The Customer is NEVER Right - A Nurse Practitioner's Perspective
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First complain...or was it...regardless, the beginning of the end.

I might have had my first “formal” complaint at the current job. Or did I? Not to mention that of all the nights for the complaint to be vented on this one was on Thanksgiving night, yes I worked on Thanksgiving—many in healthcare do. My stating this complaint is not like it was something I been waiting for but instead that I am surprised that I had not heard of one prior.
Now, why “formal”? Well, I been working here for almost a year now without a complaint that I been spoken to but to believe no one has complained prior to this incident is not only a fantasy but outright wishful thinking. So then, why was this complaint different? Because for the first time an administrator got involved. That being the only reason for a complaint to be a “formal” complain and not just someone burning off steam. On that note, from my experience, not only does an administrator’s involvement make it a formal complaint but most significant it is but the beginning of the end as administrator’s were the engines behind past dismissals.
That aside, when asked I always mention my greatest fear in healthcare is not that I may cause injury, disability or death to a patient but that I would return a patient, a child or an adult, to their abuser and that fear is always on my mind.
With that in mind, lets begin. This latest complaint would be a school age child brought in by an “uncle” and an “aunt”, or so they said, when I asked if they were the parents. Keep in mind, that simple question, “Are you the parents?” being something I always ask when I see patients less than 18 years of age. On that note, something else I always ask patients, whether a child or an adult, is what is their last name.
Because of my just mentioned greatest fear always running in my subconscious the moment the “uncle” stated the patient’s last name I became suspicious. Why? Because the last name the “uncle” gave was incorrect. Do not get me wrong, I get it and understand the “uncle” could have misspoke and stated his last name as the child’s so that was not the issue. What caught my attention most was the “uncle” made no attempt to correct himself. On top of that and making me even more suspicious of the adults was the “aunt’s” abrupt behavior to immediately jump in to correct the “uncle’s” misspoken words and the “uncle” still made no attempt to point out he had misspoken.
Again, I understand the “uncle” making a mistake and stating his last name instead of the child’s last name. But the “uncle” making no attempt to correct himself, especially after the “aunt” abruptly jumped in, sent my gut-feeling meter from its common level of DEFCON 3 (Increase in force readiness above normal readiness) to DEFCON 5 (Maximum force readiness) in a nanosecond.
To make a long story short, and what a long story, a debate ensued regarding the need for guardianship documents, which the “uncle” and “aunt” did not have and something that caused even more hairs on the back of my neck to stand up and my gut-feeling meter to sound the alarm. In my brain all I heard were the DEFCON 5 alarms, saw red lights flashing everywhere and could feel the thunder of heavy-duty metal gates immediately falling over every window and door as the emergency department went into lock down.
Again, do not get me wrong, I am well aware and understand that in a number of cultures parenthood and guardianship are almost synonymous or used loosely. In Hawaii it is called Hanai and in Puerto Rico, if not all of Latin America, it is called Hijo/Hija de crianza. In both of those cultures it is the family, aunts and uncles being the most common, who raise the child rather than biological parents. So I get it. But something about this interaction just did not sit well. Not to mention, the “aunt” was argumentative and standoffish when I challenged them with regard to guardianship documents. Not that that is my role but obviously the system had failed. Yea, right, the system, as administrators choose to say because pointing out that an individual failed is not politically correct they say, but that is another topic. Nonetheless, the system had failed as the child was in a room to be seen and guardianship had not been established.
The “aunt” went on to add that I was inappropriate, imagine that, and even worse, that I was inappropriate in front of the child, because that is even a greater sin I guess. Then, on her own as it was not solicited by me or had anything to do with my challenge as to why they did not have guardianship documents, the “aunt” went on a diatribe about how bad the organization I work at was and on and on and on she went. Yet, there she was, seeking medical attention at the same organization she so disapproved of. ANY HEALTHCARE ADMINISTRATORS OUT THERE—THEY COME BACK! REGARDLESS THEY BADMOUTH THE ORGANIZATION THEY COME BACK! Not to mention, she recruited her so-called nephew to be seen at the same healthcare facility she so detested.
Again, something I cannot make up but more important none of which I had anything to do with as she listed a number of other “bad experiences”. Whew! I thought as I mentally wiped my knitted brow knowing the “aunt” had issues with the organization and I was the most recent person she felt she could unload on as if I were her punching bag. So it was not really about me. Unfortunately, administrators NEVER see it that way as they ALWAYS side with those who complain.
Well, maybe not really “Whew!” as it does not matter to me if a patient or family wants to add me into their dissatisfaction list or not. I just added “Whew!” for comic relief thinking it was something someone else would do.
Anyhow, for now, let’s just say that by this point my fear the child was abducted had subsided and my concern had transitioned to what a breach of the system meant. That something so significant, at least in my brain, like the requirements for guardianship was nothing more than words written in a policy book and not something others fretted over.
Having said that, as I have mentioned over and over and will say here once again in hopes SOMEONE(!) is paying attention, that most of those who complain do so for no reason other than their exaggerated unrealistic emotional expectations are not being catered to. And here was yet another incident to cement my claim. AND! AND! They always come back, TOO. Even if they were previously dissatisfied, regardless the number of times, they always come back.
Lets continue on, the patient was brought in because of a headache, sore throat and asthma. None of which I appreciated as an emergent condition from where I stood in the room. The patient was neither in distress or looked ill as I found him laying on the bed and when he sat up to listen to the exchange between me and the adults that accompanied him he was holding his lips together with his fingers.
On that note, what I saw, as is so common among the many who complain, was another exaggeration of symptoms by the patient or those accompanying them. Why? Not sure but from my experience the phenomenon of exaggerating illness is pretty common when there is a hidden agenda, another reason I was suspicious, not of the patient but of those who accompanied him.
Nonetheless, the patient did not have an emergent medical condition. Not that at this facility we use EMTALA’s medical screen examination for the purpose of dismissing those without emergent medical conditions. Not that I have a problem with that as that is the bread and butter in every emergency department across the nation as was cited in the book and a separate topic from this story.
So the fact that at this organization we see every single patient that comes to the emergency department that is not an issue with me. That includes, “I [patient] need a note for school” which might as well be, “I [patient] have a hot date tonight and I need a refill of my Viagra.” Not to say that the latter would not show up to be seen but instead that it is just a matter of time. Nonetheless, it does not matter what the medical complaint, or visit of convenience for that matter is, we will see them all here.
So if the patient did not have an emergent medical condition what was all the commotion with the patient then? Well, after the heated exchange between the “aunt” and I, I said I will be right back and left the room to find out how the patient had been registered and how the “uncle” and “aunt” had been vetted. Again, not my job but I just did not feel well with the circumstances in front of me.
Again, at this point the issue was no longer that this child was abducted but that there was something wrong with the way guardians are vetted, or not.
While asking the charge nurse how it was possible that a non-emergent child not with his parents but with undocumented guardians got to a room the charge nurse could not give me an answer and deferred me to the triage nurse. At the same time, the patient and the adults accompanying him were walking out. That decision to leave by the adults caused me to revisit the possibility that the child might be abducted. However, the child appeared to be comfortable with joining the adults as all three walked out of the emergency department as I kept eye contact with the patient in hope he would give me some signal that he was in danger, he did not.
Despite my intellectual brain doubted the child was abducted my conscious, my gut, my experiences and my education all fought each other in trying to convince me otherwise and even that maybe I was overdoing the possibility that the patient was being abducted. Nonetheless, in my brain each of those aspects of me were at each others throats as I tried to figure this out while at the same time I watched the child leave the emergency department.
At this point, as the patient walked out and me not seeing him turn around, my gut told me the patient was going to be fine but then it was my brain who fretted over my gut feeling. Once the adults and the patient walked out I asked the triage nurse how this had happened and it did not go well. My fury had gone from 0 to 100+ in a nanosecond and that is never good. Not for me and not for others.
After that much-heated exchange between the triage nurse and I, I sat in front of the computer I was using and continued to struggle in my brain with whether this child was abducted or not. Was the child abducted? Should I call the police? Was I overreacting? AAAHH!!! It just would not go away.
The greater irony is that complainers and their sympathizers alike all the time claim that I do not care and/or that I lack compassion. Yet I sat there and struggled. Makes no sense. Let me share why. My struggle was not that this patient was leaving without his sore throat, headache or asthma being addressed. My struggle was that I might have allowed this child to return to those who were abusing him. That being my greatest fear. Yet so many claim that I do not care and/or that I lack compassion.
Interestingly, had this child had an emergency whether he was abducted or not would not have been addressed, which is even more tragic. As, the vetting system is incapable of discovering that horror when the importance of time in completing that simple requirement was least significant that during an emergency it would be useless.
On that note, the one thing I was sure of was the patient had a non-emergent medical condition. How did I know that from standing at the door? I just knew. There was nothing the adults told me or the patient did or his appearance that caught my attention. Except it was Thanksgiving and here they were, in the emergency department, without an emergency and the patient’s guardianship was in question when instead they should be at home with family and friends. Is that not what Thanksgiving is for? Who ever heard of going to the emergency department for no reason rather than being at home  with your family and friends? That was what was most concerning to me after I was sure his medical complaints were benign.
From my experience, neither of the mentioned medical complaints, headache, sore throat or asthma were emergent medical conditions on their own. Not to mention, that collectively the symptoms where even less emergent. On top of that, the patient did not appear to be in any discomfort and much less in any distress or even appeared ill as he played with his lips. And when I asked the adults if they had given the patient anything for his headache, sore throat or asthma their answer was, “That was why we brought him.”
Oh, not the all too common answer, “That was why we brought him.” As if there are not enough commercials on television that advertise about over-the-counter treatments for the same symptoms. On the other hand, that is the healthcare so many think so many are deprived of, but that is another topic.
Nonetheless, I asked, “Why? Do you not have his medicines at home?”
“We do. But thought if we gave him his medicine he would get better.”
WHAT!!!???!!! I know I heard them correctly. They just admitted that, “…he would get better.” Are you FREAKING kidding me!?! My brain exploding, silently, if that is at all possible!!! Trying to keep calm, after all the drama, I said, “But that is what his medicine is for so that he gets better.” But I am sure my knitted brow gave away my frustration not to mention my anger as well.
“He has asthma really bad,” the “aunt” fired back, literally, as if I were standing at the other end of the emergency department.
“Has he ever been hospitalized because of his asthma?” I asked. Wait! Wait!
“No,” the “aunt” fired back again.
Oh, to myself of course, so he really does not have “really bad asthma” after all.
So yes, I felt comfortable this was not an emergent medical condition. Maybe he did have asthma. And maybe he was having an exacerbation as many children and adults do. But most get better after using their prescribed medicines. That’s what their medicines are for. Because of the use of their medicines most, like a whole lot of most, do not need to be seen at the emergency department at all.
Not to mention how many of them wait days before seeking medical attention yet do fine once they take their medicines? Do not get me wrong I know asthma kills. Those patients have crashed in front of me a number of times and needed to be intubated so I know. But this was not the case. So my point, although I am sure many will disagree, this was not an emergent medical condition. Neither was his headache or his sore throat as Dr. Thomas Doyle wrote in his book, Suck it up America, “Not every headache is a tumor.” Dr. Doyle, an emergency medicine physician with decades of experiences in emergency medicine and not Dr. Doyle some PhD administrator somewhere.

Again, this organization does not implement the medical screen examination for the purpose of dismissing non-emergent medical conditions from the emergency department, something I have quite a bit of experience with and have dismissed many headaches and sore throats. Just because there is presence of disease it does not constitute an emergency and they can be seen for those non-emergent conditions elsewhere. But that too is another topic.
To the triage nurse who felt my wrath, and where I suspect the complaint to the administrator came from and not from the patient or the adults with the patient as the administrator was not available at the time of the incident and showed up long after the drama. But I could be wrong, anyhow, to that nurse I want to say, "I am on your side" and...
I, too, AM A NURSE!
To me those are not just words. I truly believe nurses are the foundation of healthcare and in that sense I am an advocate for nurses and only wish others would champion nurses as well. Not to mention, the nurses who I work with at the current organization are not only a pleasure to work with but many times I have asked them to be my conscious regarding a patient’s care and/or disposition. Those consults not because I am not able to make those decisions on my own or because I need the nurses’ blessing before making those decisions but because the nurses offer another point of view and I do not have issues with that.
Having said that, I came down hard on the triage nurse that night. However, after the fact, I would have to say I permitted my frustration with the situation to get the best of me and thus my interaction with the triage nurse was inappropriate and not deserving of the triage nurse. For that I have apologized to the triage nurse.
Just so critics know, not that I care about my critics but in case my critics care that I do not care about them, that apology was on my own and not at the administration’s suggestion and much less with the administration's blessing or knowledge, as I do not need any administrators to be my barometer of conduct, fairness and much less leadership. On top of all that, the complaint wheels were already in motion. Meaning, I have nothing to gain and much less can influence the complaint in any manner by me apologizing to the triage nurse. Regardless if it was the triage nurse or not who submitted the complaint. If there is anything that I have learned after so many complaints against me it is that there is no way of stopping those wheels once they get into motion and much less turning them back, even with reason, regardless the situation, what was said or not, yada, yada, yada. And because I expressed my discontent in public I apologized to the triage nurse in the most public manner I could as well as I believe that apologizing in private would not have been sufficient.
All that said, this is not about calling out nurses but instead, once again, this is about the culture of healthcare which has been force fed a bunch of CRAP and then chased down with the administration’s self-brewed kool-aide. An idiotology [sic] that only forces healthcare workers into a corner when pushed back by patients where the only options healthcare workers have is losing their integrity over keeping their jobs and their integrity losses every time.
I get it, it is so much easier to stand with the crowd and look away, not to mention, no one wants to be blacklisted, excommunicated, vanished and much less unemployed. I get it! I have been there MANY times! I also know that leadership, something healthcare administrators lack, takes COURAGE but at some point healthcare has to find that COURAGE and stand up from living on its knees and apologizing to every one that gets offended or is challenged.
Interestingly, the patient’s nurse questioned registration regarding the incident and the policy and I was shocked as to what I was told. The patient's nurse informed me that when these incidents of guardianship lack documentation in the Express Care those patients are referred to the emergency department because the Express Care providers will not see those patients. And I agree they should not see them as those are nothing more than visits of convenience and another reason we should not have to see them in the emergency department either. Having said that, what is most important and what is being missed is that during these incidents it is the NEED to establish guardianship that is most significant regardless if the visit is of convenience or an emergency. 
Instead, now what we have other issues. One, the lack of guardianship being so common that the system has mutated in order to accommodate that expectation. So where I was fretting on whether this child was abducted or not, maybe, just maybe, it was just “the way of doing things” that the “aunt” and “uncle” had gotten accustomed to. So maybe, just maybe, the issue was not that children are being abducted but instead that the system is so lackadaisical in vetting guardianship that the systems has mutated to a more accommodating system, once again, way to go healthcare. Just look away and the next time that patient comes in with his “aunt” and “uncle” who disagree with the parent's religion, or whatever else, and they consent to a blood transfusion the parents disagreed with, among the slew of other disputes, the issue of guardianship will make sense to administrators, or maybe not.
Two, why is Express Care referring those patients to the emergency department when the issue is lack of guardianship and not an emergent condition? Granted, I cannot imagine it is an influx of patients who lack guardianship but it is so inappropriate! As if a lack of guardianship somehow upgraded the patient's condition to emergent. NO! It only caters to exaggerated unrealistic emotional expectation as the patient still lacks guardianship. Unless, and I know I am wrong, that the emergency department at this facility does not care to establish guardianship for pediatric patients. 
Is anyone paying attention here? This is nothing but another great idea from stupid people, which has broke the system.
Whatever! As by this point in my career and my on going struggle with healthcare administrators I am not surprised. So when the administrator shows up after the fact and jumps into this episode after hearing of the confrontation somewhere or somehow from someone I am not surprised that the administrator would side with the patient. Again, that is par for the course and, as customarily, without getting the healthcare worker’s side of the story before administrators chalk it up for the patient.
Patient: 1. Healthcare worker: ZERO!
Having shared that, it was no surprise as well that in keeping with past administrators and more than likely those in the future as well that this administrator, TOO, went fishing to find those to blame and the conversation went something like this, “I [administrator] heard the night did not go well with some kid.”
Unknown to the administrator there was another kid, although the other one was an adult kid and the son of an adult patient, with which there was also a dispute that night. Again, Thanksgiving night of all nights that patients and family decided they would challenge those trying to help.
The synopsis of the adult patient was that the patient needed transfer to a facility of higher care due to the services the patient needed were not available at our facility. Everything was done. The patient agreed to be transferred and a physician had accepted the transfer at the other facility. All that was left was to call an ambulance for transfer. However, just before the call was made the adult patient’s son showed up and the son did not want the patient transferred due to the cost. As far as I am concerned, as long as a patient is awake, alert, oriented to person, place, time and situation and the patient is competent and the patient’s judgment is appropriate that is a decision the patient makes. Simple! This patient posed all those faculties. However, the son convinced the patient there was no benefit in being transferred by ambulance and that he could drive the patient himself.
That is fine and I would even agree that the cost of transfer is an added cost and the son could drive the father over to the accepting facility as well. However, and a big however, this was not one of those patients. Instead, this was one of those patient with who I always share, “Your condition can worsen between here and there and you do not have the ability or the equipment an ambulance and crew have if intervention were needed and that is the purpose of the ambulance. I have nothing to gain by sending you by ambulance other than your best interest.”
On that note, I do not take risks with patients but patients who want to take the risk may do so. However, sometimes those adventures do not turn out well and the reason we make decisions that are in the patient’s best interest.
Just recently, a young man’s family thought they could get him to the emergency department faster than the ambulance could and they were correct. What the family did not anticipate was the patient’s condition would worsen while in route and by the time the patient reached the emergency department he was not breathing and did not have a pulse. Despite a lengthy attempt to resuscitate him that young man died. It is very unlikely that unfortunate outcome would have been the end result if the patient had been transported from his home to the emergency department by ambulance—a tragedy just to avoid the cost of an ambulance. Not worth it.
Interestingly, most ambulance runs are non-emergent according to discharge diagnosis but that too another topic. However, that is something those using the services are not expected to know.
Anyhow, in keeping with healthcare administrators everywhere, this administrator was no different in dismissing the patient leaving against medical advice as not a concern of the organization’s administration. Why? Anyone? Anyone? Anyone want to take a crack at that obvious answer? Simple. Patients, who leave against medical advice rarely, if ever, complain, as it is a decision the patient is making.
Having said that, in “The Customer is NEVER Right” I mentioned a patient who did leave against medical advice because of an issue with a cat. However, it is rare those who leave against medical advice complain. Unless, of course, they are patients I cared for because somehow I manage to bring out the best in people. That comment for the purpose of comic relief, although some might disagree, that the former was comic relief and that I really do bring out the best in some.
Nonetheless, patients who leave against medical advice rarely, if ever, complain or badmouth the organization, the latter being every administrator’s fear. On that note, one would think healthcare administrators would be most concerned about a patient leaving against medical advice over a dissatisfied non-emergent patient in the emergency department. Yet, over and over and over, that is not the case. Something I find interesting, because in most cases, if not all, those leaving against medical advice are doing so without a completed evaluation that being the purpose of healthcare, to help others. Not to mention, I believe no one has the patient’s best interest in mind, to include over the patient, than the healthcare worker taking care of the patient. But again, something I have not learned is that healthcare administrators, despite what they may say out of the side of their mouths, they are not as interested in patient’s care as they are about what patients may tell others. Critics will say, “How dare you ‘paint’ every healthcare administrator with a broad paint brush like that?” Easy, and although it might hurt their feelings, it is a FACT!
And to those who disagree with my assessment of healthcare administrators I challenge you to call out those bad apples “up the street” you compete with than. Because healthcare is about helping others and not about what numbers they have “up the street” or what they are doing to attract customers. As healthcare workers do not see those “up the street” as the competition but as colleagues trying to help others.
Nonetheless, in an attempt to make a point the administrator added, “If you thought the child was abducted why did you not call the police?” Touché! And correct. However, unknown to the “concerned” administrator I did struggle with calling the police. On that note, the adjective “concern” being sarcastic as to whether or not the administrator’s concern was genuine or not as there was no offer by the administrator to call the police either and who I would believe would have been as concern that an abduct child was allowed to leave the facility. The latter being something that would not look good on the front cover of the morning paper.
Something I chose not to share with the administrator was that I did think of calling the police but did not after convincing myself, and what a struggle it was, that maybe I had overreacted with this patient being abducted. Having said that, despite that my concern for this specific child was no longer that he been abducted but I was still, VERY MUCH, concerned that the system was broke with regard to my greatest fear, a patient returned to their abuser. After going through all that, both in my brain and being inappropriate with the triage nurse, I can only hope that my concern, a legitimate and genuine concern I will add, was now being missed, rather than intentionally dismissed, by the administrator.
On that note, to include the additional point that the patient was not an emergency as the administrator’s suggestion to the problem, if there was such a problem, that a simple call to the patient’s parents to obtain consent over the phone was all that was needed. Again, and I know it is redundant, yet it keeps getting missed so bare with me while I share with those most concern, the administrator.
That was my point, that no one had bothered to call the parents or made any other attempt to vet these adults and more so despite THE PATIENT DID NOT HAVE AN EMERGENCY! Your system is broke!
Now imagine. Just imagine. Had this child had an emergency at the hands of his abusers and they brought him to the emergency department, where procedures likely would take place of whatever scope, to only return the child to his abusers who were impostors. Far fetched? ABSOLUTELY. Possible. In this broke system, ABSOF&#KINGLUTELY! Imagine if this child would have been Elizabeth Smart who came through the doors with her abductors. Is there still doubt?
Having said that, when I mentioned to the administrator that the adult had not only pushed back when I challenged her, with regard to guardianship, but that the adult had also interrogated me as to who gave me the authority to challenge her the administrator’s response was the all to common response of healthcare administrators. That being that challenges by patients and families were common and acceptable in healthcare and that if I was not aware of that that I should get with the program and get over it. Oh. Okay.
NO! It’s not okay. Yet, again, yes again, because it seems I am the only one noticing, once again, healthcare’s accommodating culture at its finest. Not to mention, the healthcare worker, those trusted with caring for others after only being extensively vetted, is brushed off by the administration. This clash with a healthcare worker for being concerned that something was not right about the bigger picture—regardless if this specific child was abducted or not. But, instead, that the system was so lackadaisical that a child could have been abducted and had the adult not been challenged things would have gone as usual and no big deal.
Then after it was all said and done, the administration’s answer to the whole ordeal was just to call the parent to get consent over the phone. Again, it is redundant yet no one gets it that that was the issue. Obviously, calling the parent’s for consent was correct BUT(!) no one had done that and the patient ended up in the room. Where! Where! It was up to the healthcare worker seeing the patient would, making an ASS(!) of themselves, assume the parents were contacted by phone and consent was obtained. BUT(!) that was not done. Is anyone paying attention!?! IT WAS NOT DONE! Because of that, who ever saw the patient could have seen a child who WAS(!) abducted and no one would have known the child was abducted.
Is anyone paying ATTENTION!?!
Again, when the administrator was informed of a patient who was to be transferred to a facility of higher yet left against medical advice the administrator dismissed that scenario as it being a decision the patient made. And I agree. However, leaving against medical advice at the risk of worsening condition, permanent damage/disability and even death HAS to be worse for the patient than a patient badmouthing an organization. Yet, healthcare administrators are not a  bit concerned of those leaving against medical advice, because, again, few of those patients complain as the patient's decision to leave, rarely, if ever, has anything to do with customer service. Although some might disagree when it is a patient that I might have seen but that is another story.
On the other hand, a challenged adult who becomes angry and choses to leave because they are dissatisfied IS a concern for administrators. Mind you, that is a non-emergent medical condition patient, which has no risk with leaving, and, and, may, if not likely, will, get better without medical intervention at all.
What is the difference, not for the healthcare worker whose role is healthcare and the goal of helping others but for the administrator? Simple, the administrator’s interest and intent is to avoid a complaint, more so, avoid that the dissatisfied customer might badmouth the organization.
No one, to include their family or friends, who leaves against medical advice and dies as a result of their decision ever badmouths the organization. How could they? It was their poor decision-making that led to their demise.
Is that not amazing? That healthcare administrators are okay with someone who needs a higher level of medical care leaving against medical advice, despite the risks. Yet, someone who does not have an emergent medical condition and likely not need medical intervention at all is chased down. I cannot make this stuff up.
The end point for me is that this incident is likely the beginning of the end. Meaning, that I am certain of, as I have seen this movie so many times before that I have memorized the lines, that this incident will likely be the beginning to the end of my tenure here.
Once again, I have to come to terms that “My brain has no heart and my heart has no brain. That being the why as to when I speak my mind, ‘that healthcare is broke,’ I seem heartless and when I do what’s in my heart, ‘like looking out for a patient’s best interest’, I seem thoughtless.”
Just my two sense [sic]!

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