Sunday, March 17, 2019

Why Our Medical Practice Won't See Nursing Home Patients

Our practice will no longer see nursing home patients in our office.  If a nursing home patient is already established with us, then we will see him; but, we have decided not to accept new patients.

Of course, we believe that these individuals – like the rest of us – deserve medical care.  This demographic not only deserves care, but has the greatest need for medical services.  Our practice will see every person who wants to see us, including the uninsured. 

Why, then, would a welcoming practice like ours close our door to new nursing home patients?  We just couldn’t take it anymore.

These patients, who often have serious physical and mental challenges, would typically arrive to our office accompanied by a driver, who naturally has no medical knowledge.  The patient often had no awareness of the reason for the visit.  The ‘medical record’ consisted of a nearly indecipherable list of medications of uncertain accuracy.  Typically, no reason for the visit was documented, or there might appear a scrawl - ‘stomach problems’ - not quite a road map that a consulting gastroenterologist can follow.  I would then, in the middle of my practice day, call the nursing home in search of a nurse (or nurse’s aide or secretary or janitor) who might enlighten me on what my focus should be. This task is about as fun and efficient as calling the IRS customer service line with a tax question.  Often, the nurse who might actually know the reason for the visit is off that day or works a different shift.



Why Should We Have to Work Wearing a Blindfold?


It took several years before our practice declared ‘no mas’, but our level of exasperation finally exceeded our patience.  Our repeated attempts to improve communications  were not successful. 

Here’s what didn’t happen.
  • The patient’s doctor or nurse would call us in advance to discuss the case so that we might gain information that would make an office visit worthwhile. 
  • We are contacted in advance and we advise that a diagnostic test or blood tests be performed prior to the office visit.
  • We are contacted in advance and, after discussing the case, request certain prior medical records to be sent prior to an office consultation.   If a patient is having rectal bleeding, for example, I want to review the prior colonoscopy records.  Perhaps, a repeat procedure is not necessary.  
  • A family member accompanies the patient to the office visit.  I am not judging folks here, and family members may live out of town, but I was always surprised that these ailing and elderly patients rarely arrive with a family member who could play a critical role of providing (or obtaining) medical knowledge and advocating for their loved one. 
This has been a vexing issue.  If you were sending an elderly patient, perhaps demented, to a doctor, why wouldn’t you give that physician a full briefing so that he or she could do a decent job?  Even when we are sufficiently informed, the task is challenging.  But, we shouldn’t be asked to work blindfolded in the dark.

Sunday, March 10, 2019

Quality Indicators in Colonoscopy - A Three-pronged Test for your Gastroenterologist


One thing that gastroenterologists know about is stool.  But, I’m not referring to that kind of stool in this post.  Follow along.

When we do a colonoscopy, for example, we are relying upon stool, or more accurately a stool, as in a three-legged stool.   This metaphor illustrates that the three legs must be equally strong or the stool will not stand.  The three pillars of support that a colonoscopist needs include:
  • Knowledge
  • Skill
  • Judgment

All 3 Legs Needed


As the gastroenterologist guides the colonoscope along your long and winding colon, he may discover a lesion.   He needs knowledge to identify the intruder.  Is it a cancer or a benign polyp?  Could it be Crohn’s disease or some other form of colitis?  Is it a normal structure that simply appears atypical? Obviously, the more experienced the gastroenterologist is, the more likely he will be able to identify the abnormality. But, every gastroenterologist, regardless of experience, confronts lesions he has not seen before. 

The gastro specialist must have the requisite technical skill, not only to perform the colonoscopy properly, but also to manage any lesions discovered.  Removing colon abnormalities requires an assortment of techniques and instruments.  What good is having the knowledge that can identify a lesion if you don’t have the skill to remove it?  Would we permit a cardiologist to perform a cardiac catheterization on us if he couldn’t insert a stent if a narrowed artery was discovered?

Most importantly, the gastroenterologist needs judgment.  In my view, this ‘leg of the stool’ is what distinguishes good physicians from truly seasoned medical professionals.  Medical judgment, in my judgement, is much more difficult to learn that knowledge or skill.  By definition, judgment is subjective.  There is no medical bible to consult that can confidently advise what constitutes the optimal judgment in a particular circumstance.  There are so many variables.  This is why a patient could consult several specialists regarding a medical issue and receive differing opinions all of which might be ‘correct’.  The facts don’t change, but the physicians’ interpretations of those facts and consideration of the overall medical context, may lead to opposing recommendations.  One physician might advise repair of a hernia which is causing discomfort while another may counsel against it because the patient has severe emphysema and has high operative risks. 

Consider how many U.S. Supreme Court decisions are decided in 5 to 4 votes.  The facts are the same for all 9 justices but their decisions often vary profoundly.

Two hours before writing this, I performed a colonoscopy.  I discovered a medium sided polyp right at very end of the colon at the spot where the appendix is connected.  I had knowledge of the lesion and had the skill to remove it.  But, I was concerned that resecting it – a simple task I’ve done for decades – might cause a complication by injuring or puncturing the appendix.  Primum non nocere, or first, do no harm, is medicine’s sacred mantra.  Perhaps, another gastroenterologist would have removed the lesion without any consequence.  His patient would not need any surgery to remove the lesion, as my patient might.   The patient will return to my office in a few weeks.  I thought that he was entitled to a sober discussion of the options while he was awake and alert, rather than sedated on a gurney. 

Sunday, March 3, 2019

Medical Practice Hassles Torture Patients and Doctors

We do most of our colonoscopies in our ambulatory surgery center (ASC), which is attached to our office.  We are proud of the work that we and our staff do every day and are grateful for the outstanding feedback that we consistently receive from our patients.  Some insurance companies will not cover procedures in our ASC so these patients must get ‘scoped’ at the hospital instead.  For many of them, this means required blood tests a few days in advance of the procedure, which we would not have required for an ASC procedure.   On the procedure day, the patient and the driver will enjoy spending hours in the hospital for parking, checking in, interviews with various medical personnel, the procedure and the recovery period.  And, since it is a hospital, delays are inevitable.  Not only does this experience take hours longer than it should, but we are mystified that an insurance company would take on the expense for a hospital test that we could do more efficiently and cheaper in our ASC.  Can you make sense out of this?

It is typical for a physician’s prescription for a patient to be ‘denied’ by an insurance company.  Such denials, of course, are never issued by a medical professional, but are form letters kicked out automatically if the physician’s preferred drug is not included in the insurance company’s sacred formulary.  Appealing a denial – which we will attempt – is just as smooth and stressless as calling the IRS for questions on your tax return.  It is designed this way so that physicians and patients simply give up.  What physician has the time or fortitude to make several phone calls to hear repeatedly, ‘please listen carefully as our options have changed…”  Sometimes, my recommended drug is denied because my patient has not first tried a different medication, which I did not prescribe because it is not indicated for my patient’s condition.  Should I prescribe the wrong drug so that few weeks later when it is not effective, I can then hope that the correct medicine will be approved?  Can you make sense out of this?



The System Can Make Doctors and Patients Batty


Some insurance companies will only permit me to prescribe a 30 day supply of a medication.  Some of these medicines need to be taken indefinitely.  Why should these patients have to make 12 stops to the pharmacy every year?  Why can’t I prescribe a 3 or 6 month supply?  Can you make sense out of this?

A patient comes to me for a screening colonoscopy.  His insurance company covers this preventive service.  I do the exam and find a polyp, which I remove.  This changes the definition of the procedure from screening to diagnostic.  Why does this matter?  Because the insurance company may require that the patient pay a greater share for a ‘diagnostic’ procedure?  In other words, the patient gets penalized because his gastroenterologist removed a polyp, which is the goal of a screening colonoscopy.  Can you make sense out of this?


If any reader can make any sense out of these real life medical absurdities, then the medical profession needs you STAT.  You are much smarter than we are.

Sunday, February 24, 2019

Insurance Company Denies Coverage for Drug - Part II


Last week, I related a vignette where a routine medication refill was denied by a patient's new insurance company.  The patient had developed symptoms 2 weeks after he ran out of the medication. I surmise that 100% of gastroenterologists surveyed would have agreed that refilling the medication was the next step.

So, even though the best medical option was to refill the medicine that we know has worked, the new insurance company won’t cover it and the patient cannot afford to pay retail for the drug. (As a separate point, I challenge anyone including those with PhD's in economics to explain retail drug pricing.)  The patient did his best to navigate the insurance company’s website and found a colitis medicine that is covered, but it is medically inferior.  Should we just cave and prescribe it to save money and a hassle?  Is this an issue that we want on our sick patients' agendas?  How would you like to face surgery and be told that the newer clamps and scalpels are out of network, but there are some rusty tools in the back that are fully covered?

I tried using our electronic medical record to ascertain if there were effective alternative colitis medications that would be covered, but neither me nor my staff could get a straight answer on this.   If we were to call the pharmacist to ask which colitis medicines were covered, which we have tried in the past, we would be told that we would have to officially prescribe each drug individually in order to determine its coverage status.  Doesn’t that sound fun and efficient?

Does this vignette show medical care at its finest?  How much time do physicians and our staffs burn up on tasks like these?   Does this anecdote reinforce the notion that insurance companies’ mi$$ions are to protect profits and not patients?

Do we want sick patients and physicians to have to fight just to get medicines approved?  Shouldn’t they be focused on health and healing?   Keep in mind that my patient was not seeking exotic or experimental treatment.  He only wanted the medicine that he and I knew could keep him well which is approved by the FDA for his condition. 



Beware the Medicare for All Express!


If an avaricious shoe manufacturer decides to hike prices, no customer will be harmed.  If the insurance industry, however, aims to maximize their profits, folks can get sick or worse.  If this industry doesn’t reform itself, then at some point others will do it for them.  Wouldn’t they be wiser to earn some good will with their customers and the public rather than create an army of enemies? 

Who will be there to defend private insurance companies once the Medicare for All Express gains momentum?   If insurance companies won’t do the right thing for the right reasons, perhaps, self-preservation will motivate them to do better. 





Sunday, February 17, 2019

Insurance Company Denies Coverage for Drug


A patient came to see me recently with a suspicion that his colitis was recurring.   In general terms, colitis describes a condition when the large intestine is inflamed or irritated.  Typical symptoms are diarrhea, abdominal cramping and rectal bleeding.  This patient was concerned as his last 3 bowel movements were diarrhea.  He had been on a medicine called mesalamine, a safe and effective treatment for colitis, but he ran out of it 2 weeks ago.  While he was taking the medicine, he felt perfectly well.  So, his bowel change developed 2 weeks after he ran out of his medicine. 

For readers who like to play doctor, choose among the following options:
  • Schedule an urgent colonoscopy to verify that nothing has changed since his colonoscopy 6 months ago.
  • Observe the patient without any treatment to give him time to heal himself.
  • Recommend probiotics to restore his digestive health.
  • Refill the mesalamine at his usual dosage.
  • Request a 2nd opinion because the case is mind boggling complex.
  • Prescribe an antibiotic because most cases of diarrhea are caused by an infection.
I thought that the most reasonable option was to reunite the patient with mesalamine, which had been extremely effective.  Moreover, since the symptoms developed after a 2-week medication hiatus, this suggested that his colon was pleading for a medication refill.  The patient, who is not a doctor, also thought this was the optimal choice, since he attempted to refill the mesalamine on his own prior to seeing me.  However, he had new medical insurance and their response to the routine refill request was DENIED!

My Staff and I became Gerbils

Next week, I’ll share how we responded to this frequent and frustrating development.  Don't get your hopes up.   It was a gerbilesque experience. We all felt like we were running on a wheel, expending lots of energy and effort, but with no traction. 

Sunday, February 10, 2019

Blockchain


First there was Bitcoin, a cryptocurrency that utilizes blockchain, a decentralized system of data collection and transactions that we are told will defy hacking.  (Wasn’t the Titanic said to be unsinkable?)   We read that cryptocurrency and other blockchain functions will be a societal gamechanger, much like the internet was when Al Gore invented it some years ago.

My own state of Ohio will now accept Bitcoin as payment for commercial taxes. 

And, of course, there are many other cryptocurrencies mushrooming around us.  In my life, many innovations seem to be solutions in search of problems.  I don’t find my current methods of transacting business – cash and credit cards – to be so onerous that I am screaming for a new way to conduct commerce.  But, I will admit that I have security concerns about my credit card number and other highly personal data being ‘safely stored’ all over the internet.  Some years ago, I enjoyed the thrill of being a victim of identity theft, which in gastrointestinal terms, is about as pleasurable as a rigid sigmoidoscopy.  Just contacting the 3 credit agencies in the quest to reach living breathing human beings is a task that separates the weak from the robust. 

Northeast Ohio is prepared to invest over $100 million to attract and cultivate blockchain investors.  Will this create a Blockchain Bubble?  We will see.  Initial investors in Bitcoin hit the jackpot.  But for many others who didn’t time their investments at a propitious moment, they lost big.

There are many aspects of our personal and professional lives that could utilize blockchain.  And, like any new innovation, we don’t have to understand it to benefit from it.  Do we really know how our routers at home work?  Of course, whenever a new disruption breaks in on the scene, many existing businesses and organizations will be threatened.  Consider Amazon, the Mother of All Disrupters.  Bitcoin, for example, could assume many functions of traditional banks and perform them better, more securely and at less cost.  If cryptocurrency can really deliver, then those under threat will have to adapt or they will be run over.  Those players who are not adaptable will become obsolete.  Typewriter repair is no longer an occupation.


Who Can Fix This?


In my own profession, blockchain could offer incredible benefits.  As a physician, the notion that I could easily access all of a patient’s medical data from my office would be a gamechanger.  And, every new medical event would be instantly and securely added to a blockchain.  The HIPAA police would become unemployed, another blockchain casualty.  Imagine how this would affect medical care in an emergency department.  Physicians, with access to the entire record, would be less likely to order medical tests if they could determine that they had already been done elsewhere.  And, beyond the medical advantages, I’m sure the billers, coders and insurance companies would also be hitching rides on the Blockchain Express.

Patients and I today are often frustrated that even in our digital era, I do not have easy access to their electronic records, which often exist in different medical systems and institutions.  Wasn’t electronic medical records supposed to solve this? 

Will blockchain become the coin of the medical realm?  Has this post induced you to invest in cryptocurrency?  My advice?  Buy a CD instead. But, stay tuned. 

Sunday, February 3, 2019

Hospitals Seek Donations from Patients


Many organizations solicit private donations from benefactors and philanthropists.  Is there a stadium in the country that does not bear the name of a prominent donor?  There are also anonymous donors who are not cursed with egos that require their names to be emblazoned in giant font on a building’s fa├žade.  But, most donors want recognition which is often used as an incentive when soliciting the donation.

Donors understandably receive perks and privileges that ordinary folks will never be offered.  If you give a ton of money to a theater, you might receive prime season tickets as a gift.  If you make a sizable donation to a symphony orchestra, you may be invited to a private event to meet the conductor and leading musicians.  If you make a robust financial contribution to your city’s art museum, you won’t have to worry about competing for limited tickets to view the visiting Picasso exhibit.  You may very well have your own private tour.

There is nothing venal about any of this.  If you give money, then you get stuff.  But, sometimes this quid pro quo is improper and unethical.  For example, if I donate to a campaign, and the candidate wins, am I entitled to a higher level of constituent service?  (Of course, this example is hypothetical, as no politician would ever confer special favors to a donor.)

The New York Times reported recently a donation scheme in my own profession that I found to be ethically problematic.  Hospitals across the country determine which of its hospitalized patients are wealthy and then contact them asking for money, sometimes while these folks are still in the hospital!  The article states that physicians and nurses – actual medical professionals – have played a role connecting patients with hospital fund raisers. 

First of all, there is an unseemliness to trolling through public data on sick patients to ascertain their history of political donations and property records to determine if they have sufficient net worth.   This stealth review of data sounds more like the skulduggery that we have all learned is part of Facebook’s culture.   It is possible that a grateful patient who is approached and then gives a mighty donation might not enjoy any future special treatment from the institution.  But, it is also possible that the donor, like the example of a museum donor I cited above, might be given a higher class of service.  While we expect to reward donors to cultural and educational institutions, would we condone a donor to a hospital receiving special treatment which might include better medical care?  Shouldn’t all patients receive the same level of quality?  Do you think it might be possible that a donor would be more likely to get a private room, get access to the best surgeon, get a complaint resolved expeditiously, get phone calls to the hospital returned promptly or get better access to appointments after hospital discharge? And, if a potential donor declined to contribute, particularly if his doctor initiated the solicitation, might this affect the doctor-patient relationship?



The MD Whistleblower Stadium

If you want to give your life meaning by donating to a worthy endeavor, consider donating to this blog.  Imagine the prestige and fulfillment of having a post named after you. 


Sunday, January 27, 2019

Diagnosing Sleep Apnea - Leave it to the Amateurs!

It seems that there is an epidemic of obstructive sleep apnea (OSA) out there.  Snoring, a harbinger of OSA, seems to have captured the national attention, at least judging by the ubiquitous ads I am subjected to hourly on the radio.  Gastroenterologists routinely inquire about the presence of OSA in our patients as this may increase the risks of sedation and anesthesia. 

Most patients with OSA are undiagnosed.  Many of them are not aware that the condition troubles them, but experts warn of potential long term consequences if the condition is not treated.  The diagnosis is classically made after an overnight sleep study when the patient is monitored.  I have equal confidence in the diagnostic skills of those who sleep in the same room as the individual at home.  For example, if a patient’s wife tells me that her husband regularly (and fortunately temporarily!) stops breathing during sleep, I think that the diagnosis has been securely made.  In these cases, I am unsure how an overnight sleep study would alter the treatment plan, but I suspect that most sleep physicians would still recommend it.


Why is everyone so tired?

The usual treatment is for the patient to don a clumsy and noisy helmet apparatus called CPAP while sleeping.  Many patients find this remedy to be worse than the disease and have eschewed this recommendation.   I expect that technological innovation will make progress on this front.

I offer readers an interesting side note on one of the warning signs of OSA – snoring.  I find that patients often regard snoring as if it were a moral failing.  For example, if I ask a patient if he snores, he may point to his wife in the exam room exclaiming, “you should hear how loud she snores!.   This scenario has repeated itself over the years and always amuses me.   Snoring isn’t a vice that needs to be minimized by pointing to a fellow sufferer.

Sleep is important and most of us don’t get enough of it.  Wouldn’t life be better if an afternoon siesta became a daily routine in our culture?  

Sunday, January 20, 2019

Physician Weight Loss Tips

Although I have confessed that I am not a seasoned expert in this field, here are some tips and pointers I’ve gleaned over the years.


Slow and Steady Wins the Race!

  • Avoid gimmicks.  We’ve all seen ads and telemarketing pitches that promise to melt off pounds by the hour.   These products are very effective for the companies, but not for you.  They don’t work.  Yes, you may enjoy some short term weight loss for as long (or short) as you can stay motivated, but the chance of keeping the weight off is vanishingly small. 
  • You don’t have to be perfect.  Allow yourself some backsliding and seek continued motivation from these events.  The path to your successful destination may include some zigzagging.
  • Weight loss medications don’t work well.  Of course, the notion of a pill solving any medical problem is seductive, but the history of weight loss medications includes an array of side effects and relatively modest results. 
  • Bariatric surgery, including gastric bypass procedures, has made great strides in recent years.  I have seen many successes and failures in my practice.  These procedures will not work unless the individuals have made the difficult mental commitment to a profound life changing procedure that will be present every day of their lives.  In my view, these procedures should not be casually or prematurely entertained.  Is a candidate for surgery unable to lose sufficient weight in any other way?   If the candidate couldn’t stay motivated to stay on a diet, will they have the motivation to make surgery a success?
  • I recommend partnering with a professional, such as a dietician, to offer guidance, support and accountability.  If not, recruit a family member or a friend to serve as your coach.
  • You will not exercise the weight off.  Patients lament to me all the time they can’t understand why their weight stays the same or even creeps up despite their walking and exercise routines.  To burn off serious weight, a person would have to intensely exercise for hours and hours each week – far beyond the capacity and willingness of almost all of us.  From a weight loss perspective, a more successful strategy is to restrict the calories that are coming in rather than burn them off after they have been swallowed.  In other words, eat less. 
  • Set reasonable and achievable goals for yourself.  
Achieving sustained weight loss is hard.  If it were easy, all of us would be skinny.

Sunday, January 13, 2019

Memorial Sloan Kettering in Bed With Industry


Is there corruption in the medical profession?  Recall Captain Renault’s iconic rejoinder to Rick in Casablanca.

“I’m shocked, shocked to find there is gambling going on in here!”



In any enterprise with billions of dollars at stake, and when different players have competing interests which may not coincide with the public’s interests, there will be skullduggery.  How do you think our Defense Department and its relationships with vendors would look if we were able to shine a bright light on all its faces?  Do you think it’s possible that a weapons manufacturer might argue, through lobbyists and salesmen, that its weapons are essential to national security and superior to those of a competitor?   How about when a congressman argues for the continued purchase of military equipment manufactured in his district that military experts state is no longer needed?  And, there’s the quintessential and craven corruption of legislators refusing to close military bases in their districts that the military want to close down.

And, so it is with the Medical Industrial Complex where the arena is filled with jousting pharmaceutical execs, hospital administrators, insurance companies, the government, medical device companies, physicians, pharmacy benefit managers, politicians and the public – all competing to protect their interests.  Does this system seem optimal to achieve a greater good for society?

Recently, the Chief Medical Officer of the Memorial Sloan Kettering Cancer Center in New York City ‘resigned’ in the wake of disclosures that he failed to disclose financial relationships with outside health care companies.  In other words, it was a failure to disclose that ousted him, not the conflict.
 
Here’s my riposte to this.  The obvious weakness in our current disclosure policy is that the emphasis is on the disclosure and not the conflict.  Following nearly every medical article that I read, appears a long list of disclosures, often in small font, listing the various business relationships that the authors have with various companies.  Apparently, in the authors’ and the editors’ minds, the disclosures have provided them with adequate ethical insulation.  They argue that readers can weigh the disclosures when they assess the authors’ credibility. For example, if an article is extolling a new diagnostic test, readers may be informed that the author is a paid speaker for the company that manufacturers the test.  The actual conflict, however, remains. 

Over the past 10 years or so, practicing physicians and scientists have been so deluged with disclosures in our journals and at our professional meetings that we have become numb to them.  (How carefully do we listen to the safety presentation given by flight attendants prior to take off?)  The ongoing tsunami of medical disclosures have vitiated their potency, and as I stated above, do not address the actual conflicts. 

The connections between medical science and medical industry can create great benefits for humanity.  I accept and encourage this.  And, I’m all for full disclosure.   But, personal and institutional integrity must be paramount.  Oftentimes, the conflict itself should be disqualifying and no simple disclosure should be permitted to cure it.

Addendum:  The Chief Medical Officer who 'resigned' was immediately hired by... yes, you guessed it, a pharmaceutical company!  And, Sloan Kettering (SK) now prohibits its leaders from serving on corporate boards.   Can we assume this to be an admission that SK now recognizes that such business relationships are improper or did they simply feel the optics were uncomfortable.

Comments, confessions, and disclosures welcome. 


Sunday, January 6, 2019

Medical Device Sales Rep Kills the Sale

A few weeks before writing this, two device salesmen came unannounced to our small private gastroenterology practice.  They were hawking a product that could quickly and non-invasively determine how much scar tissue had formed in a patient’s liver, a useful tool for assessing patients with hepatitis and many other liver conditions. 

We are physicians, not entrepreneurs.  We do not regard the colonoscope as a capitalist tool.  Yet, these two salesmen were barraging us with facts and figures on how much money we could make off their product.  They knew the insurance reimbursement rates and could quickly calculate our practice’s return on investment depending upon our projected volume.  They recognized that the cost of their device would be beyond our reach and offered to sell us a ‘refurbished’ product at a huge discount.

Liver Sales Reps Ignored the Liver!

For a host of reasons, we were not interested in acquiring the device, which we could not afford.
Here’s what was so striking.  Not once did either of them mention, even by accident, that their product was a device that might help a human being.   These guys were so clumsy and so transparent that they weren’t even adept enough to feign an interest in contributing to the health of liver patients.  Of course, we would have seen right through this pretense anyway, but at least they would have gone through the motions with the hope that we might not have recognized their charade.

Afterwards, our office manager was deluged with e-mails beseeching us to reconsider our refusal, offering ‘new and improved’ calculations that promised us profitability.  And, borrowing a technique from late night infomercials, they now offered an even steeper discount on a newly discovered refurbished product that was a deal they advised that we should not pass on.

We have many sales folks who come to see us.  Of course, we understand that they are selling products.  But a true sales professional understands his customer, and these guys massively misfired.  We are physicians, not hedge fund managers who regard income generation as our primary objective.  How should salesmen sell to doctors?  When device or pharmaceutical representatives come to see us, they are best poised to sell us on how their wares can help our patients improve their lives.  The product that can sell itself, sells best.  

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