Showing posts with label AMC Clinical. Show all posts
Showing posts with label AMC Clinical. Show all posts
Wednesday, September 18, 2013
Wednesday, June 20, 2012
Are The OSCEhome Systematic Approach Flowcharts The Answer To Today’s Short Patient-Physician Encounters?
Recently, I received an email from one of OSCEhome.com newsletter subscribers concerning a valuable article in Newsweek Magazine titled “The Doctor Will See You- If You’re Quick”. In that article, the Author, Shannon Brownlee, points out that ‘they are signs that something in the world of medicine is seriously amiss’. She said patients ‘tell tales of being rushed out of the office by harried doctors who miss crucial diagnoses, never look up from their computers during an exam, make errors in prescriptions, and just plain don’t listen to their patients. Studies show a steep decline over the last three decades in patients’ sense of satisfaction and the feeling their doctors are providing high-quality care. And things don’t seem much better from the other side of the stethoscope. In a recent survey by Consumer Reports, 70 percent of doctors reported that since they began practicing medicine, the bond with their patients has eroded’.
The main issue she stated is that ‘Today visits are still short… The number of required tests and conditions primary-care doctors are supposed to screen for has skyrocketed’. One physician in the article said: ‘When you have only 15 minutes per patient, then there are home visits and hospital visits, you feel like you’re on a hamster wheel’.
Then, she reported studies that concluded that ‘This is not a recipe for optimal care. One Canadian and U.S. study found that doctors interrupt their patients on average within 23 seconds from the time the patient begins explaining his symptoms. In 25 percent of visits, the doctor never even asked the patient what was bothering him. In another study that taped 34 physicians during more than 300 visits with patients, the doctors spent on average 1.3 minutes conveying crucial information about the patient’s condition and treatment, and most of the information they provided was far too technical for the average patient to grasp; disconcertingly, those same doctors thought they had spent more than eight minutes’.
On the patient clinical management side, she said ‘At the same time, doctors often prescribe too much of the wrong kind of care. Between 2000 and 2005, the number of CT scans performed annually nearly doubled to more than 75 million a year, many of them given, say experts, out of habit or fear of litigation, not because they were likely to help the doctor make a diagnosis’.
Concerning patient-physician relationship, she emphasized that ‘Numerous studies have found a link between how well the doctor and patient communicate and the patient’s sense of well-being, his number of symptoms, and his overall health.’
Bottom line reality is; 1) physicians have limited time allocated to each patient visit. There are more patients than physicians and training more physicians with these economical circumstances is not possible, 2) have a wide list of differentials to cover in order to be a good physician and to protect themselves. Obviously, the focused history and physical approach became so focused that failed frequently, 3) have no time for establishing an effective patient-physician relationship, and 4) have limited time to explore patient management options.
Currently, physicians have to adopt a focused approach. It is kind of the third world out-patient approach for treating patients’ symptoms. In order to protect themselves, they instruct patients to come back if things don’t improve! It is kind of an initial screening process during which physicians omitted several important issues concerning clinical and patient-physician communication. This may work initially. The problem is that when the patient comes back for a second visit, will he be allocated more visit time and addressed differently? What if the patient will see another physician who will re-initiate this focused approach?
So, how to solve this?
Since 2004, OSCEhome.com introduced the Systematic Approach to focused history taking, physical examination, and counseling in which a set of grouped carefully phrased questions and actions sets are arranged based on patient complaints, not body systems or physician specialty. It has the same rationale of ATLS APLS, ALSO, and ACLS approaches. After memorizing and practicing all the flowcharts, physicians can pick specific sets of history taking questions and physical exam actions to perform during the patient encounter based on the presenting patient complaint.
Verbal and non-verbal communication skills are embedded within this system. By practicing these flowcharts over and over until it become a second habit, physicians can be confident that they accomplished a professional conduct. This focused approach puts the physician on an autopilot mode to cover all relevant differentials without thinking about them as they have no time in today’s short patients’ visit.
This approach ensures that the physician won’t forget to ask or examine crucial things. In stead, they’ll have relatively more time for clinical decision making, establishing rapport, and discussing the patients’ options, attitude, and compliance.
Read more about the OSCEhome Systematic Approach at http://www.oscehome.com/.
Read the full Newsweek article at The Doctor Will See You- If You’re Quick.
Have a nice day.
Dr Al Imari.
http://www.oscehome.com/
The main issue she stated is that ‘Today visits are still short… The number of required tests and conditions primary-care doctors are supposed to screen for has skyrocketed’. One physician in the article said: ‘When you have only 15 minutes per patient, then there are home visits and hospital visits, you feel like you’re on a hamster wheel’.
Then, she reported studies that concluded that ‘This is not a recipe for optimal care. One Canadian and U.S. study found that doctors interrupt their patients on average within 23 seconds from the time the patient begins explaining his symptoms. In 25 percent of visits, the doctor never even asked the patient what was bothering him. In another study that taped 34 physicians during more than 300 visits with patients, the doctors spent on average 1.3 minutes conveying crucial information about the patient’s condition and treatment, and most of the information they provided was far too technical for the average patient to grasp; disconcertingly, those same doctors thought they had spent more than eight minutes’.
On the patient clinical management side, she said ‘At the same time, doctors often prescribe too much of the wrong kind of care. Between 2000 and 2005, the number of CT scans performed annually nearly doubled to more than 75 million a year, many of them given, say experts, out of habit or fear of litigation, not because they were likely to help the doctor make a diagnosis’.
Concerning patient-physician relationship, she emphasized that ‘Numerous studies have found a link between how well the doctor and patient communicate and the patient’s sense of well-being, his number of symptoms, and his overall health.’
Bottom line reality is; 1) physicians have limited time allocated to each patient visit. There are more patients than physicians and training more physicians with these economical circumstances is not possible, 2) have a wide list of differentials to cover in order to be a good physician and to protect themselves. Obviously, the focused history and physical approach became so focused that failed frequently, 3) have no time for establishing an effective patient-physician relationship, and 4) have limited time to explore patient management options.
Currently, physicians have to adopt a focused approach. It is kind of the third world out-patient approach for treating patients’ symptoms. In order to protect themselves, they instruct patients to come back if things don’t improve! It is kind of an initial screening process during which physicians omitted several important issues concerning clinical and patient-physician communication. This may work initially. The problem is that when the patient comes back for a second visit, will he be allocated more visit time and addressed differently? What if the patient will see another physician who will re-initiate this focused approach?
So, how to solve this?
Since 2004, OSCEhome.com introduced the Systematic Approach to focused history taking, physical examination, and counseling in which a set of grouped carefully phrased questions and actions sets are arranged based on patient complaints, not body systems or physician specialty. It has the same rationale of ATLS APLS, ALSO, and ACLS approaches. After memorizing and practicing all the flowcharts, physicians can pick specific sets of history taking questions and physical exam actions to perform during the patient encounter based on the presenting patient complaint.
Verbal and non-verbal communication skills are embedded within this system. By practicing these flowcharts over and over until it become a second habit, physicians can be confident that they accomplished a professional conduct. This focused approach puts the physician on an autopilot mode to cover all relevant differentials without thinking about them as they have no time in today’s short patients’ visit.
This approach ensures that the physician won’t forget to ask or examine crucial things. In stead, they’ll have relatively more time for clinical decision making, establishing rapport, and discussing the patients’ options, attitude, and compliance.
Read more about the OSCEhome Systematic Approach at http://www.oscehome.com/.
Read the full Newsweek article at The Doctor Will See You- If You’re Quick.
Have a nice day.
Dr Al Imari.
http://www.oscehome.com/
Tuesday, November 29, 2011
How would you deal with someone who is insisting to have mammogram without indication?
From:
Sent: Tuesday, November 29, 2011 12:08 PM
To: info@oscehome.com
Subject: Conflicted roles Dear Doctor Al Imari, Could you please give more idea about dealing with conflicts as there is only one phrase you have mentioned in the remedy part, can you elaborate what to be explained about the conflict in the case and what should we inform as a doctor about what we could do. This is from OSCEhome ebook “How To Unlock Difficult Medical Encounters”. To be more precise how would you deal with someone who is insisting to have mammogram without indication or a mother who is asking why her teenage daughter was in your clinic etc.
Kind regards
Ravi
Hello Ravi,
For "how would you deal with someone who is insisting to have mammogram without indication ":
1- Address their needs with respectful, empathic, and generous care directed towards physical and emotional comfort. Ask why she is really concerned to have the mammogram now? Hidden issues? Educate the patient about the limited benefits of mammogram, as the fact is that the younger the women is, the more difficult to efficiently read the mammogram films as younger women have more glandular breasts which limits the benefit, and its risk of radiation.
2- Set limits of your “Contract” with the patient:
1) Provide written instructions: brochures, web sites about the recommended guidelines. Discuss a risk-benefit balance
2) Set follow-up appointments.
3) Set limits on phone calls.
4) Set limits on prescriptions refills.
3- Emphasize the patient responsibilities:
1) Understanding the nature and characteristics of their health problem.
2) Behavior change and adherence to therapy. Self examination and periodic physician exam.
3) Fulfilling his/her part of the “therapeutic contract”. Negotiate a plan TOGETHER. Don't be confrontational. The agreed upon plan is for her best interest and you gain nothing for ordering the mammogram or not.
4- Avoid making promises that you cannot keep (e.g. nursing or insurance problems). Apart from reconsidering the issue on next appointment.
5- Remind the patient that available time is limited. “You certainly have a lot of important problems, but since our time is so short, I’d like to get back to your …cc ”
6- Do not take credit for remissions in the patient’s symptoms, because you will be blamed for a relapse in the future. Note: Sometimes physicians order tests to relief anxious patients, but try to avoid that during OSCEs. ----------------------------------------------------------------------------------
About "a mother who is asking why her teenage daughter was in your clinic":
1- Clearly communicate to the patient, individual, and institution your double role right from the beginning. “Mr./Ms. …, although I am your doctor and I am obliged to do all my best to serve your interests, I also have other obligations and duties by profession or law that might limit my obligation towards you. I’ll do my best to serve both obligations.
2- Clearly explain what the conflict is in this case. "Your daughter is mature enough to take care of herself and, by privacy and professional laws, I cannot give you any relevant information."
3- Clearly inform him/them about what can you do. "I cannot help you here and I recommend discussing this issue directly with your daughter. Please excuse me. I don't want to waste your time as well as other waiting patients' time." and end the encounter. If she continues to ask in different ways, just keep saying “Discussing this issue directly with your daughter.”
Hopefully this answers your questions.
Have a nice day.
Al
Sent: Tuesday, November 29, 2011 12:08 PM
To: info@oscehome.com
Subject: Conflicted roles Dear Doctor Al Imari, Could you please give more idea about dealing with conflicts as there is only one phrase you have mentioned in the remedy part, can you elaborate what to be explained about the conflict in the case and what should we inform as a doctor about what we could do. This is from OSCEhome ebook “How To Unlock Difficult Medical Encounters”. To be more precise how would you deal with someone who is insisting to have mammogram without indication or a mother who is asking why her teenage daughter was in your clinic etc.
Kind regards
Ravi
Hello Ravi,
For "how would you deal with someone who is insisting to have mammogram without indication ":
1- Address their needs with respectful, empathic, and generous care directed towards physical and emotional comfort. Ask why she is really concerned to have the mammogram now? Hidden issues? Educate the patient about the limited benefits of mammogram, as the fact is that the younger the women is, the more difficult to efficiently read the mammogram films as younger women have more glandular breasts which limits the benefit, and its risk of radiation.
2- Set limits of your “Contract” with the patient:
1) Provide written instructions: brochures, web sites about the recommended guidelines. Discuss a risk-benefit balance
2) Set follow-up appointments.
3) Set limits on phone calls.
4) Set limits on prescriptions refills.
3- Emphasize the patient responsibilities:
1) Understanding the nature and characteristics of their health problem.
2) Behavior change and adherence to therapy. Self examination and periodic physician exam.
3) Fulfilling his/her part of the “therapeutic contract”. Negotiate a plan TOGETHER. Don't be confrontational. The agreed upon plan is for her best interest and you gain nothing for ordering the mammogram or not.
4- Avoid making promises that you cannot keep (e.g. nursing or insurance problems). Apart from reconsidering the issue on next appointment.
5- Remind the patient that available time is limited. “You certainly have a lot of important problems, but since our time is so short, I’d like to get back to your …cc ”
6- Do not take credit for remissions in the patient’s symptoms, because you will be blamed for a relapse in the future. Note: Sometimes physicians order tests to relief anxious patients, but try to avoid that during OSCEs. ----------------------------------------------------------------------------------
About "a mother who is asking why her teenage daughter was in your clinic":
1- Clearly communicate to the patient, individual, and institution your double role right from the beginning. “Mr./Ms. …, although I am your doctor and I am obliged to do all my best to serve your interests, I also have other obligations and duties by profession or law that might limit my obligation towards you. I’ll do my best to serve both obligations.
2- Clearly explain what the conflict is in this case. "Your daughter is mature enough to take care of herself and, by privacy and professional laws, I cannot give you any relevant information."
3- Clearly inform him/them about what can you do. "I cannot help you here and I recommend discussing this issue directly with your daughter. Please excuse me. I don't want to waste your time as well as other waiting patients' time." and end the encounter. If she continues to ask in different ways, just keep saying “Discussing this issue directly with your daughter.”
Hopefully this answers your questions.
Have a nice day.
Al
Wednesday, October 26, 2011
Friday, February 20, 2009
Tuesday, February 10, 2009
Wednesday, February 14, 2007
A Step By Step Guide to Mastering the OSCEs!
The One Of A Kind Systematic Approach To Medical OSCE Exams Preparation!
Objective Structured Clinical Examination, OSCE, also called Objective Standardized Clinical Examination is tough. OSCE exams like USMLE Step 2 CS, MCCQE II, PLAB Part 2, AMC Clinical, TRAS 2, Medical Students OSCEs, Medical Schools Finals, and Clinical Skills Assessments for International or Foreign Medical Graduates are really difficult and stressful. That is what it is. I’m not going to say it is easy as what clinical educators and OSCE organizers usually claim trying to make it acceptable for you.
OSCE Exams consist of several clinical encounters (called stations) with specially trained actors playing the role of a patient with some sort of a medical complaint (called Standardized Patient, SP).
Let’s take few minutes here to imagine your situation during the OSCE. This is an important step as you may realize that the first step to deal with any issue is to completely understand what it is.
You will find a lot of articles and web pages describing what are the OSCE exam procedures. They present the OSCE in a scientific academic context. I am sure you already have read several of these.
Are you?… Did you read between the lines?… Have you achieved an understanding about how your physical and mental status will be during the OSCE exam?
Well, let me explain it for you. Just concentrate. Imagine yourself in a hallway with several other candidates each standing in front of a closed door. Several individuals are watching you for any violation of the rules. Then a bell or a buzzer goes on. You have one or two minutes to read a full page hanged on that door describing what the station ahead is and what is you required to do.
Usually, you’ll need to read the instructions several times because you’re nervous, you heart is racing and your mind isn’t catching what your eyes are reading!
Then, a second bell/buzzer sounds. You knock the door and enter the room. In each room, you will find a new patient and a different room setting. In some OSCE Exams, an examiner is present in the room. In such cases, you have to hand out the examiner one or two of your identification stickers that you may have looked for them and didn’t find. Remember you are nervous.
Then you have to start as your limited time has already been started when the second bell/buzzer went on. You need to get information from the SP or may be examine or consult him/her. Your voice is low. Your hands are shaking. You look unconfident and don’t know what to do. You are at the center of focus of both the SP and the OSCE examiner (present or through video monitoring). Both are watching you carefully. Listening to you.
Those SPs are well trained not to give you any information unless you specifically ask for it. That is not like real life medical encounters where the patient will say everything when you ask about the reason of their visit. So, you have to know what questions you need to ask, The OSCE Examiner checklist.
As you were asking, the patient replies by questions for you. Questions like ‘What do you mean?’, ‘Do I have to answer that?’, ‘Is this relevant to my problem?’, ‘Why are you asking this?’. All these questions are intended to shake you if that wasn’t a reflex of your poorly phrased questions. You start to lose control over yourself and the encounter. You start to make fatal mistakes like being disrespectful to the patient and unprofessional. You’ll jump from topic to topic unorganized. And you’ll forget to ask questions that are important to fulfill the examiner checklist! That examiner who is sitting or standing closely observing you and filling out your checklist and writing comments.
.
Suddenly the bell/buzzer goes on again. The station is over. Oh my God. There are still tons of questions that I have to ask. I missed this station. You’ll start the process of self-blaming. You’ll feel hopeless.
.
As you proceed, you’ll try to hold yourself up. You’ll find that you had already wasted substantial time of the minute before the next station or in some exams where there is a post encounter oral or writing question period or patient notes writing period.
.
The cycle starts again and again.
By the fourth or fifth station, you’ll feel exhausted and your brain starts to ache. You’ll feel unable to think about the coming station and you start to give up claiming that you’ll do your best.
.
Did you get what I wanted you to understand? Let me put it in summary:
.
· You will be nervous, irritable and cannot think straight.
· You will be physically and mentally exhausted.
· Your time is running fast and is not enough.
· Some SPs will be challenging you intentionally and waist your time.
· You need to be organized and manage your time effectively.
· You need to know in advance what to ask, as there is no time to think.
· You need to be careful about how to phrase your questions and comments in order to be respectful and empathic. Remmeber, no time to think.
· You need to ask your questions intelligently in order not to lead the patient or trigger programmed time wasting and problem evoking conversations.
· You need to be and appear confident, organized, and professional.
.
Is that easy?… Of course not.
Is it impossible to do?… Of course not.
Thousands of medical students, residents, and graduates have done it…. Okay, so it is not easy and at the same time not impossible. You need to assign the needed time and effort to prepare yourself to the OSCE Exams and you’ll be just fine.
.
But how to prepare yourself for the OSCEs?
.
This ebook, A Step By Step Guide To Mastering The OSCEs, will help you to:
.
1. A Step By Step Flowcharts To Follow Through Out Your Organized Controlled Medical Interview OSCE Exam.
2. A Complete History Taking Templates For All Common OSCEs In ALL Specialties.
3. Ready To Use Questions Templates Of What & How & When To Ask, Not Only Checklists That You Need To Figure Out How To Cover In Your OSCE Exam.
4. Question Templates That Cover All Related Differential Diagnosis And Covers The Checklists Without The Need To Think About The Case.
5. A Step By Step Guide Of How To Perform A Physical Examination, What To Examine, And What To Tell The Patient And The OSCE Examiner (if present) While Examining The SP.
6. A Step By Step Guide To Follow About What, When, And How To Manage Any Emergency Setting OSCE Station.
7. How To Organize A Counseling Station In The OSCEs.
8. Complete Carefully Phrased Sentences Of How To Approach Sensitive Issues Like Menses, Sexual History, And Abuse In An Ethical Manner.
9. Master Verbal Communications Indirectly By Just Memorizing The Templates and Perform Them In Your OSCE Exam.
10. How To Unlock Difficult Medical Encounters? To Deal with 20 Difficult OSCE Scenarios Like Depression, Breaking Bad News, .......
Let’s start. You can do it.
We can help you pass the OSCEs with high score.
You just need someone to show you specifically how to do it, and We can help. Let’s start.
Download it NOW, Don't waste your time
Dr. Alimari, MD
www.oscehome.com
Objective Structured Clinical Examination, OSCE, also called Objective Standardized Clinical Examination is tough. OSCE exams like USMLE Step 2 CS, MCCQE II, PLAB Part 2, AMC Clinical, TRAS 2, Medical Students OSCEs, Medical Schools Finals, and Clinical Skills Assessments for International or Foreign Medical Graduates are really difficult and stressful. That is what it is. I’m not going to say it is easy as what clinical educators and OSCE organizers usually claim trying to make it acceptable for you.
OSCE Exams consist of several clinical encounters (called stations) with specially trained actors playing the role of a patient with some sort of a medical complaint (called Standardized Patient, SP).
Let’s take few minutes here to imagine your situation during the OSCE. This is an important step as you may realize that the first step to deal with any issue is to completely understand what it is.
You will find a lot of articles and web pages describing what are the OSCE exam procedures. They present the OSCE in a scientific academic context. I am sure you already have read several of these.
Are you?… Did you read between the lines?… Have you achieved an understanding about how your physical and mental status will be during the OSCE exam?
Well, let me explain it for you. Just concentrate. Imagine yourself in a hallway with several other candidates each standing in front of a closed door. Several individuals are watching you for any violation of the rules. Then a bell or a buzzer goes on. You have one or two minutes to read a full page hanged on that door describing what the station ahead is and what is you required to do.
Usually, you’ll need to read the instructions several times because you’re nervous, you heart is racing and your mind isn’t catching what your eyes are reading!
Then, a second bell/buzzer sounds. You knock the door and enter the room. In each room, you will find a new patient and a different room setting. In some OSCE Exams, an examiner is present in the room. In such cases, you have to hand out the examiner one or two of your identification stickers that you may have looked for them and didn’t find. Remember you are nervous.
Then you have to start as your limited time has already been started when the second bell/buzzer went on. You need to get information from the SP or may be examine or consult him/her. Your voice is low. Your hands are shaking. You look unconfident and don’t know what to do. You are at the center of focus of both the SP and the OSCE examiner (present or through video monitoring). Both are watching you carefully. Listening to you.
Those SPs are well trained not to give you any information unless you specifically ask for it. That is not like real life medical encounters where the patient will say everything when you ask about the reason of their visit. So, you have to know what questions you need to ask, The OSCE Examiner checklist.
As you were asking, the patient replies by questions for you. Questions like ‘What do you mean?’, ‘Do I have to answer that?’, ‘Is this relevant to my problem?’, ‘Why are you asking this?’. All these questions are intended to shake you if that wasn’t a reflex of your poorly phrased questions. You start to lose control over yourself and the encounter. You start to make fatal mistakes like being disrespectful to the patient and unprofessional. You’ll jump from topic to topic unorganized. And you’ll forget to ask questions that are important to fulfill the examiner checklist! That examiner who is sitting or standing closely observing you and filling out your checklist and writing comments.
.
Suddenly the bell/buzzer goes on again. The station is over. Oh my God. There are still tons of questions that I have to ask. I missed this station. You’ll start the process of self-blaming. You’ll feel hopeless.
.
As you proceed, you’ll try to hold yourself up. You’ll find that you had already wasted substantial time of the minute before the next station or in some exams where there is a post encounter oral or writing question period or patient notes writing period.
.
The cycle starts again and again.
By the fourth or fifth station, you’ll feel exhausted and your brain starts to ache. You’ll feel unable to think about the coming station and you start to give up claiming that you’ll do your best.
.
Did you get what I wanted you to understand? Let me put it in summary:
.
· You will be nervous, irritable and cannot think straight.
· You will be physically and mentally exhausted.
· Your time is running fast and is not enough.
· Some SPs will be challenging you intentionally and waist your time.
· You need to be organized and manage your time effectively.
· You need to know in advance what to ask, as there is no time to think.
· You need to be careful about how to phrase your questions and comments in order to be respectful and empathic. Remmeber, no time to think.
· You need to ask your questions intelligently in order not to lead the patient or trigger programmed time wasting and problem evoking conversations.
· You need to be and appear confident, organized, and professional.
.
Is that easy?… Of course not.
Is it impossible to do?… Of course not.
Thousands of medical students, residents, and graduates have done it…. Okay, so it is not easy and at the same time not impossible. You need to assign the needed time and effort to prepare yourself to the OSCE Exams and you’ll be just fine.
.
But how to prepare yourself for the OSCEs?
.
This ebook, A Step By Step Guide To Mastering The OSCEs, will help you to:
.
1. A Step By Step Flowcharts To Follow Through Out Your Organized Controlled Medical Interview OSCE Exam.
2. A Complete History Taking Templates For All Common OSCEs In ALL Specialties.
3. Ready To Use Questions Templates Of What & How & When To Ask, Not Only Checklists That You Need To Figure Out How To Cover In Your OSCE Exam.
4. Question Templates That Cover All Related Differential Diagnosis And Covers The Checklists Without The Need To Think About The Case.
5. A Step By Step Guide Of How To Perform A Physical Examination, What To Examine, And What To Tell The Patient And The OSCE Examiner (if present) While Examining The SP.
6. A Step By Step Guide To Follow About What, When, And How To Manage Any Emergency Setting OSCE Station.
7. How To Organize A Counseling Station In The OSCEs.
8. Complete Carefully Phrased Sentences Of How To Approach Sensitive Issues Like Menses, Sexual History, And Abuse In An Ethical Manner.
9. Master Verbal Communications Indirectly By Just Memorizing The Templates and Perform Them In Your OSCE Exam.
10. How To Unlock Difficult Medical Encounters? To Deal with 20 Difficult OSCE Scenarios Like Depression, Breaking Bad News, .......
Let’s start. You can do it.
We can help you pass the OSCEs with high score.
You just need someone to show you specifically how to do it, and We can help. Let’s start.
Download it NOW, Don't waste your time
Dr. Alimari, MD
www.oscehome.com
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