to practice outside of the hospital. Author's disclosure (Jan 11, 2013) I have no relevant disclosures to make in connection with this topic.
	# 13 of 24	January 11, 2013 03:17 (EST)
	Andrew Powers	"We have met the enemy and it is us" - Pogo/Walt Kelly Spending limits are inevitable yet it seems that few wish to face the reality that drives the crisis in healthcare costs. The crisis is a direct consequence of our success in using advanced medical practices to extend patient lives, and the unwillingness of our society to admit our economic shortcomings and spending limits. The most any physician can do is extend and improve patient lives until the inevitable fatal malady occurs; which is a truely noble occupation. However, instead of suffering and dying at an 'early' age, fortunes are spent to enable patients to survive until they die at an 'older' age of the same or another malady which generates even more healthcare costs. Reductions in smoking or other vices may decrease morbidity and increase longevity, but this wouldn't translate into lower healthcare costs due to the expansion in the elderly population needing costly health services - not to mention losses in economic activity and tax revenues. Any idea that reducing malpractice litigation, medical errors, etc. will enable limitless healthcare spending for an expanding elderly population is a fantasy. Author's disclosure (Jan 11, 2013) I have no relevant disclosures to make in connection with this topic.
	# 14 of 24	January 12, 2013 01:53 (EST)
	Michael Kruse	Pharmacists should be providers I feel for you, but I'm not even a "provider". I can't be cut because I don't even exist as far as cognitive services. One of the above posts mentions deaths from medication adverse events. I would love to meet with your patients to counsel and revise medications rather than just run a zero dollar reimbursed Coumadin Clinic. Let's make a pact to support each other. Pharmacy's professional organizations are pushing this year to get pharmacists recognized as providers. Please help. Michael Kruse, PharmD Hospital Clinical Pharmacy Specialist Anticoagulation Clinic Pharmacist Author's disclosure (Jan 12, 2013) I have no relevant disclosures to make in connection with this topic.
	# 15 of 24	January 12, 2013 04:30 (EST)
	Giovanni Gulli	You should know better than dreaming Melissa, I really feel for you, but it seems you are still wearing a pair of floral-print Bermuda shorts deep in your soul! Do you really believe that you/we can fight law/insurance firms, drug/medical supplie companies, tax revenues on unhealthy activities? We can not expect these changes from our governments; we can (only) teach our patients on a personal basis (secondary) prevention: only the strongest (most informed/educated/clever) will survive. Author's disclosure (Jan 12, 2013) I have no relevant disclosures to make in connection with this topic.
	# 16 of 24	January 13, 2013 09:14 (EST)
	Melissa Walton-Shirley	Well......here goes Giovanni, I saw a couple of movies back to back this weekend and in one of the movies the question was asked to a gentlemen who was standing up at great cost " Don't you think what you need is a bathing suit instead of a bucket???". That is where I have lived my entire life: Smoke- free movements (23 years here where I practice), primary PCI without surgery onsite for our state-(6 year battle through three governorships) and now a local political battle for the rights of poor sick people who find themselves in a less than optimal situation on a daily basis- yet the shortest battle but the easiest to prove- still challenging but a battle worth fighting at great personal cost-totally worth it. I think the salient definition in all of these battles are the words dedication and sacrifice. Are we willing to sacrifice our time? (not extra time-real time-devotion-going to our state seats of government?local officials? discussions over coffee, at the grocery? etc. time out of office? money out of office to spread the word or gather information or make a difference? Are we willing to sacrifice some of our relationships in the the name of doing what is right? Not take the easy or the go along to get along road? YES, many of these battles can be won but the point is this: THEY MUST BE FOUGHT. Sometimes, you have to fight so hard that you don't even feel it when you are wounded. There are enough of us as physicians that we can win these battles if we stop bowing to complacency and paranoia. We have to ask ourselves the questions: Is my state smoke free? If not, what can "I" do? Does everyone in my state have access to primary PCI? If not, what can "I" do? Michael, what state do you live in? What can "YOU" do to win that battle so we can diffuse and "in"-fuse education into our public where it counts most-at the physician-RX--pharmacist interface? Do you encourage your patients to walk over and get their BP checked in your store when they come for their refills, keep a diary and present it to the doctor? Do you call the doctor and say, "it's not working-been two weeks, BP still 158/100?" Andrew and Joel, we can't be afraid of prolonging patient's lives and use that as the excuse not to help those who are still trying to live. I get your point and it's well taken, but not a deterrent for me. Timothy, I'm trying to get at the issues of unnecessary death, dying and injury-we are swimming in it in some areas of the US because we don't have adequate systems in place to implement the three A's of true tort reform: ACKNOWLEDGE, ADDRESS, ACCLIMATE when we could have done something better- so there is less of a chance for a next time. Awarding someone 10 million dollars for amputating the wrong leg helps that patient to live more comfortably but it does NOTHING to keep the next person from getting the wrong leg amputated UNLESS the system reacts to the problem. Rick, you are onto something-we need to teach health and nutrition as MANDITORY classes EVERY singe year of school-curricula need to be redesigned so children are taught how to read their own body's signals or recognize disease much better then how we teach them with more enthusiasm than how we teach them to turn on a computer and surf. Politicians should demand these changes in our education systems and make it an accountable portion of testing-must pass health, nutrition, pharamcy YES BASIC PHARMACOLOGY info to our kids!!!!! they shop all the time for other the counter stuff-they need to know what they are purchasing and what is being prescribed to them as humans in general. Espinoza and Kathleen don't be discouraged. We can all make a difference in our own immediate environments. Becky I appreciate as always your support and James-I have no idea what you are talking about. I suggest you go to your local cinema and watch "Gangster Squad" and "Zero dark thirty" to get a dose of what it must be like to live in the true interface of sacrifice and evil. Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 17 of 24	January 13, 2013 09:19 (EST)
	Melissa Walton-Shirley	I hesitate to use the term "interface of good and evil" ....because we all have to decide what's really good and what's really evil-pray about it, dedicate ourselves to it and stick with it until it's done or until we die-which ever comes first. Some of us were built for it, some not-but the least any of us can do is to do what we can to support those who are willing to take on those battles. Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 18 of 24	January 13, 2013 09:44 (EST)
	Melissa Walton-Shirley	and........ I really appreciate ALL of your posts on this topic. Discussion: the first and most important step toward success!!! Thank you!! I'm sufficiently fired up for the day!!! :) Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 19 of 24	January 24, 2013 04:04 (EST)
	kac young	Prevention IS the magic bullet After my heart attack in 2006 I realized how much I didn't know about heart health, diet and exercise. My physician didn't warn me that 268 was too high for cholesterol. I've taken matters into my own hands now and I am out lecturing and blogging about heart health and the things we DON'T know and could know that could save our lives, literally. I'm only one person, but I am determined to spread the word and make a difference. One of the proactive things I did was take my entire recipe book and convert them into heart healthy versions. People will change their diets if the shift isn't too radical, I've learned. If we can take America one step at a time towards heart health and diet consciousness we can shave billions off health care costs. Yes, my cookbook is for sale, but it also contains 23 pages of nutritional information and the reasons WHY we should eat differently for our hearts. I reduced my cholesterol from 268 to 147 by lowering saturated fats, salt and sugar and using substitutes for animal fats. If I can do it, so can everyone else. My mission is to help all American live longer and healthier. My promise is to keep educating as long as I am able and to enlighten folks about how easy it is to take care of your heart. It's not only easy, but delicious, too. Ask my friends. They love my heart healthy Mac & Cheese, Lasagna, and Enchiladas. And so do their hearts. www.HeartEasy.com for more information about keeping Americans heart healthy. Author's disclosure (Jan 24, 2013) Heart Easy, The Food Lover's Guide to Heart Healthy Eating is the cook book I created to keep America's heart out of the ER.
	# 20 of 24	January 24, 2013 05:06 (EST)
	Joe Turnbow, M.D.	PREVENTION DOES WORK! Excellent piece, Melissa. Thank You. Prevention does work. I used the Bale/Doneen method for seven years, five of them in a subspecialty practice totally devoted to heart attack, stroke and diabetes prevention in Boulder, Colorado. Many of our patients had already had a cardiovascular event, and a lot of others had atherosclerosis proven by CIMT scanning or EBT heart scanning. Not one patient who took our advice had a heart attack, stroke, stent or bypass. But I had to close my office last May because we could not make it financially. And I am not aware of any private practice in this country solely devoted to cardiovascular prevention that has made it financially. I could not find the answer. Author's disclosure (Jan 24, 2013) I have no relevant disclosures to make in connection with this topic.
	# 21 of 24	January 24, 2013 05:09 (EST)
	garry holland	fiscal cliff LESSON #1: * tax revenue $2,170.000.000.000. * fed budget $3,820,000,000,000. * new debt $1,650,000,000,000.* nat debt $14,271,000,000,000. *recent budget cuts $38,500,000,000. now lets remove 8 zeros and pretend it a household budget: * annual fam income $21,700 * money family spent$ 38,200. *new debt on credit card $16,500. * outstanding balance on credit card $142,710. * total budget cuts so far $38.50. LESSON #2 lets say you come home form work and find there has been a sewer backup in your street...and your home has sewage all the way to the ceiling..what do you think you should do...raise the ceiling or remove the proverbial? Author's disclosure (Jan 24, 2013) I have no relevant disclosures to make in connection with this topic.
	# 22 of 24	January 25, 2013 06:48 (EST)
	Melissa Walton-Shirley	Excellent discussion Garry, appreciate your dumbing down our situation. I wish that Perhaps the next time the secretary of the treasury speaks, you could stand up there beside him and interpret! (not kidding......99% of the US population would probably laud this!). Joe, thanks-find so often that physicians are rewarded less and less for doing the right thing. Many of us could sign on the dotted line and double our salaries by selling our souls when we go against our conscience-but we must seek ways to affiliate ourselves with systems who truly have the patient's best interest at heart and then by staying solvent-still inject your caring brand of health care into the system. I don't know what your resources are, but surely you could find someone to affiliate yourself with such that you can continue to bestow your caring attitude on your local masses. Kac, congratulations on your stance for better health and for trying to help others. I always tell my patients your vitamins and supplements are found only in the fresh produce aisle in states landlocked by weather and at local farmer markets during the growing season. Good luck! thanks for your posts-marvelous discussion! Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 23 of 24	January 25, 2013 09:19 (EST)
	Giovanni Gulli	Language barrier Melissa, I really appreciate your enthusiasm and the passion of all of your followers. Too bad that my English skill and my limited knowledge of the American system do not allow me to fully understand the discussion, although I think I got the general meaning of it. Thank you all so much and yes, keep wearing your floral-print Bermuda shorts. Author's disclosure (Jan 12, 2013) I have no relevant disclosures to make in connection with this topic.
	# 24 of 24	January 25, 2013 10:13 (EST)
	Melissa Walton-Shirley	Giovanni :) Author's disclosure (Jan 7, 2013) I have no relevant disclosures to make in connection with this topic.

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