Wednesday, August 27, 2008

Reasons I'm Leaving Emergency Medicine (number 2)



This is a turd.

In medicine today this is what's known as a beautiful turd, a really nice turd, or not a turd at all, but something that only resembles a turd to the untrained eye. What this really is, according to those in charge today, is an opportunity to partner.

See, while I see this as a turd, this observation is not welcome. In fact, it may impact our Press-Gainey scores or our core measures, and this is unhealthy for the group and for the contract. The cynical amongst you might say, at this point, that those seeing this as a golden poo are merely motivated by money but no! They are motivated by a collectivist wisdom which is but a foretaste of humanity's next step up the ladder of evolution.

I admit that my feeble brain is not able to see this, so I am going to go hang out with other non-Mensans and other non-leaders.

To me, medicine today is a turd because we call patients 'customers', try to do better 'customer service' with all comers, most of whom do not meet the traditional definition of 'customer' (ie someone who pays for their services), worship at the feet of a terrible unfunded mandate called EMTALA, and also worship at the feet of a bunch of worthless committee hacks called TOFKAJCAHO (the organization formerly known as JCAHO).

We also shuffle money from the folks who actually gave more than a second's thought to their health to those who have made, and continue to make, poor decisions. In other words, there are tons of doctors and hospital CEOs and legislators who fancy themselves as modern-day Robin Hoods. They are not, they are the Sheriffs of Nottingham, but then again who am I to say, I think the thing at the top of this post is a
turd

EMTALA has killed the best medical system in the world, and why? Because some douchebag legislators thought that it would buy them votes (and they were right). I also know how to fix our mess, but, since I major in plain-talk, I will never be elected nor will anyone who says this and here it is.

Everyone in the country should pay for their own medical care even if only for a small portion of it. Buy insurance or not, your choice. Get catastrophic coverage only and establish an HSA. Finance your care. Can't get insurance? There's no one to blame but the authors of EMTALA.


If you walk out of the hospital or out of the ER two hours after calling an ambulance AND you really have no money, no problem, we can arrange for a few hours of community service at the local free clinic. If "the government" wants to mandate that no one be turned away from the ER then let them pay for the care we are legally obligated to give or at least let us deduct it from our gargantuan income taxes.

Emergently ill patients should get our best and that's exactly what they get. They should then pay for what they received in whatever way they can. Insurance rates? Down immediately. ER waits? Gone. Bullshit EMS calls? Gone. Doctor retention and satisfaction? Up (and quickly). My job? Immediately better because I am not constantly presenting the golden turd to my consultants. In other words I'm for the good old American notion of personal responsibility. Hard in the short run, the only sane way to do things in the long run.

Pictured above is a turd. It can not be polished and there's no way to pick it up by the clean end.

55 comments:

  1. I'm only going to say this once. That is an awesome looking turd. If only all turds looked that good, maybe, just maybe, this world could all get along. We wouldn't have all the triangle turd people fighting the oblongs, or the corns fighting the runnies. But I'll keep on waiting, waiting for the world to change.

    ReplyDelete
  2. 'cat,
    you have an unhealthy appreciation for all things turdy. i hereby diagnose you as being a coprophile. i hear there's this website...

    ReplyDelete
  3. One of my all time favorite quotes by one of my all time favorite authors, Albert Camus, reads, "The welfare of humanity is always the alibi of tyrants"....I actually have that as a bumper sticker on my car.

    These liberal "Robin Hoods" have created quite the perfect place for themselves. They continually take the moral high ground with their peace, love, and other hippie bullshit....yet take none of the responsibility for the actual implementing of such superior lofty ideals...that's up to the government....through their robbing of people like us.

    Now THAT would be a great idea.....next time some drunk/druggie/teenage mom has a hospital bill to be paid....don't make them do the community service.....go drag that latte swilling, Che Guevera shirt wearing, Marxist college student in and make him sweep the floors.........they will be fiscal conservatives in no time!

    I kind of dread your number one reason....coz that means you are almost gone :(

    ReplyDelete
  4. Looks like the Shrodingers Cat is into John Mayer as well. Nice!

    The system always seem to favour the ones who are poor, uneducated or just plain stupid. And yet for some reason, society tells us that being a dumbass is bad. Well, if you're not in a hand to mouth situation, know enough math to handle your cash, and when someone tells you not to drop your bar of soap in a prison, you just take their word for it instead of giving it a shot.. I guess you can get the best of both worlds!

    In conclusion to my fairly aimless post, I would like to issue a warning to all you patients who think they own us...

    All your turd are belong to us! We may not own your asses.. at least we own what's in them.

    ReplyDelete
  5. I think it was Albert Camus who also said: "Life ain't nuthin' but bitches and money."

    911: That is one shiny turd! If that is your own fecal creation, I diagnose you as using too much ass lube.

    ReplyDelete
  6. I, for one, am sick to death of the sugar-coated, Pollyanna, glass half-full, Jesus wants me for a sunbeam attitude you've taken lately. And the pretty pictures have to go.

    ReplyDelete
  7. Man! Did you have to start with a steaming pile. Do you realize how much shite I see on a regular basis because I have 2 children in diapers and one who still needs help wiping.

    ReplyDelete
  8. Devorrah *snort* If only I were as funny as you. Your wit is wasted in kindergarten.

    ReplyDelete
  9. Amy: Thanks, but kindergartners are my perfect audience. When they teeth start to fall out I explain that soon their ears will loosen and fall off too, but brand new, big-kid ears will be replacing them, so not to worry. But they have to keep them really clean, or they'll rot and fall off.

    ReplyDelete
  10. Oooh, cat fight!

    * grabs a soda and a pack of microwave popcorn *

    ReplyDelete
  11. geez. this is so sad and so true.
    we have a press ganey binder in our beloved department.. to see our " customer" comments.

    i know they say that shit rolls downhill.. but the above pile ain't going nowhere.

    ReplyDelete
  12. I would love to work at a clinic for free health care. I realize that everyone can't volunteer because there'd be an oversupply of workers and an undersupply of income to pay your mortgage, but man, I loved working in a hospital setting. I was good at my job too. Too bad I've got no education to speak of, so I'm not very marketable. Once my kids are in school though, I'm going back. To do what, I'm not sure.

    ReplyDelete
  13. Yeah, Devorrah, I know they've got to be better than all the crap you did as a lawyer. So much more rewarding. Good thing you've got blogging as an outlet for that lawyerly cynacism.

    ReplyDelete
  14. Did you intentionally make the turd post "number 2"... sort of clever... not really.

    ReplyDelete
  15. Dev

    I'm telling my kids the ear thing tonight. I laughed out loud and hope they will too.

    CAT

    ReplyDelete
  16. I was so surprised when in the 90's we had to read up and be tested on the concept/reality of hospital customers..inside and outside. Doctors are customers to the hospital, patients are customers, vendors.. you name it.

    So.. yeah they bring in revenue and so want to keep em happy..but then like you said..with the pts.. many don't pay or not much when it comes to the ED.

    When I was first hired (mid 80s) my new supervisor said most hospitals operate in the red and are not the profit makers everyone thinks. Unfortunately... it gets out of control with hiring agencies and what not to implement BS that wastes money, time and ruins morale.

    Our hospital admitted that they made a mistake hiring an outside group to come in and evaluate all 4 campuses and went with downsizing recommendations, etc. I think it cost them a million or so and I don't recall why they regretted it..but they did.

    It's all so complicated! I hate to hear of good docs leaving. I know of an OB doc who gave up his practice to go off on a boat..drive one around. I can't imagine going through all that schooling to give up your career in your prime..although the boat thing sounds nice.

    Thinking of water... i am going to go float in the pool and listen to political commentaries. :)

    911 Doc... I still think you need to unite and have that feast. Target one area, devour it and then maybe if enough docs/nurses are hungry enough they could eventually set off a domino effect. it all has to start somewhere.

    It probably has to hurt the finances to get their attention.

    Last thing... it truly bothers me to know that docs have sacrificed so much and have one of the most important jobs ever (responsible for human lives) and are being treated as they are.

    And yes...there needs to be checks and balances and improvements where possible... but it's all the inane stuff that is crazy making and wastes everyone's time...including the CUSTOMER'S and potentially or does compromise CUSTOMER care AND ultimately CUSTOMER satisfaction.

    ReplyDelete
  17. Don't you just love it when your Turd tapers off at the end, so your Asshole doesn't slam shut, and you don't even need to wipe?

    ReplyDelete
  18. We had an opening at an ED that was 90% admin / 10% clinical and the amount of Doc's clamoring to get in there was like the floodgates opening.

    So...uh, I guess what I'm asking is; why was that so attractive?

    ReplyDelete
  19. TOFKAJCAHO (the organization formerly known as JCAHO)

    I guess JCAHO just wasn't long enough? Why not add WTF to that as well..

    ReplyDelete
  20. dear significant snail,

    the thing about TOFKAJCAHO is that, first of all, they suck ass. second of all they have forbidden providers to use abbreviations such as QHS for 'every night' and PRN for 'as needed' but, at the same time have changed their name from JCAHO to simply 'the JC', so i refuse to go along with this, they are, therefore TOFKAJCAHO, and they can kiss my ass.

    ReplyDelete
  21. I wish my poops looked as gorgeous as that one!

    ReplyDelete
  22. My husband likes to harrass me by saying he didn't have to wipe because it was a "clean poop." I believe he's mentioned the whole asshole-snap-shut effect as well. It drives me freaking crazy which is why he does it.

    For anyone interested, I had the most interesting experience at the doctor's office yesterday with a hot Ukranian nurse(female). Sorry I don't usually plug my blog, but it...well I had to share.

    ReplyDelete
  23. read this.

    http://www.davis-floyd.com/USERIMAGES/File/Windows%20in%20space%20time.pdf

    *sob*

    ReplyDelete
  24. Well said, as always.

    This is the end result when the monkeys run the asylum.

    Customers and for sake of argument clients are not what we should refer to patients to. They are neither. Customers are people you sell a product to. I am not selling a service, I am providing it, my services come with a cost.

    http://www.merriam-webster.com/dictionary/customer

    If I wanted to go into sales/business I would be my roommate from college with the MBA making more money than I ever will.

    ReplyDelete
  25. What's EMTALA? I also need you to spell out all the other accronyms. That is a nice turd. I'm framing mine if it ever comes out like that one did.
    If you care come over to my site after 10am to see who I've chosen to be the McCain's VP.
    http://www.thenewconservatives.blogspot.com/

    ReplyDelete
  26. EMTALA = the emergency medical treatment and active labor act. 1985. intended to prevent 'dumping' patients from one hospital to another, result is that we can't turn anyone away from the ER. search blog for EMTALA and you will get more than an earful. absolutely killing us and hurting the very ones it was intended to help. simple wealth redistribution scheme. ruining medicine.

    ReplyDelete
  27. WE know have OB count at our hospital. It is counting who is leaving next. So far 6. I did t-shirts for one group that said on the front "Endangered species" and on the back was the name of their company and obstetrician. Now another group is jumping ship and they want to know when their T-shirts are arriving. That goes for the Midwives too. Who would want to be a Midwife in this country when you make the same as the nurses but get not benefits?

    Soon out of necessity, I will be delivering the babies but I can't sew too well so all these women will have to go to vagina plastic surgeons in the future.

    ReplyDelete
  28. Your website, which I LOVE reading, leads me to believe that a doctor who is on the staff at a hospital works for some kind of commission based salary. I know that my family doctor is paid by me and/or my insurance when he comes to see me at the hospital, but how does a "staff" doctor get paid? And how does it work when a family doctor, like mine, is working the ER some weekends?

    I live in a (REALLY) small town and get excellent care and service from my family doctor. I know he is rare breed these days and love him to pieces. This fact, combined with all the information I’ve been getting from you, and Rush, and Glenn Beck, has me really wondering about this stuff.
    Would you mind ever posting something about these questions?


    It would be much appreciated.
    Thanks.

    Small Town Lady

    ReplyDelete
  29. STL:
    "Staff docs" are paid a salary by the hospital, which then bills insurers or the gov't or the individual for the services provided.

    Your family doc probably bills insurers etc. directly. He may have to cover the ER to retain hospital privleges. He likely gets paid very poorly or not at all for much of his ER service due to a multitude of freeloaders / scumbags who use the ER as a "free" primary care service. You, personally, through being a good citizen and contributing to society, pay for the freeloaders. Fun stuff.

    I glad you enjoy the blog. We try to keep it chock full of rainbows and puppies.

    ReplyDelete
  30. Everyone in the country should pay for their own medical care even if only for a small portion of it. Buy insurance or not, your choice. Get catastrophic coverage only and establish an HSA. Finance your care.

    Dear Dr. 911dDOC,

    That was really a good start on the solution, but you've left out a critical piece, which is required in order for the above to work.

    STOP ALLOWING EMPLOYERS to deduct the cost of providing health insurance to their employees. Better yet, stop allowing employers to provide health insurance at all.

    HSA is good, but it doesn't really level the playing field between employers and those providing their own insurance.


    My own idea to extend your thoughts would be that for anyone walking into a hospital or clinic without insurance and who couldn't pay cash, the care would be a tad different. For example, you don't really need pain medication for childbirth, unless you have a C-section. So you don't get that unless you can pay for it upfront. The purpose of this kind of rule would be to "encourage" young people to buy insurance. They often don't, and the more people who buy insurance, the better the system will function.

    ReplyDelete
  31. Yeah but Tresa that's not exactly right either.

    What about kids with cleft lip and palate? You can very certainly survive with a hare lip. Your psyche may be destroyed and you might have a wee bit of trouble functioning in society, but hey, if your parents are douchebags and can't pay, too bad kid.

    And as far as limiting pain meds for childbirth to exclusively those who can pay would make us a brutal society. What about forceps deliveries and vacuum extractions? 4th degree tear? Sorry ma'am your ass is ripped to hell. Please hold still while I stitch your muscles back together. You don't need pain meds because you can't pay. We've got a free stick for you to bite.

    I'm not advocating that the government remedy the inability for the poor to pay. There are charitable organizations who could help with this. Back in the day there were charity hospitals for the indigent. Our country is the most generous in the world. Surely we could come up with a non-governmental solution to help the poor among us.

    ReplyDelete
  32. Please, please, PLEASE don't just blog but call the McCain office RIGHT NOW and implore them to pick Palin.

    See my blog. Get all your friends and family to do it.

    Tell them to delay making the announcement if they have to, it's worth it.

    Tell them to LISTEN TO THE PEOPLE/VOTERS.

    THANKS IN ADVANCE!!

    ReplyDelete
  33. With all due respect... I don't agree with penalizing the poor by letting them be in excruciating pain (or withholding any other necessary service) because they don't have insurance. Not all poor people are bleeding the system or want to be. There are sometimes hard working, productive people that through job loss, divorce, catastrophic illness whatever...that can find themselves uninsured and unable to pay a bill up front. It would be inhumane to take that approach. There are a lot of people who work hard but are poverty level. They are the people who fall in between the cracks because they work, make too much money for public assistance and yet don't have the money for extras or paying for medical... but they make payments.

    Not every poor or uninsured person is a mindless, abusing system sucking dirt bag. There are good people in that mix.

    I would think that pain meds are just the tiniest tip of the iceberg financial woes in medicine. It's the expensive tests and unfortunately..anything through the ER that is expensive..or hospital stays.

    ReplyDelete
  34. Ummm...Paul me thinks you're just a bit late. Nothing we do is going to change that decision now. The speeches have been written...

    ReplyDelete
  35. hmmm,

    too many questions to answer completely.

    dear small town lady, you do, in fact, have a 'rare breed' doctor. hold on to him!

    staff physicians are paid in various ways. the biling and coding bureaucracy that has developed to shuffle money around is too complex to understand unless you are knee deep in it and the rules change every week.

    here's how i get paid. i am a 'staff physician' and i am paid more if i see more patients. i am paid more based on the complexity of the care i deliver, but i have absolutely no clue, with any particular patient, how much their bill will be. here's why...

    and all you attorneys out there... here's a question for you. do we have a potential 'qui tam' action here? hospital bills are closely guarded secrets. it is my belief, and one that i am currently trying to prove, that your bill will be based on your ability to pay.

    example. with 'elective procedures' take a boob-job for example, almost no insurance will cover it (unless you are in the military and then you can get one for free... yes, one to make them smaller or bigger... you choose), so you pay cash or finance it. click on my sidebar 'the best plastic surgeon in america' (and he really is) and you will see that on his site he offers medical financing.

    let's say you don't want to pay his fee and will be satisfied with a 'pretty good' boob job rather than the best... okay, you can go to the guy who advertises in the yellow pages and you will get what you pay for.

    however, let's say you are a retired railroad employee (whether it's true or not the railroads for a long time have had the reputation of having the best medical insurance) and you need a cardiac bypass (open heart surgery).

    one of my family members had this procedure recently and we saw the bill from the whiz-bang academic institution. his charge for a single EKG? $300... it's a piece of paper. the machine itself can be purchased on ebay for about $2000. a single tablet of percocet? $40.

    let's say you are the same patient but have no money and no insurance. you still get the procedure but your bill vanishes into the ether. sure the hospital will try to retroactively get you medicare or medicaid and will try to collect something from either you or 'the government' but your bill vanishes.

    it also works the same if you are in prison (bill to 'the government') or are in the country illegally (bill vanishes).

    it is my belief that those with insurance or money are funding the best health care in the world for anyone who happens to stumble into the country. it is also my belief that the extent to which this happens would raise a huge outcry if it were known. this is why you will never be able to get a straight answer from a hospital if you call them and ask what they charge for, say, an EKG or an appendectomy. the charges are different for everyone.

    here's a bit of advice for any of you out there 'waiting for your insurance to kick in' prior to getting your stress test or your cath our your cholecystectomy. you may die waiting. call your favorite surgeon or cardiologist and ask them how much it is IF YOU PAY UP FRONT. the answer might surprise you.

    for instance, an ENT friend of mine will do a tonsillectomy for $900. add in the OR time and anesthesia and you are probably looking at $2500.
    same bill from going in house with insurance? about $10000.

    so, lawyers, do we have a 'qui tam' action here? if so i want in.

    finally, as to how staff physicians get paid let's talk about me. i see patients and administer treatments etc... i write up the chart. it vanishes and goes to a billing and coding service. some months later payment is received from insurance, the patients, or, more likely, YOU. equations are used, paper is shuffled, the billing and coding people get paid, the hospital gets paid, and whatever remains comes to my pocket where it is taxed and goes to my wallet. that is, literally, as much as i know about how my paycheck is figured.

    realize that with this system, which has grown to the size of rosie o'donnels thighs, is a. byzantine b. unfair c. unnecessary if not for EMTALA and d. incredibly inefficient. all of it adds up to taxpayers footing the bill, once again, for free care for, very often, folks who have smoked, drank, or drugged themselves into their emergency.

    the responsible are punished, the irresponsible are rewarded. madness.

    ReplyDelete
  36. Dear Objecters to my proposal,

    I'm more of a big picture person rather than the specifics, (Myers-Briggs N not S, if that helps), and I see that my comment was pretty poorly stated. Let me just say I agree with most of your specific objections. I meant to say in there that the ridiculous example I gave should apply only to people who could afford insurance but decided not to buy it. And it wasn't meant to be taken literally. It was more of a stake in the ground to get people thinking. Obviously, it failed.

    I do want to address one specific objection. Let me just point out that people who cannot afford to pay for an epidural SHOULD NOT BE HAVING CHILDREN in the first place, because if they can't afford an epidural, they sure can't afford to raise that child. Oh, and the yeah-but-they-were-millionaires-when-she-got-pregnant-but-were-bankrupted-by-a-financial-disaster-over-which-they-had-no-control exceptions fully granted. No need to respond with exceptions like that, I gotcha.

    ReplyDelete
  37. Thank you for the answers Etotheipi.

    Very informative, and, wow!

    Now I know why I’m billed apart from the hospital whenever I am admitted. And I wonder why the hospital is charging me so much! It seems like my doctor should be getting the bulk of the fees, but apparently he’s not. I kind of feel sorry for him now. What is it? 13...16 years of school!

    Good God!

    And 911 doc, thank you too.

    So, you’re sort of commission based? But you don’t really know your commission? That is totally nuts and really, really hard to believe. How is that possible?

    Um, nevermind. :)

    And you’re right about my doc. He’s a gem. When we were uninsured (and still paying our hospital bills ($7,000 worth, just in case you were wondering)), he charged me a about a hundred bucks for 3 days in the hospital. He is so awesome. I pray that he never, EVER moves away.

    I really love that guy.

    I loved your tiny rant about health care, billing, insurance, bureaucracy and all their woes. I understand what you’re saying and realize the problem. And I hope, for my sake and all other non-freeloading Americans, that something gives soon.

    Starting with NO-OBAMA!

    Keep writing. I love it.

    ReplyDelete
  38. Teresa: I'm guessing you've never been pregnant. Fully half of the pregnancies in this country occur by accident, and some women, including myself, get pregnant just by thinking impure thoughts.
    It would increase the abortion rate to withhold anaesthesia from women in labor. and women would obviously be the ones penalized, though they didn't get pregnant by themselves. I did, but they didn't.

    911: Let's give the other attorneys a shot--if they bag out I'll chime in. Love those old common law writs.

    ReplyDelete
  39. Hey Dev, you're not trying to tell us something are you?

    What with your whole newlywed/ultrabiker thing you've got going on. I'm just saying...I KNOW there's been some unpure thoughts at your house. *snort*

    ReplyDelete
  40. Dev, you totally missed the point. But I'm giving up on trying to explain it.

    ReplyDelete
  41. Teresa: Sorry. Horrified by the very thought of having babies without drugs.

    Amy: Nah--I went to the vet and got fixed when I was just a sex kitten (-:

    ReplyDelete
  42. "and all you attorneys out there... here's a question for you."

    Dear 911Doc,

    I will be glad to answer your question. Please call my secretary and make an appointment. She will tell you how much money you need to bring with you just to get in the door to see me. I will provide you with a half-ass answer to your question, and then tell you that in order to fully answer your question, I will need to do some research. Of course, that will require a larger retainer.

    After I flog your file for a few weeks, I will send you a one paragraph letter with my answer, along with a bill for fees and expenses in excess of the retainer.

    Love and kisses,

    me

    PS Can you give Eto a message for me? Tell him I will bring the Peppermint Scope if he brings the balls.

    (Hell, yeah, this is an anonymous comment. I don't think your crazy fans will realize I'm just playin' with ya.)

    ReplyDelete
  43. Well, I'll do for free, after I take a nap. Teaching kindergartners is way harder than practicing law.

    ReplyDelete
  44. Nothing of interest to add other than that poo poo makes me want to yak my lunch. 911, you're the jam in my jelly doughnut and I want you to be where you're happy. What scares me is what will we all do when the good guys have all left the ER? I know what my reply will be to the meatwagon as they load me up; "Screw the hospital, take me to the Ritz!"

    ReplyDelete
  45. One more to go 911, Thank God.

    Lynn Price: Do you ever have anything to add besides sucking up to the blogmaster? You remind me of a brown-nosing college freshman

    ReplyDelete
  46. dear anonymous,

    here's a simple solution. turn the channel, tune us out, go elsewhere. but no. that's fine. we will give you the forum in which you may continue to prove yourself a fool.

    lynn, we do appreciate your 'sucking up'... it's what we live for in our otherwise boring and unimportant lives.

    ReplyDelete
  47. Break out the knee pads lynn. Slurp...slurp...slurp.

    ReplyDelete
  48. Anonymous: Remind me--what have you added?

    ReplyDelete
  49. Anonymous: Remind me--what have you added? --Devorrah

    Snort.

    ReplyDelete
  50. Lynn Price: Do you ever have anything to add besides sucking up to the blogmaster? You remind me of a brown-nosing college freshman
    Um, let's see...(thinking)...(thinking)...nope, I guess I just brown nose. Really, thanks so much for catching my best talents. You rock.

    But you know, I think this brave anon has a problem with me on a personal level. Gosh, if I knew who you were, I could brown nose to you as well. Help me out, oh brave anon...

    ReplyDelete
  51. Oh, and I just LURVE you guys, MDOD.

    ReplyDelete
  52. Can you possibly please post -quickly- about 2 more posts, so this picture disappears into the next page?

    Thanks. :-)

    ReplyDelete
  53. Political activists propose solutions with the same general theme:

    () They have a solution that will work if we would only stop arguing and agree with them.

    () They may need to omit some information about the new arrangements and what these will cost. They observe that ordinary people do not think well enough to make decisions in their own long-term best interest. Dissenters are either uninformed or selfish.

    () There is no need to argue about the specific meanings of words. The good of the society justifies telling some lies, if it comes to that.

    () They do not limit themselves to offering another possibility. They reorganize everything into a comprehensive new system, breaking the existing relationships between people and defining a new set of relationships described by charts, graphs, committees, and regulations. It is an awesome task that keeps many of them at work in the bureaucracy.

    () If there are not enough resources to pay people for their work according to the solution, then those people with the appropriate knowledge and experience (eg. doctors) will contribute some of their effort for free. Whatever it takes for success.


    (Continued at EasyOpinions - Leading the People)

    ReplyDelete
  54. OMG. I thought it was a donut.

    ReplyDelete

ALL SPAM AND GRATUITOUS LINK POSTINGS WILL BE IMMEDIATELY DELETED.