Talking Heads

February, in case you haven't noticed, is "Heart Month" full of associations with Valentine's Day, love, peace and tranquility.  It's also a month to sell cardiovascular health care.

Everywhere you look these days are advertisements for the latest and greatest heart care, finest heart care facilities, touching stories of the latest cardiovascular intervention saving a life at this medical center or that.  Go ahead.  Type in "heart" as your Google alert phrase to see what I mean. 

Heart month, you see, is business month for most medical centers since the cardiovascular disease product line is sold more often than any other in medicine.  But what is good for the business of medicine is not always good for the reputation of physicians.  As one surgeon has wisely pointed out, physicians are devalued when breathless claims of magical health care delivery promised on TV can't be delivered. 

Most doctors say little about the problems inherent to this advertising trend.  We see no problem with advertisements for the latest drug or procedure on TV or the radio.  That's because doctors are becoming comfortable with their new subliminal marketing role for their new employers and as figureheads to quality.  

I worry that we doctors, overburdened with our new reality of declining pay, seemingly bottomless administrative meetings, data entry, coding requirements, and the million other regulatory changes that are detracting from direct patient care, are becoming comfortable (and worse, complacent) in our new role as talking heads.   We pretend that really there's no problem with "innovations" to care, when deep in our souls we know otherwise.    I get that we're all in survival mode right now, and perhaps this is why I'm concerned.

Recently the Wall Street Journal discussed the business case for using lower level providers in lieu of physicians.  The article discussed the "clash on proposed oversight" that exists when a less costly nurse anesthetist is substituted for a fully-trained anesthesiologist.  These capable nurse anesthetists don't want oversight.  They feel they can do their job just fine, thank you.  After all, they're the one's at the patient's side most of the time as the anesthesiologist flits in an out of several operating rooms instead of sitting in just one.  Is this the best quality for the individual patient to have a person with only two years' experience working independently?  Probably not.  Is it fiscally innovative for both doctors and hospitals to do anesthesia this way?  Absolutely.   Consequently, I wonder if tomorrow's "Top Doctor" will be a much-heralded clipboard-carrying oversight manager of an army of lesser-trained health care providers.

Perhaps these changes are inevitable given the realities of American health care delivery today.  In our rush to get more work done faster than ever, we use physician extenders to see patients first, then make cameo appearances at the patients bedside, more for PR (and billing purposes) than real clinical discovery.  Is this quality?  It seems that in our new world of upcoming Press Ganey patient satisfaction surveys linked to hospital payments, inpatient medicine is evolving to PR.  During the brief patient interactions, doctors had better smile, look good, and wash their face and hands lest the facade of quality fade.  After all, good doctor, big screen TVs, marble foyers, and extensive menu selections at the bedside can only get your hospital so far.  Yet if this trend is allowed to go to its next iteration, will image consultants be the next recertification requirement for physicians?

I wonder….

Sadly, conflicts such as these are only the tip of the iceberg.   For instance, instead of insisting that information technology giants and bureaucrats correct he horrible data entry requirements imposed by today's electronic medical records, many of us have succumbed to hiring costly scribes.  We justify the benefits of these scribes because they allow us to see and touch more patients, while not admitting that we have thrown up our hands to the root problem that created this mess in the first place.  Likewise, when physicians allow their administrators to purchase cheaper, inferior equipment or allow maintenance contracts to lapse in the name of "alignment" of doctors' and hospitals' financial interests, who are we serving?  Or as personnel ranks are slashed from hospital payrolls and patient wards consolidated, are our patients being served best? Can a nurse used to caring for post-surgical patients really manage a cardiac patient as well?

The list goes on and on.  While employee-physicians are losing our autonomy and ability to provide direct one-on-one patient care in all cases, there's a growing need to educate those who don't have a clue about patient care in hopes of improving that care without compromising its quality (if that is possible).  Perhaps more than ever, doctors are needed to fulfill a leadership role in the education of all factions involved in patient care - from administrators to ancillary care providers - about what is needed for their patients and when.  Doctors need to push to dismantle what is broken and organize those systems that work.  Being railroaded by a system that has changed way too soon and way too fast thanks to forces outside our control won't help anyone.

But before we embark on this seemingly impossible task, physicians will first need to ask themselves a very important question, one that strikes to the very core of being a doctor: will we dare to speak up as advocates for our patients and as advocates for each other as doctors, or will we just become a talking head?

Given what's transpired to our health care system so far, I'm not sure I really know the answer.

-Wes

When Health Care is Promoted As "Free"

Health expenditures in the United States neared $2.6 trillion in 2010, over ten times the $256 billion spent in 1980. The rate of growth in recent years has slowed relative to the late 1990s and early 2000s, but is still expected to grow faster than national income over the foreseeable future.

So imagine my surprise when I saw this Medicare commercial last night that stated preventative health care services provided by Medicare were "free:"



CMS also uses the word "free" in the description of the new health care law's provisions on their Youtube channel:

"For those with Medicare, the health care law offers most preventive health care services for free."

Describing health care services as "free" dissociates people the cost reality of providing these services. It perpetuates the myth that we can have health care services without having to pay for them. Further, calling services "free" devalues the expertise and cost of facilities and regulatory oversight required to support such services.

Of course, public policy experts who promote these deceptive advertising techniques argue that these ads are justified because they encourage people to participate in preventative health services, thereby saving costs.  But where are the data that these ads really work?    Scientists know the realities of indeterminate, false positive and false negative testing of any screening test.  We know the huge costs of additional testing that occurs in such in instance.   Given our overriding health care cost concerns, should we not insist on proof of the cost-effectiveness of such a large-scale, national approach to preventive medicine services rather blithely assuming it works?

After all, the reality of health care today is that it is anything but "free."

-Wes

Tough Guy Does CPR Hard and Fast

While it might not be quite as funny as the Portugese Cardiology Foundation's Big Belly People video which takes a stab at the obesity epidemic, the British Heart Foundation does a pretty good job getting the "hard and fast" message out for "hands-only CPR" using British tough-guy Vinnie Jones in its new TV ad:



Heh.

-Wes

Why Hospitals Should Permit Physician Blogs

Hospitals that permit physicians to participate responsibly on social media can reap significant benefits:

Click to enlarge

Just sayin'...

-Wes

We Interrupt This Blog...

... to bring you Pharmagossip's infomercial.

-Wes

Tomorrow's News

Tomorrow marks the day that $125 million in ad spending will commence to convince folks they really DO like the new health care reform law recently passed.

With that kind of government and special-interest spending, it looks like direct-to-consumer Viagra ads on the Nightly News will seem be a bit, er, limp.

To kick things off, a pro-Dem group will air a $2 million dollar ad campaign touting the law's benefits:

"The ad campaign launching Wednesday will focus on the theme “Not Anymore,” showcasing how health reform combats existing insurance practices. The ads will highlight the industry reforms coming online Sept. 23, such as provisions that bar insurers from denying coverage to children younger than 19 who have pre-existing conditions.

“The idea is you don’t have to worry about the stability of your coverage anymore,” said Health Information Campaign communications director Erikka Knuti. “These are all things that you don’t have to be concerned about now with the new law.”

And yet this ad campaign will fail to mention what the health care law has already done to insurance premiums:

Health insurers say they plan to raise premiums for some Americans as a direct result of the health overhaul in coming weeks, complicating Democrats' efforts to trumpet their signature achievement before the midterm elections.

Aetna Inc., some BlueCross BlueShield plans and other smaller carriers have asked for premium increases of between 1% and 9% to pay for extra benefits required under the law, according to filings with state regulators.

These and other insurers say Congress's landmark refashioning of U.S. health coverage, which passed in March after a brutal fight, is causing them to pass on more costs to consumers than Democrats predicted.

Look, as one much more astute health care policy analyst has noted, you can't have your cake with insurance for millions more beneficiaries and and eat it too with lower costs, no matter what the politicians and advertisers would like us to believe. Oh sure, we can work to cut waste, and that always helps to cut costs, but how long has Medicare been existence without an ability to prevent such fraud in a meaningful way?

There is no place is easier to hide money than in a bureaucracy - just ask Don Berwick, our now head of CMS, who managed to receive over a whopping $1.4 million (Source, IHI's most recent Form 990) toward his retirement in just six short years from sources with interests in health care that he recently refused to disclose to the Senate Finance committee chairman.

See how technicalities can play to your favor in governmental bureaucracies?

No matter how we cut this, the lack of financial transparency, governmental and special interest inner-dealings, and political side-games spell disaster for this new law's ability to control health care costs and we haven't even gotten out of the gate.

And all the advertisements in the world will not change these sad facts.

-Wes

References:

Senator Grassley's letter to Dr. Berwick
Dr. Berwick's response to Senator Grassley

Some Blogging Insights for Doctors

Nearly five years ago, I started this blog. As you can tell, I gave it a bit of a facelift yesterday. Over the years I have struggled with the question: should I have ads? Will they make my blog look cheezy? Am I less of a purist if I have ads? So I started slow and tried to keep the blog as unencumbered by ads as possible, placing Google Adsense ads in the footer area of this blog. I made about $1-3 dollars per month with that approach. In essence - pretty worthless. But recently I embarked on an Google Adsense experiment. I added one Google Adsense ad below my post of the day and to my RSS feed. That one move increased my ad revenue about 10-fold - not much, but a significant jump up. With my readership, that amount should just about over the cost of renting server space so my co-workers can see the images on my blog at work. (I appreciate my "Deep Throat" contributors at work who contribute ideas for new content here...) Many wonder, why not just use Google's servers for your images? Well, there's several reasons. The main reason is our workplace firewall. You see Google uses multiple servers on which it holds its images. While images might be easily retrieved using their picture manager software, Picasa, the server on which those images might be held might be held at very different internet addresses. This wreaks havoc on workplace firewalls - until I started using my own server (which my employer has approved), many of my images could not be seen by my co-workers. The second reason is simply one of organization - I know where my images are and how they're organized. I can resize them or edit them as I need and place them on my own server for later use and recall. Just my preference. But renting your own server space costs about $150 (or so) per year. (In contrast, Google offers about 5 Megabytes of server space for free - plenty for most - then charges a bit for more) So, to offset this server expense, I have placed some ads on this blog. No I can't quit my day job, but it appears these ads will help at least defray my server expenses. Not to say that I don't market my ads in the sidebar for considerably more. The relative paucity of cardiology blogs out there makes that space valuable for some. But even when I place an ad there for a month or more, I find that the revenue generated will never serve as my day job. (Moral of the story: be nice to your employer - you need 'em). But more importantly, I have found that this blog has opened many entrepreneurial ventures that are much better drivers for revenue than advertising revenue. I'm betting most serious bloggers find this. (Quick definition: a "serious blogger" is anyone who is crazy enough to do this for over three years) Bottom line: Blogs, in and of themselves, are very poor ways to try to make a living, but can open doors. I also have invested in liability insurance for this blog. It costs about $100-$300 per year, depending on the type of blog you have, but my one experience with defending a frivolous "cease and desist" letter that set me back about $14K in legal expenses makes this expense worth it to me. Learning point #2: Be careful, blogs can be risky. There are tons of resources out there to help anyone who wants to start a blog and try to keep with it. Consider reading just about everything at Problogger.net, for instance. I completely understand the challenges for doctors maintaining a blog - it's damn hard work. But it also serves as a useful avenue for teaching, advocating, venting (when done professionally and with an appropriate amount of restraint) and fills a little creative void that I still enjoy. -Wes

Super Sexy (Adult) CPR

Employment Alert: While there is no frank nudity, viewing video might be best done after hours.

Although this ad for lingerie might not be sanctioned by the American Heart Association, I'll bet you'll never forget CPR after seeing it:



Yeah, I know: I'm a dog. And the ad doesn't use the latest no-breath CPR technique.

Still, you have to admit...

... it beats the heck out of the Bee Gees...

-Wes

"Reasonable Consumers" Unite! Kill Drug Ads

It seems the FDA is looking for input on how drug companies explain the side effects of their drugs in direct-to-consumer advertising.

But the pharmaceutical industry is requesting that only "reasonable consumers" need to be addressed about those side effects. Anyone that doesn't act "reasonably," well, so sorry.

Seriously?

About the only reasonable thing that can be said about direct-to-consumer advertising are three things:

1. They are horribly expensive, with the US shunting over $2 billion dollars annually per pharmaceutical company to the advertising industry.


2. It should also be noted that the FDA has a huge conflict of interest with the pharmaceutical industry, since it receives large sums from them to review their new drug applications.


3. Note, too, that only two countries in the world permit these ads: the US and New Zealand.

I find it interesting that I can't get a $0.10 pen from the drug companies any longer, but our patients can get billions of dollars in advertising given to them "free" without any concern about what this is costing our health care system.

-Wes

Not Seeing the Forest for the Trees

Congress, in their efforts to be conciliatory to specialists, is now working to alienate primary care physicians, too:

(Medicare payment) Reductions will be made over four years rather than imposed at once in 2010, the U.S. Centers for Medicare and Medicaid Services said yesterday in a statement. In July, the agency said it planned to slice $1.4 billion, or more than 10 percent, in payments for each of the two specialties, triggering what an advocate promised would be a “tooth and nail” battle.

The administration argued that the lower reimbursements for specialists would make more dollars available for lower-paid non-specialists who can focus on preventing expensive, chronic illnesses. That would tame the growth in medical costs, one goal of President Barack Obama’s effort to remake the U.S. system of care. Under yesterday’s plan, family doctors and nurse practitioners would get half the proposed increase.

So while specialists won't be cut quite as bad, primary care will not see their efforts rewarded significantly either.

And yet, any real effort to look for simple ways to cut costs in health care system is ignored by Congress. One only has to look at the waste of health care dollars implicit in pharmaceutical direct-to-consumer advertising - and the fact that only two countries in the world (the U.S. and New Zealand) permit it - to see the hipocracy of the reform efforts underway. Instead, doctors are the easy target for "reform" as more and more ads for Viagra, Lipitor, and "P.A.D." flash accross our TV screens.

Sure it's not the only place costs can be cut. But how about ridding our system of such bloat before biting the hand that cares for us?

-Wes

Colonoscopy Sweepstakes

I'm not making this up. I saw this on TV tonight.

It seems CBS Broadcasting has teamed with the advertising giant Marden-Kane, Inc. and Loews Regency Hotel to develop the CBS Cares Colonoscopy Sweepstakes open to 40-79 year olds. Yep, that's right: people under 50 are eligible, even though they should not be screened for colon cancer.

The website states:

"When the colonoscopy is about to begin, you'll be given drugs which will make you feel like you're at Woodstock... only without the music. If you start to believe that you actually are at Woodstock (for example, Dr. Miskovitz starts to look like Jimi Hendrix or you feel inclined to say "far out!" in response to questions), please report the side effect to Dr. Miskovitz or Jimi Hendrix (whomever you see first) immediately."

While sounding like I might have a cob up my... well, you know... I wonder, what in the world are they promoting? A free "high" or colon cancer screening? Is this how we discuss screening tests now? Where are the risks of colonsocopy and sedation discussed? How will the list of people who register for the "free" colonoscopy that don't win be used? I wonder, will they be targeted later by the posh Center for Specialty Care, with its origins in plastic surgery and where the colonscopy will presumably take place, for mailings about more testing?

We're not sure.

But we are told on CBS's website:

"If you post personal information in User Forums or on other publicly available areas of the Web Sites then you may receive unsolicited messages from third parties. Company cannot ensure the security of any information you post on publicly available areas of the Web Sites. Under no circumstances will we be liable in any way for any of Your Upload Information including, but not limited to, any errors or omissions in Your Upload Information, or for any loss or damage of any kind incurred as a result of Your Upload Information."

Furthermore:

"Your Upload Information will be treated as non-confidential and non-proprietary and we will not be liable for any use or disclosure to anyone, including but not limited to claimed intellectual property owners. When you upload Your Upload Information via the Web Sites, you irrevocably grant to Company, its parent, subsidiaries, affiliates, and partners a non-exclusive, worldwide, royalty-free license containing, without limitation, all right, title and interest in Your Upload Information, including, without limitation, all patents, trademarks, service marks, trade names, trade identities, copyrights, trade secrets, logos, domain names, know-how, source code and object code, mask-work rights, inventions, moral rights, author's rights, algorithms, rights in packaging, goodwill and other intellectual property and proprietary rights whatsoever in Your Upload Information. You further agree that Company, its parent, subsidiaries, affiliates, and partners and the directors, officers, employees, licensees and other representatives of each of them will have the unfettered right throughout the universe, in perpetuity, without any credit or compensation to you, to use, reuse, modify, alter, display, archive, publish, sub-license, perform, reproduce, disclose, transmit, broadcast, post, sell, translate, create derivative works of, distribute and use for advertising, marketing, publicity and promotional purposes, any of Your Upload Information or portions of Your Upload Information, and your name, voice, likeness and other identifying information, in any form, media, software or technology of any kind now known or developed in the future for any purposes whatsoever including, without limitation, developing, manufacturing and marketing products using such Uploaded Information. You hereby waive any moral rights you may have in and to any of Your Upload Information, even if such material is altered or changed in a manner not agreeable to you. You agree and understand that Company, its parent, subsidiaries, affiliates, and partners are not obligated to use Your Upload Information submitted through the Web Sites or otherwise, and may alternatively choose to discard, and limit or block access to Your Uploaded Information without any liability whatsoever."

Now if these rules don't fly in the face of the privacy intent of HIPAA, I don't know what does. What's worse is this whole cute charade is being "supported and helped" by our own National Cancer Institute.

Here's the thing: CBS, through this sweepstake, is offering free health care to one lucky "winner." As such, shouldn't this media company be bound by HIPAA privacy laws, too? Does this campaign really have the patient's best interests at heart or is this really about driving more business to gastroenterologists? Finally, if cancer is found on the screening and the patient is uninsured, who will assume responsibility for ongoing treatment of the patient?

Oh, but we're not asking those questions...

... because that wouldn't be so funny.

-Wes

The Nightly News

Now that the stimulus bill has passed and President Obama has promised another $638 billion for a health care reserve fund, perhaps we could put a down-payment on the largess granted by the packages by changing the format of our evening news programs.

In case you missed the news last night, I've compiled the entire informative content in a short video that lasts a little over a minute (with apologies to Itzhak Perlman):



-Wes

Addendum: NYT: "The pharmaceutical industry spent nearly $4.8 billion last year on television and print ads, according to Nielsen Media Research."

What Do Hospitals Have to Do With Baseball?

Everything:

Parkview Health announced it would pay $3 million over 10 years for the right to have its name atop the new downtown baseball stadium. Parkview Field will be the first major venue in the Summit City to have a corporate sponsor.

And we think drug company direct-to-consumer advertisements are bad. It is interesting to note that 1/2 the monies pay the city and the other half pay the owner. But for people like me who question this practice, they retort:

For those upset the stadium will have a sponsor at all, Grinstead said that is simply the way sports businesses are run today. Because minor league baseball teams have no control over their players, they need to be creative in making money. He said some teams are even having corporate-sponsored patios and parking lots.

Certainly hospital system advertising is not new, and this is just another format, albeit a big one, for the same. Paul Levy, CEO of Beth Irael Deaconess Medical Center, has commented that advertising is less likely to affect hospital's bottom lines, but placate doctor's narcissism about working at the best medical center:

Another purpose is to respond from pressure from your doctors and show them that you support their programs. Before I took this job, I talked with the head of a major Boston hospital who gave that as the primary reason for ads. "There is no evidence that ads work in creating business," he said, "but we need to keep our doctors happy." I have certainly felt that pressure in my place, and so I understand the desire to send a signal to your doctors -- who, after all, are essentially free agents who can easily change hospital affiliation -- that you support their practices.

He also comments later what the real motivation for academic center for this branding is:

I think the ads are posted mainly as a component of creating a broader brand identity. In this regard, hospital ads are remarkably similar to many other corporate ads. But unlike other industries that use it to drive sales, brand identity in the medical field is probably minimally important in generating and maintaining a sufficient level of clinical business. Perhaps more important, it helps create a mindset that the hospital has standing and stature and permanence in the community. This is important in attracting employees, enhancing physician recruitment and affiliations with other hospitals and physician practices, and generating interest from lay members of the community to serve on the hospital's governing bodies and to offer philanthropic support. These three purposes are actually fundamental to commercial viability in the health care world, especially for academic medical centers.

It seems to me that supporting baseball stadiums (and their owners) as a means of maintaining "commercial viability," especially for tax-exempt non-profits, is a bit of a stretch, particularly in light of the cost issues that patients must endure in medicine these days.

-Wes

Jarvik's Out - Idiocy is In

Well, Pfizer pulled the million-dollar man, Dr. Robert Jarvik, from its pharmaceutical (Lipitor) ads today due to "misimpressions." It's just too risky to use a make-believe clinical doctor, I guess.

Instead, we can look forward to more beavers, butterflies, and animated pipemen to promote drugs more objectively.

Hell, I see butterflies in my bedroom when I take Lunesta, don't you? Especially since they paid over $182.7 million in the first half of 2007 to make sure I see them over and over and over again...

-Wes

Sleep Deprivation and Sleeping Pills

My thoughts on this topic are up over at MedPage Today.

-Wes

Great Game

The Superbowl exceeded by expectations this year - Jordin Sparks did a nice job with the Star Spangled Banner, Tom Petty and the Heartbreakers were pretty good at the halftime show that lacked the usual Superbowl schlock of prior years, some great football and amazing defense of the Giants that lead to their unexpected HUGE upset - with suspense that lasted to the last few minutes of the game. It doesn't get much better than that.

The ads, however, were mediocre, for the most part. But fortunately, there were only two drug ads: both OTC meds - Zantac (appropriately placed right after halftime) and Claritin antihistamine. Gosh, only $5.4 million spent - really, remarkable restraint was demonstrated by the pharmaceutical industry. It is interesting that these two ads did not appear on the MySpace webpage summarizing all of the ads shown - wonder why?

But there was one ad in particular that caught my cardiologist's eye:




The little legs that sprouted from the heart were cute, but I'm still trying to figure out how she stays conscious after her heart leaps from her chest...

... maybe she had a LVAD installed first ...

-Wes

Will Big Pharma Run SuperBowl Ads?

Some think it might not be such a good strategy:

"There is a heavy price to pay for mistaking components of strategy for strategy itself, or misreading the strategic effect of components. The pharmaceutical industry, for example, is going through a process of profound transformation and intense negative reaction to its marketing activities. Part of the reason for that has been the lack of strategic thinking around the deployment of direct-to-consumer advertising. While claims can be made for the business value of DTC at a tactical level, the strategic effect of spending nearly $5 billion a year on consumer promotion of prescription medicine (editor's note: breakdown of costs here) has been to open the industry to scrutiny and sanction. Nearly every major drug company active in the United States is facing multiple federal and state investigations into its business practices. Tactical success does not necessarily yield successful strategic performance."

At $2.7 million for a 30-second spot, I just can't see how showing a Superbowl would ad be a good strategy for the pharmaceutical industry either.

But then, I don't make their marketing decisions, do I?

-Wes

"It's Deplorable"

More criticism of the Cypher stent ad campaign appears in the New York Times.

Such an initiative is so pernicious and wasteful (can you say, "expensive?") at a time when doctors and patients are being squeezed by corporate interests over healthcare delivery that I hope this ad becomes a battle cry to steer patient's away from their device.

Why do you think Medtronic quietly buried their direct-to-consumer ad campaign? (Hint: It wasn't just because of lead recalls. Referring doctors, seeing the avaricious nature of such a campaign, revolted as well.)

-Wes

More Direct-to-Consumer Insanity

Now it's Johnson and Johnson's turn: starting on Thanksgiving Day, coronary stent (specifically Cypher stent) advertisements began airing on television directly to "consumers," our patients, promoting the ability of stents to "prop up your life" that has been "narrowed" by coronary blockages. "Life wide open" is the tag line.

It's so catchy. As though our patients can go down to the corner store and pick one of these up for their heart. I guess J&J feels patients can discern when a drug-eluting stent is preferred over a bare metal stent, or better yet: when a stent is appropriate and when it is not. Why didn't their ad mention that other non-invasive options might be more appropriate before stenting in some circumstances?

Well, it's simple. The best medical care isn't important to J&J. What is important is that J&J sells more stents. To that end, what's really important to J&J is that patients ask their doctors why their life isn't "wide open" and full throttle yet. As if we don't have better things to discuss.

But I guess J&J figures our patients' wallets are wide open, given the cost of such advertising, especially in prime-time TV slots. This advertising, by the way, is in addition to an already re-worked website and other print media that has appeared in major newspapers.

And J&J seems to be taking a path that is in direct conflict with their own credo, their guiding mission statement, that has hung on their walls for over 60 years:

"We believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services. In meeting their needs everything we do must be of high quality. We must constantly strive to reduce our costs in order to maintain reasonable prices."

And where's the FDA who promised to monitor such advertising to our patient "consumers?"

Oh, I forgot - they're enjoying "monitoring" the commercials with a beer in their hand in front of the TV.

-Wes

Image credit.