nurse practitioners

[Jochi1543]

I'm assuming any FP would at least do a basic exam and history to rule out come to a working diagnosis and rule out serious problems, unlike the things I have seen midlevels do. I haven't done my family rotation yet though, and I guess even if I do, the type who works in the academic setting will probably not be the type you're describing.

 

You just wait. My jaw sure dropped a few times throughout my rural rotation where there was a big transient population and so quite a few people would come in under our care from some other GP elsewhere in the country/province. It's amazing how some GPs continue to practice medicine with some of the stuff they do (and more so, DON'T do). And sometimes patients don't know any better, unfortunately, and they happily walk away with a dx of fibromyalgia or whatever with no work-ups and just continue to suffer thinking there's no cure for them.

[leviathan]

You're not familiar with anesthesia, are you? I don't know that there's currently much prospect for CRNAs - we do have anesthesia assistants, who come from RRT backgrounds, but they do not have an independent scope of practice and aren't likely to get one. If one of my preceptors is to be believed as well, there are considerable differences between the overall standard of anesthesia care in Canada versus the US and even quality of training.

Meh...ive worked with both Canadian and American anesthesiologists....found they were pretty equal in knowledge. Go to the SDN forum and read some of the epic discussions (the ones about anesthesia care, not firearms or best brands of tequila or their new land rover etc).

[moo]

To elaborate further on my last post: If a NP saw a pregnant patient with a headache, her differential was basically the following: pre-eclampsia or non-pre-eclampsia associated headache. She either had pre-eclampsia or she was fine. After ruling out the former, treatment for the latter was esgic.

 

Seriously.

 

This is the kind of thing where yes, the vast majority of these midlevels didn't miss anything bad, not because they were skilled providers, but because 99.9% of the time this population of young healthy pregnant women are going to have some benign primary cause of headache. I'd hate to be that 0.1% of pregnant patients going to this provider with serious pathology and end up being harmed by their negligence. It's that low frequency that also prevents any study from detecting their incompetence, unless you had a trial with tens of thousands of patients...

 

Trust me, family docs miss many diagnoses too. Case in point, I saw a patient in walk-in clinic. Had Parkinson's. Was fatigued for several months. Family doc told her due to PD. Neurologist told her due to PD. I did some BW. Liver enzymes sky high. U/s and CT showed pancreatic mass. Dead within 1 month.

 

It's not that she would've survived the pancreatic cancer had her FP or her neurologist diagnosed it earlier, but my point is people WILL miss things, regardless of whether you're an NP or an FP or a specialist even. This is particularly true in Canada where you don't have the fear of a lawsuit hanging over your head and you're not going to investigate every little complaint.

 

And your example of the headache in the pregnant patient: After ruling out pre-eclampsia, are you going to perform a CT scan on this patient? On every patient that comes in with a headache? Sure you can examine them, but physical exams are not 100% specific and sensitive for diagnosing brain tumors. No test is, not even a CT scan. Not even an MRI. You're saying you'd hate to be this 0.1% who went to this provider who missed something. Well, if I told you a test was 99.9% sensitive, you'd say that's a pretty darn good test, right, at least for ruling things out. Yet, very few tests are 99.9% sensitive. Would you say that I'm a bad family doc because I ordered a test that was 99% sensitive, and you happened to be that 1% that this test missed but I told you it was unlikely that you had cancer because of it? Point is, you WILL miss things. As a public health guy, I once called a family doc because he had ordered a botulism test on a patient. Med micro was upset because this test is expensive (plus you have to sacrifice a lot of mice) and wanted me to see if the family doc really wanted the test done. I called him, got the history on the patient, and when I asked the family doc if he had examined the patient, his answer was "her neuro was grossly intact." Inquiring further, he said "oh I just tested her grip strength, you know how busy clinic can be". I'm like, of course I know how busy clinic can be, I see 50 patients in 5 hours at times... but that doesn't mean I won't examine the patient, especially over the course of 3 visits in a week! Blindly ordering tests like this is bad medicine.

 

My point is, there are a lot of bad family docs out there. You can't label all NPs as bad, just like how you can't label all FPs as bad. And EVERY doctor will miss things. It's statistics.

[moo]

4 years spent learning about how the body and disease and biochemistry and organ systems work? yes i think that has something to do with being a doctor.

 

a 4 year math degree? not so much

 

and i know all about all the health care professions i've researched for a very long time' date=' i know the nursing/nurse practitioner curriculum and looked at becoming one for a very long time - also my sister is a nurse.

 

you're underestimating just how much more knowledge doctors have than nurses.[/quote']

 

I did math and physics. Not relevant to medicine? Hardly

 

Bio and biosciences are not helpful at all to being a doctor. How many times do doctors really think about underlying pathophysiology when they diagnose something?

 

YOu will need to have some math skills... at least the good doctors do. Why do you think all the hard core specialties (gen surg, neurosurg, ortho, etc.) all have their residents do a masters in epidemiology? It's because of the analytical skills that they gain. Premeds and medical students don't think about epi, don't think about statistics because it's out of their realm and that scares them. But when you're diagnosing a patient, understanding what really constitutes a good diagnostic test, what constitutes a good screening test, pre-test probability, post-test probability... that's what you need to become a good doctor. Sure you need anatomy if you're a surgeon, histology if you're a pathologist, and neuroanatomy if you're a neurosurgeon or neurologist, physiology if you're an internist/anesthesiologist, etc. But you learn all of this in medical school. The undergrad training you undertake, whether in bio, or biochem or physiology is largely irrelevant. What you need to know you'll learn in med school.

[moo]

If you give them an inch, they'll take a mile.

 

It sounds good now. NPs can work under the supervision of family physicians to provide citizens with better access to care. Then they will try to legislate their own equivalence to doctors, and obviate the need for supervision. Patients will be calling their nurse "doctor". After that, they'll try to legislate unsupervised practice in other areas like anesthesia, dermatology, cardiology etc. It's happening in the USA now. In fact, nurse anesthetists get paid more than family physicians for far less training and responsibility. Sounds like a good deal for the nurses.

 

The whole nurse practitioners can do family medicine notion is only true if one thinks family practice consists of nothing more than canned algorithms. It does not.

 

The best way to prevent this encroachment is to put the kibosh on it immediately.

 

Of course, you could argue that they could train to become equivalent. But that would be called going to medical school.

 

I don't care so much about NPs because they at least are not quacks.

 

What bothers me is that the provinces are giving prescribing rights, and lab test ordering rights to naturopaths. They are essentially equating naturopaths to primary care providers and legitimizing their profession. And what bothers me even more is that the governments want people to have "choice" in health care. Well, I'm sorry, but first of all, paying for ND services draws money away from real health care. Second, there should be no choice in health care, because health care is defined as care provided by doctors (CHA). PERIOD. Why not legitimize care provided by some random quack off the street? By the straight chiros? I think this is what we need to be afraid of. NPs are pretty legit. I've worked with them; they make your life simpler. Sure there's nothing from stopping them from lobbying for more power, but to be honest with you, we have a pretty strong medical lobby in this country and we'll protect our turf (case in point, no CRNAs-yet).

[leviathan]

Trust me, family docs miss many diagnoses too. Case in point, I saw a patient in walk-in clinic. Had Parkinson's. Was fatigued for several months. Family doc told her due to PD. Neurologist told her due to PD. I did some BW. Liver enzymes sky high. U/s and CT showed pancreatic mass. Dead within 1 month.

Ah man..that's sad. See, even a nurse practitioner would follow a standard 'fatigue' algorithm workup...order liver enzymes, get a CBC, get a BUN+creatinine, get a TSH etc etc. You're right though, it probably would have been too late regardless.

 

And your example of the headache in the pregnant patient: After ruling out pre-eclampsia, are you going to perform a CT scan on this patient? On every patient that comes in with a headache? Sure you can examine them, but physical exams are not 100% specific and sensitive for diagnosing brain tumors.

I was more referring to just an H+P. Before I presented to this midlevel. I checked her vitals, made sure temp was normal, asked about neck stiffness, asked about the characteristics of the HA to try and rule out SAH, meningitis, temporal arteritis etc. It's also getting into the cold months and I asked what kind of heating source she had and if she had other household members with similar complaints to rule out CO poisoning. I did a quick exam and checked for things like focal neuro findings or papilledema.

 

All I had a chance to tell the NP after the usual pre-natal info was that the patient had a headache. The NP went in and did the following: no proteinuria, no hypertension, no non-dependent edema? She asked about RUQ pain and visual changes? No to all of the above? Here is a script for esgic. Bye!

 

 

No test is, not even a CT scan. Not even an MRI. You're saying you'd hate to be this 0.1% who went to this provider who missed something. Well, if I told you a test was 99.9% sensitive, you'd say that's a pretty darn good test, right, at least for ruling things out. Yet, very few tests are 99.9% sensitive. Would you say that I'm a bad family doc because I ordered a test that was 99% sensitive, and you happened to be that 1% that this test missed but I told you it was unlikely that you had cancer because of it?

I totally agree with you, BUT, if the patient had anything bad going on with her, since she did absolutely no workup, this midlevel has a 0% sensitivity. She had a 99.9% negative predictive value, but that's simply due to the sheer low prevalence of any bad pathology in a young patient. When a patient rolls through the door and is actually sick, she will miss 100% of them. Let's be fair and say someone legitimately sick is usually obvious even on a simple visual inspection, so she might catch some of them. The point is, a family doctor would hopefully catch far far more of those bad cases with their far superior knowledge base and clinical accumen.

 

When you try to study the difference between the two you will still not find a change in mortality or morbidity. The negative predictive value of both the RN and the MD will both be 99.9% (and a good enough study might find it is actually 99.91% vs. 99.92%). Does that mean from a population health point of view, a nurse practitioner can do as good a job as a family doctor at keeping the community healthy? Absolutely. Does that mean I want a nurse practitioner taking care of my parents? Absolutely not!

 

My point is, there are a lot of bad family docs out there. You can't label all NPs as bad, just like how you can't label all FPs as bad. And EVERY doctor will miss things. It's statistics.

Agree with you 100%, but I am just arguing that family doctors will miss MUCH less. Or maybe I have just had bad experiences with midlevels so far and they are not as bad as the ones I've seen.

[thebouque]

I did a quick exam and checked for things like focal neuro findings or papilledema.

 

Did you perform a funduscopic exam on all those headache patients?

[leviathan]

Did you perform a funduscopic exam on all those headache patients?

I always do this on anyone if they don't have a history of headaches / this is something new to them. It's also good practice as a student. Why?

[Dongzhuo]

It's not about the years spent in school at all. Canadian med schools produce outstanding physicians because the admissions process is so stringent and tough. It's kind of like private schools vs public school. Why do exam scores and university placement in private schools outshine public schools each and every year? It's not because they teach you better stuff, it's just that the student pool was preselected to succeed.

[A-Stark]

I was more referring to just an H+P. Before I presented to this midlevel. I checked her vitals, made sure temp was normal, asked about neck stiffness, asked about the characteristics of the HA to try and rule out SAH, meningitis, temporal arteritis etc. It's also getting into the cold months and I asked what kind of heating source she had and if she had other household members with similar complaints to rule out CO poisoning. I did a quick exam and checked for things like focal neuro findings or papilledema.

 

All I had a chance to tell the NP after the usual pre-natal info was that the patient had a headache. The NP went in and did the following: no proteinuria, no hypertension, no non-dependent edema? She asked about RUQ pain and visual changes? No to all of the above? Here is a script for esgic. Bye!

 

Wait... was this a pre-natal visit or a more general appointment? Unless the patient specifically came in complaining of a headache, I don't know that I'd start probing about SAH much less temporal arteritis. I don't remember making a point of doing a thorough functional inquiry in pre-natal clinic. It's true that you can miss stuff if you don't ask about it, but I always find that if you just let most patients talk about what's been happening, they can lead you to what might be relevant.

 

Having said that, I've found that most midlevels are quite good, but NPs often have odd gaps in experience or knowledge - while on an inpatient cardiology rotation, for example, the NP had a patient with BRBPR and abdominal pain, though as I recall there was nothing concerning with respect to vitals or blood work. She thought the patient had an "acute abdomen" (she did NOT have frank peritonitis by any stretch), and a CT was arranged which predictably showed severe diverticulosis. Pain was unusual in that setting, of course, but it also eventually settled on its own.

 

What the NP did NOT do was a DRE to check for, say, a bleeding rectal tumour. Of course, such a thing might up on CT, but if it was intraluminal it certainly wouldn't. I don't know that she did anything wrong per se - there is definitely a tendency these days to rely on imaging to get a diagnosis rather than to confirm a suspicion or clarify a diagnosis. I'm really not sure what she expected to see on CT, but either way it wasn't the most appropriate first step in management. And she didn't do the DRE because she'd hardly ever done one before.

[leviathan]

Wait... was this a pre-natal visit or a more general appointment? Unless the patient specifically came in complaining of a headache, I don't know that I'd start probing about SAH much less temporal arteritis. I don't remember making a point of doing a thorough functional inquiry in pre-natal clinic. It's true that you can miss stuff if you don't ask about it, but I always find that if you just let most patients talk about what's been happening, they can lead you to what might be relevant.

For the specific example I gave, this was prenatal clinic and this was their chief complaint when I walked into the exam room. They had already called the on-call service over the weekend and were given tylenol for the headache, which they'd been using for 4 days with increasing severity of the HAs and no relief from the tylenol. Maybe it is overkill and maybe I'm being too anal, but I feel if you're going to treat someone's problem you need to work it up appropriately.

 

Having said that, I've found that most midlevels are quite good, but NPs often have odd gaps in experience or knowledge - while on an inpatient cardiology rotation, for example, the NP had a patient with BRBPR and abdominal pain, though as I recall there was nothing concerning with respect to vitals or blood work. She thought the patient had an "acute abdomen" (she did NOT have frank peritonitis by any stretch), and a CT was arranged which predictably showed severe diverticulosis. Pain was unusual in that setting, of course, but it also eventually settled on its own.

 

What the NP did NOT do was a DRE to check for, say, a bleeding rectal tumour. Of course, such a thing might up on CT, but if it was intraluminal it certainly wouldn't. I don't know that she did anything wrong per se - there is definitely a tendency these days to rely on imaging to get a diagnosis rather than to confirm a suspicion or clarify a diagnosis. I'm really not sure what she expected to see on CT, but either way it wasn't the most appropriate first step in management. And she didn't do the DRE because she'd hardly ever done one before.

Well this is the main problem with midlevels. They can function well in their small little niche of medicine, but as soon as a patient has a complaint that falls outside of that area, they crumble. The NP in that OB clinic was excellent at prenatal care, but her differential for any complaint a patient had were diagnoses that only fell under under OB problems.

[moo]

leviathan, as a student, I think you're being way more thorough than you need to be. I too can rattle off a differential for a general headache, but those things you mentioned are extremely rare to begin with. As you progress, you'll realize that physicians take short-cuts too and are nowhere near as thorough as you are at your stage of training. If you have a young pregnant woman with a headache, temporal arteritis is not going to be a consideration because the epidemiology doesn't fit. Also, you can tell a lot just by observing the patient. If they're nodding or shaking their head, meningitis is not going to be the cause of their HA. I guarantee that you too will change and will learn to develop targeted histories and physicals. When I was at your stage, I asked everything, not because I didn't know what to target. It's like working up a 20 year old guy with chest pain for an MI. Can it happen? Yes. Will I do it if the history doesn't fit? No. You don't know how many patients who are in their 20s come in with chest pain. Sometimes if I suspect something (pneumothorax or PE), I'll send them to emerg to get worked up. But sending every 20 year old who comes in with chest pain is not something I do.

 

The other thing I need to say is that studies have shown one difference: and that's that NPs tend to be MORE thorough than they need to be than physicians. This probably results from their strict adherence to algorithms, much like how you are when you first start off as a student.

 

A-stark, not doing a DRE in someone with rectal bleeding is all too common among family doctors. I once was talking with a surgeon and he was like saying how many family docs don't even bother doing a rectal on patients that come in with bleeding. Whether it's due to laziness or lack of intelligence, I don't know.

[thebouque]

I always do this on anyone if they don't have a history of headaches / this is something new to them. It's also good practice as a student. Why?

 

I'm not criticizing your judgement and it's true that doing lots of funduscopic exams is excellent practice, but from my point of view you might be taking your assessment a little too far for a prenatal/labor triage service. Most pregnant women are under 35 and a new onset of typical migraine or tension headache at that age is not a red flag. Unless there are obvious concerns that they might have elevated intracranial pressure, no OB GYN or family doc would do a fundoscopic exam. They might do an extremely superficial neuro exam and that's about it. I think that if the NP wasn't doing any thorough assessment it's because that's the way it is in such OB units, not because they're NPs.

[leviathan]

I was taught to always rule out the emergent causes of any chief complaint. That doesn't mean you need to do serial trops and ECGs on a 20 year old with chest pain, but you at least have to get them to characterize their pain, rule out family hx of other relatives having MIs in their 20s, and recent cocaine use and that kinda stuff.

 

I'm surprised that people are saying this NP's treatmet is appropriate. Not checking papilledema is totally fine (i didnt elaborate on her HA but it didn't sound like increased ICP at all), but not even asking her to characterize the pain or ask about red flags I still do not agree with. Especially in someone who is a repeat visit for headache. I guess I have lots to learn!

[A-Stark]

A-stark, not doing a DRE in someone with rectal bleeding is all too common among family doctors. I once was talking with a surgeon and he was like saying how many family docs don't even bother doing a rectal on patients that come in with bleeding. Whether it's due to laziness or lack of intelligence, I don't know.

 

I've never understood the reluctance to do DREs. Patients never seem to mind them as much as you think they will, and it takes all of 10 seconds. Or less. The case I mentioned was a good example of a failure to construct a proper differential prior to going to CT and doing an inadequate exam in the meantime. That NP is excellent at most aspects of ward work, though, and - as you point - family doctors are *hardly* always much better.

 

I was taught to always rule out the emergent causes of any chief complaint. That doesn't mean you need to do serial trops and ECGs on a 20 year old with chest pain, but you at least have to get them to characterize their pain, rule out family hx of other relatives having MIs in their 20s, and recent cocaine use and that kinda stuff.

 

I'm surprised that people are saying this NP's treatmet is appropriate. Not checking papilledema is totally fine (i didnt elaborate on her HA but it didn't sound like increased ICP at all), but not even asking her to characterize the pain or ask about red flags I still do not agree with. Especially in someone who is a repeat visit for headache. I guess I have lots to learn!

 

Well, it's hard to criticize someone on a single incident, and I expect it incorporates "pre-test probability" into how it was managed. If the patient has only recently started having a headache and has experienced no mental status changes, with normal vitals and no other symptoms or findings (especially re: pre-eclampsia), I'm not sure what else is reasonable to do. As mentioned, things like SAH, meningitis, and temporal arteritis are so unlikely given this presentation. I don't think you need to do a full functional inquiry to really rule them out, as they'd almost be covered in the chief complaint and the onset. Short of "worst headache in my life" or "thunderclap headache" or "lights are bothering me and my neck is stiff and my head hurts", I don't think that "headache" is itself an especially specific thing that requires such level of thoroughness.

 

Having said that, I don't think you did the wrong thing at all. I just probably wouldn't have done the same, despite being at a similar level of training.

[leviathan]

If you have a young pregnant woman with a headache, temporal arteritis is not going to be a consideration because the epidemiology doesn't fit.

That was a bad example to use in a list, but the majority of the other things require some sort of history or exam to say you ruled it out. Even for t.a it at least comes across my mind, and I immediately can rule it out because of her age<<50.

 

The other thing I need to say is that studies have shown one difference: and that's that NPs tend to be MORE thorough than they need to be than physicians. This probably results from their strict adherence to algorithms, much like how you are when you first start off as a student.

That is actually reassuring to me in a way. This person I observed was the exact opposite.

[leviathan]

Well, it's hard to criticize someone on a single incident

I can provide many others, this was just one example.

 

I don't think that "headache" is itself an especially specific thing that requires such level of thoroughness.

I guess it's the fact that "headache" is not an especially specific thing that in my opinion requires further questioning to elucidate what's really going on. You need to do your OPPQRRST questions, you need to do a review of systems and rule out stiff neck, photophobia and worst headache of my life and thunderclap etc. While usually I get a 'no' to every ROS question, I'm sure you have seen as many patients as I have who fail to volunteer a piece of history which was alarming, but not to them. To have a patient tell you that their headache has been getting worse since the last visit and not responding to tylenol, and to pull out an rx pad and give them Esgic without doing anything else just seemed inappropriate. And while most of those things are pretty unlikely, one thing which is not at this time of the year is CO poisoning, as an example.

 

At any rate, it sounds like we have to agree to disagree. I feel like taking a couple minutes to ask a few questions and rule out any red flags is not a huge burden. But I totally see your point of view about pre-test probability dictating she is going to be fine, and it being more efficient to manage them that way.

[A-Stark]

Well, I don't really disagree. I can't say for sure what I would have done with this patient since I wasn't there.

[aaronjw]

fascinating discussion!!!

[Prince Medward]

I find the implications of the above discussion very troubling for those contemplating a career in Family Medicine.

 

Is the existence and likely growing prevalence of NPs a reason for medical students to shun family practice?

 

Why not just end all FP training programs and let the army of cheaper to train (an probably cheaper to reimberse) NPs take over primary care?

 

Are there any good reasons why the above scenario will not happen and why current FP residents are not already walking dinosaurs?

[thebouque]

I find the implications of the above discussion very troubling for those contemplating a career in Family Medicine.

 

Is the existence and likely growing prevalence of NPs a reason for medical students to shun family practice?

 

Why not just end all FP training programs and let the army of cheaper to train (an probably cheaper to reimberse) NPs take over primary care?

 

Are there any good reasons why the above scenario will not happen and why current FP residents are not already walking dinosaurs?

 

One thing for sure, if we were to shut down the fm residencies and replace them all with NPs, we'd have a HUGE shortage of nurses and our health care system would collapse.

[A-Stark]

Honestly, I can't fully understand why RNs would become NPs only to do housestaff work on inpatient wards on an interminable basis. One nice thing about moving beyond residency - or even just the PGY1 level - is having underlings to do your scut work for you. Yet NPs end up doing lots of dictations and notes and social work consults and gods-know-what-else kind of monotonous paperwork.

[Icebox]

Honestly, I can't fully understand why RNs would become NPs only to do housestaff work on inpatient wards on an interminable basis. One nice thing about moving beyond residency - or even just the PGY1 level - is having underlings to do your scut work for you. Yet NPs end up doing lots of dictations and notes and social work consults and gods-know-what-else kind of monotonous paperwork.

 

Fairly good pay, reasonable hours as they do away with the shiftwork, and no call. So they're doing resident work but get made much more and get to leave work at a fixed time.

[Jochi1543]

For the specific example I gave, this was prenatal clinic and this was their chief complaint when I walked into the exam room. They had already called the on-call service over the weekend and were given tylenol for the headache, which they'd been using for 4 days with increasing severity of the HAs and no relief from the tylenol. Maybe it is overkill and maybe I'm being too anal, but I feel if you're going to treat someone's problem you need to work it up appropriately.

 

I feel like you are being unfair by generalizing this ONE incident as being a reflection of the competence of EVERY NP/other mid-level out there. As an example, I saw a younger adult female who had had CONSTANT heavy vaginal bleeding for 3 years straight (! esp. for the ladies here). Her GP's only investigation during those 3 years? Pap smear. But I don't think that we should make a broad generalization about ALL GPs being incompetent and unable to think of anything other than cervical cancer as a cause for vaginal bleeding just based on this one incident.

[ploughboy]

The whole nurse practitioners can do family medicine notion is only true if one thinks family practice consists of nothing more than canned algorithms. It does not.

 

And this is the crux of my concern about NPs. In my limited experience, NPs are always for the algorithm, follow the algorithm, always the algorithm.

 

And in general, it works. But occasionally that young healthy person with new onset back pain *won't* have simple mechanical back pain, and you at at least need to have thought about a malignancy, or an abscess, or CE, or ank spond or, or, or... If it's not in your world-view, if you don't think about it, then you'll never see it.

 

The standard of care is in any situation is not "perfection", but is what a reasonable physician would do in the same clinical situation. The sense that I have gotten in my admittedly limited interaction with midlevels is that their thought process is different from that of a physician, likely because their training is different from that of a physician, and that they sometimes don't know what they don't know. I'm not saying that to be a jerk...it's just an observation. I often still don't know what I don't know, but the difference is that I don't have a licence yet.

 

I'm midway through a 5-year residency and the amount of stuff that I should know but don't know is frightening. It's not because I'm stupid or lazy (although I am both), it's because there is a vast amount of knowledge that an independent practitioner needs to know in order to be both safe and effective. I remain unconvinced that NP education is sufficient to the task.

 

Maybe I'm being swayed by overhearing a few case presentations by NP students to a specific NP preceptor, where I've sat there thinking "Any staff doc here would be pimping the bejezus out of me on this case, but she's lobbing you soft-ball questions and you're still only getting half of them..."

 

Sorry, ranting.