Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Common Myths about Physician Assistants

Introduction

As we move further into the 21st century, the presence of  mid-level practitioners will become more and more prevalent in medical centers and in general health-care. Long gone are the days of one’s total health care being managed by a physician only in the ranks of primary care. For some patients (and practitioners), the presence of a mid-level practitioner is both confusing and unwelcome. Physician assistants make up a portion of the mid-level practitioners that will be found in many modern health care centers (along with nurse practitioners) but patients will often be unaware of their training and purpose in adding(extending) what a physician can do for them.  Many of my physician colleagues will feel that physician assistants will somehow encroach on their areas of practice which is far from the truth. In essence, my physician assistants extend and reinforce what I am able to do in medicine. They function as my eyes, ears and hands in places that I physically cannot be present and  my PA colleagues provide a very high level of care for my patients. In my practice it isn’t you see the physician or the physician assistant but in most cases, you will be seen by both.

Myth No. 1 -Most people who become physician assistants couldn’t get into medical school so they are physician “wannabes”.

In 2012, the entry-level for most physician assistant programs is at the level of master’s degree.  Not only is a minimum 3.0 GPA required to apply to these programs, the competition to enter these programs is much stricter and more stringent than ever. Most of the folks who applied the Physician Assistant (PA) program at my university had over a 3.5 GPA and most who were accepted into the program had over a 3.7 GPA. This would indicate that the folks who were able to enter our PA program were definitely capable and would have been competitive for many medical schools in this country. Many of the people who entered our program sought to become a PA rather than an MD because they didn’t feel that they wanted to spend a minimum of 7 years before they could practice. Our program is 27 months from start to finish with our graduates being able to enter any area of medicine one would find physicians. In addition, they can seek additional training in anesthesia and critical care if they choose to work in these areas. The vast majority of our PA grads go into surgery, pediatrics , emergency medicine and internal medicine much the same as our MD graduates.

Myth # 2- PA school is easier than medical school so these folks give inferior care

In truth, PA school is a bit more difficult than medical school. In essence, I had two years of pre-clinical didactics before I entered the clinical phase of my medical school. PA students have about one year of pre-clinical didactics before entering their clinical phase and they are taught on clinical rotations alongside 3rd and 4th year medical students. PA students attend the same clinical lectures and are expected to carry the same clinical loads as the 3rd and 4th year medical students. We often don’t know whether a student is a PA student or a medical student unless we are able to read the name badges. I ask rotating students the same questions and expect the same level of functioning regardless of which degree they will complete. In the end, the PA student will leave at the level of a  PGY-1-2 resident and function at that level  for most of their career while the medical student will leave at the level of a PGY-1 resident and move through residency to become an attending physician. Most of the patients that are treated in clinics at medical centers are seen by a combination of PAs and residents on teams that are run by a chief resident or attending physician with no compromise of care.

Myth 3- PA don’t know things at the level of a physician so they might miss something in my care

Most PAs are very adept at self-directed learning in the same manner as a physician. Whether one attends medical school or PA school, one cannot expect that what is learned in school is all that is needed to be a competent practitioner. My state requires that I complete many hours of continuing education in order for me to maintain a license to practice with PA having the same licensure requirements. In addition to seeing patients, PAs are constantly upgrading and honing their knowledge often at the same conferences and meeting as physicians.  Physicians often consult each other in terms of taking care of complicated patients and good PAs will consult with more experienced PAs or physicians in the care of their patients. The PA that work on my service know the scope of their practice and do not exceed this. While the PA may be able to do 90% of what I do as a physician, they are very aware of when a patient is beyond their scope of care the same as any physician is aware of when a patient is beyond their scope of care.

Myth #4- If I see the PA, I have to see the doctor too so why the extra step?

Many of my patients may not be seen by me on some office visits where they see the PA only. If the PA feels that the patient does not need to be seen by me, they will take care of the problem and the patient gets out sooner. On the other hand, most of the PA who work in my practice will state that, I know the doctor wants to see you so wait a couple of minutes until she is available” while in the meantime, I will consult with the PA on how the care of that patient is going along. PAs in our practice will perform treatments, manage wound care and work patients up for surgery. In most cases, just as with the residents who are on our team, the PA will assist in the surgery of the patient that they worked up unless the case is of vital learning for a resident.

Myth #5- PA education is inferior to physician education

PAs are educated under the same model as physicians. They take the same coursework in some cases but they don’t spend the same amount of time in school as a medical student and they don’t spend the same amount of time in post-graduate training as a medial student would. The ability to practice medicine with less training is something that is very appealing for most of the people who enter PA school. At the end of training and upon passage of their certification examination, most PAs start out at around $78,000 and max out around $110,000 after a few years in practice. For many people, spending a minimum of 3 years in residency above 4 years of medical school (expensive) only to earn about $47,000 as a resident is not something that they can afford financially. Most PA programs will cost far less than medical school and will enable their graduates to get into the health care work force much sooner at higher salary. Additionally, physician assistants can apply for and qualify for public health care scholarships that will pay back their student loans which are far less than the average $158,000 that a medical student will owe after medical school.

Finally…

I wrote this post because many students have negative ideas of what the training and work of a physician assistant will involve. For many students who have a strong desire to work in the medical field but family and financial obligations that will not allow them to spend a minimum of 7 years in training above  the baccalaureate level, becoming a physician assistant is something that they might find appealing. In today’s world of medical practice, PAs diagnose, treat and prescribe right alongside physicians. Often it’s the PA who gets to spend more time with the patient and who will develop a more personal relationship with their patient because the PA is not subject to the time constraints that a physician is often subject to. Good PAs build upon their clinical skills learned in school and spend as much time upgrading those skills through continuing education and journal reading as any physician would. It’s no accident that physician assistants enjoy the highest job satisfaction of any profession in health care with other professions not even coming close to their level of satisfaction.

I would encourage any premedical student to take a long and objective look at the physician assistant profession in addition to medicine. You may find that it’s a good fit for your professional ideals especially if you enjoy one-on-one interaction with your patients. One of our frequent questions for entry into PA or medical school is ,”What other health care professions have you looked at and what did you find out about them?”.  I am always surprised at the number of students who have applied to PA or medical school that didn’t do a thorough investigation of health care careers besides physician or physician assistant. Certainly if one anticipates preparing for a career as a physician, one should definitely make sure that they have done a thorough investigation of everything that is available, including alternatives and make the most informed decision before they embark on a career that takes a minimum of 7 years beyond university. Additionally,every PA that works in my practice is far from envious of my practice and love the scope of their profession. As you look at becoming a PA, make no mistake in believing that compared to medicine, it’s inferior or easier because this simply isn’t accurate and you may find that this very modern career is a great one for you.

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14 January, 2012 - Posted by | can't get into medical school, medical school, physican assistant, pre-med courses |

35 Comments »

  1. It’s interesting because I’ve read countless studies that suggested that 2 years of rotations for a medical student was no beneficial than 1 year. This would never change because it’s a business of money for medical schools and also an ego thing. As a PA, we are responsible for about 85% of the material in 15 months as a medical student is for in 24 months. Also if you compare the average of most medical schools and PA schools class room time when it’s all put together minus vacation time, it differs in time by about 2 months. I’ve also never as a student on rotation ever met a MD or DO student that knew any more than I did. I’ve read numerous articles on this topic and I trusted them but I also verified. Doctors excel beyond our education when they enter residency. PAs get on the job training and research shows that If an individual stays in the same speciality depending on what it is, for example, FP, after about 4 to 5 years, they can be as knowledgeable as the MD they are working under. Don’t want to be called doctor and in fact spend a lot of my time explaining to patients what I am because I don’t want someone else taking credit for my work. Sorry about the bad grammar, doing this on my phone plus auto correct is killing me.

    Comment by That Guy | 16 July, 2015 | Reply

    • To That Guy:
      First of all, thank you for your comments. Second, I am a physician, scientist (Ph.D) and professor who teaches both PAs and allopathic medical students, residents and fellows. I can say that medical or PA school only gives one the basic background to continue with training. Most of a physician’s training in patient care comes not from medical school but from residency. Attempting to compare students (medical & PA) on rotations is not the definitive comparison as the medical student is going end up with far more training that any mid-level practitioner which is why the physician is and always will be the final definitive word on patient care matters. Next, on-the-job experience is not a substitute for residency training (I completed 9 years of residency and fellowship training here above medical school) thus one can’t compare experience between a physician and physician assistant. While many of our duties overlap, knowledge, background and education are not comparable. I would also caution you to work as hard as possible to hone your knowledge base but resist the urge to make comparisons with physicians and strive to be the best PA that you can be. There is plenty of patient care for all of use. Cheers and best wishes.

      Comment by drnjbmd | 16 July, 2015 | Reply

      • MD-PhD….I agree that the education the physician and PA get in their academic phase is just the start of what we hope is a journey of life long education. As a long time leader of the PA profession’s only certifying body, I can say that the PA training and subsequent certification/training differ from the physician on two fundamental facts. First, USLME step 1 and the objectification of clinical learning after graduation or when practicing. PAs do not get assessed to the depth of a physician with an exam like the step 1. This is truly a “rights of passage”. Two, PAs do not formally objectify ALL of their learning once they graduate. We have learned through our CAQs process that when this is done you can approximate outcomes of a residency. Further, many PA specialties have residencies within physician programs. I cannot except your assertion if the post graduate PA practices and learns in a formalized environment with assessments and a content blueprint that this earning cannot be considered similar to that of a physician. The PA delivers physician services and some do it with significant autonomy. The patient and the system expect the same outcome from the PA encounter than what would be the case with a physician. One does not need a PhD in computer engineering to repair a computer. It is important to not take on a project outside of your knowledge, skills, and ability. Additionally, most of the world is on an MBBS model where physician training is about six years for general practice. The American model is not necessarily the best. Our fundamental problem is we may have over trained for common medicine. Warm regards PhD-PA…

        Comment by james c | 18 July, 2015

  2. Thank you for an in depth and honest look at PAs from a practicing MD. I wish it would be read in its entirety by all. I think it is a fair evaluation of our career choice. As a primary care physician I have been the primary provider for my own panel of patients, but always had a MD around to bounce a question off and to read my labs and tests so there were two people keeping an eye on the patients. Team medicine is ideal for quality patient care and my satisfaction rate was exceptionally high. In specialties I function less independently, much more as your PAs do, and still find significant enjoyment and benefits for myself and the patients!

    Comment by Carolyn Roderick | 19 June, 2015 | Reply

  3. I am sorry but some of the stuff here is incorrect. You seem to suggest that new PAs know as much as new MDs. I have no dount that PA training is hard but we(PA) learn in more “superficial” terms. Here at PCOM the gross anatomy that PAs learn is not nearly as in depth as the DO students and the same goes to other classes. If PA is the same as MD then we would be doctors at the end of our education. PAs do more than assist but they arenot replacement for doctors. You are suggesting that when you say that a new PA has the same level of education as a PGY1-2. This is simply not true

    Comment by Calvin Johnson | 5 August, 2013 | Reply

    • To Calvin J:
      At no point in the post do I state that PAs have the same level of education as a PGY1/2. They function clinically at about the level of a PGY-1/2 and carry out many(but not all) duties of a PGY-1/2. At no point does the post suggest that PA are “replacements” for Physicians. As a modern health professional, I would hope that your education never “ends”.

      Comment by drnjbmd | 6 August, 2013 | Reply

  4. I agree with most of everything here except the part of course load for PA’s being less than med students. It I’d actually the other way around. In addition to attending the same classes in the morning from 8-12 with med students or taking the same core classes as med students, since the pa program is so rigorous, most pa programs have additional class/labs till 5 pm, while most med students are done far earlier in the day. It is not uncommon for pa students to study till midnight and get up to only study more before 8 am class, it is four year curriculum squeezed into 27 months.

    Comment by Ceara Murray | 18 July, 2013 | Reply

    • To Ceara:
      My first semester of medical school was 59 hours. No other school (even PA) was even close. Many medical schools have on-line material to be completed so that students finish earlier in the day. Study hours are an individual matter and do not count into the course load as some students can take 15 hours but study more that those who take 25 hours but study less. Rigor is also an individual matter as what is rigorous for one student is not so rigorous for another. Medicine has far more hours to be completed than any other profession at the doctorate level. Course/contact hours for MD are set by LCME (Liaison Committee for Medical Education) and not set by individual schools. How long it takes one student or another to “study” for those classes will vary. PA is NOT a 4-year medical school curriculum squeezed into 27 months by any stretch of the imagination. If that were the case, you would receive a Doctorate of Medicine at the end of your 27 months (a few PA schools are still granting bachelors degrees). This isn’t a “pissing” contest but a matter of fact. The object of training a PA is not to push them through medical school in 1/2 the time but to train a PA for their scope of practice; while some of the training overlaps with medical student training in some places, the two degrees are not equivalent nor are the hours.

      Comment by drnjbmd | 18 July, 2013 | Reply

      • I enjoyed your article on Common Myths of Physician Assistants very much.
        Would you email me as I would like to discuss re-purposing this blog for other areas? Thank you.

        Comment by Mary Rittle | 18 July, 2013

      • To MR:
        I don’t answer personal e-mails but it’s fine if you re-purpose/reblog this information as long as my blog is credited as others have done. Thanks

        Comment by drnjbmd | 18 July, 2013

  5. Great points about the rigors of PA training. The profession is still very young and going through growing pains. With time, I expect that our talents will shine. One small but important point- physician assistant’s have their own medical certifications, there own DEA numbers and often, their own patient panels. We are not owned by any one particular physician and we rarely “assist,” all though the current environment dictates that we work in collaboration with an M.D. To say that your PA’s sole function is to extend your services is misleading, as we are competent, highly trained practitioners in our own right very capable of providing autonomous care in concert with a physician. Many PA’s choose to work in this field because of the lateral mobility it affords. A seasoned PA might have 5 years in orthopedics, 10 years in emergency medicine and 5 more in primary care, for example. This affords a broad knowledge base and a wealth of experience that I would argue is quite unique among health care practitioners. A good PA is always grateful for M.D. support, and conversely, a good M.D. will utilize his seasoned PA’s strengths and know when to ask his or her opinion as well.

    Comment by small point | 12 July, 2013 | Reply

  6. This was a decent article. There is variation in PA practice, just as there is in a physicians practice. Also, many PAs, since they are not completing a residency need to work more closely with a physician after school for awhile. But many who are very seasoned can function pretty much at the level of a physician. I’ve been around a long time. I work in a complex spine practice and have my own panel of patients. As we are primarily a consultative service, I see my own schedule of new consults that I will manage. The physicians I do work with are very collaborative. 99% of the time, I don’t need any help or guidance, but once in a while I’ll ask them to look at an image, or if I should be thinking of something else based on a patients neurologic exam, and guess what, they’ll do the same to me. They’ll ask my opinion and what I might think about something. It’s a collaborative, team approach, and we all do our own thing, consulting each other only when needed. I’m moving away from being a PA, but not because I don’t like it. Because I finished my research doctorate, and I want to focus just on health services research. Primarily, researching the function, and adaptation of medical team structures and team based decision science. Wonder where I got that idea.???

    Comment by Michael | 12 July, 2013 | Reply

  7. Hello… I am torn between becoming a Physician Assistant and a Physical Therapist.. reading your article has inspired me to look more into a career as a Physical Therapist… I have always wanted to be a doctor .. but as a mom.. I would also like to spend as much time as I can with my children. i am going to look more into this field… your article is great.. keep up the good work…

    Comment by Tisha | 29 May, 2013 | Reply

  8. Dr. i have many heath problems related to diabetes. I have had a heart attack and now am having problems with my para thyroid. The endroconolgist that i have been seeing for 21 years now wants me to see a PA two times then him once. I have had many problems with PA;s diagnosing me wrong in the past. I do not feel they have the same education as a DR. One PA gave me meds that the pharmacy caught, two in the same practice said i had poison ivy and the other one said poison oak which turned out to be porissis . yet they expect me to continue seeing a PA. Doctors put up a sign in their offices that i can see a physcian instead of a PA but yet they feel I’m being difficult. If i’m paying for a doctor shouldn’t I be allowed to have my choice. I will have to travel 50 miles to go see other doctors. What is your opinion?

    Comment by virginia walk | 2 March, 2013 | Reply

    • To VA W:
      When it comes to your health, you have the right to have your problems taken care of so that you can enjoy all aspects of your life. The problems that you describe in your post are complex,chronic and are best cared for by a multidisciplinary team rather than one practitioner regardless of physician or physician assistant. The educational level of the team member that you see should meet the needs of the reason for your visit. I am sorry that you have had so many things go wrong and would hope that any practitioner would ensure that your needs are addressed and would refer to another member of the team with the best experience to take of those needs.

      Comment by drnjbmd | 2 March, 2013 | Reply

    • Ms. Walk,
      That’s a shame that you’ve had a bad experience with PAs, but please don’t judge the entire profession based on one or two past experiences. And you’d be suprised at how many physician mistakes are “caught” by pharmacies…that’s the pharmacist’s job to ensure no interactions are going to take place with people’s L-O-N-G list of medications. It is unreasonable to believe that any physician assistant or physician would memorize these! Again, you have the choice of who you see, but don’t discount PAs!!!

      Comment by Jessica | 17 July, 2013 | Reply

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    Comment by Anon | 23 December, 2012 | Reply

  10. Thank you so much for posting this. I am currently in school to get my surgical tech license and have been researching the PA program for about 3 years now. I have wanted to get my masters in medical science ever since I heard about the PA program. After I get my surgical tech license I will go back to school to get my bs and then hopefully I will get accepted into the PA program. I am a single mother and I know I can do it. I am really looking forward to it. If there is any advice you could give me please e-mail me. I have spoken with a few people who have gone to Nova and they have told me it is a really great program.

    Comment by Nicole | 25 October, 2012 | Reply

    • To Nicole:
      Look at this website (you should probably join and read regularly) Physician Assistant Forum It contains many discussions about all aspects of becoming and practicing as a Physician Assistant. Good luck.

      Comment by drnjbmd | 25 October, 2012 | Reply

  11. Thanks a ton for this post… so many of the medical community in my neck of the woods are so, for lack of a much better term, “catty” and obsessed with status. I’ve heard my share of comments about not being able to afford BMWs, private jets, big houses, and so forth. Clearly, people who are not in medicine for the right reasons. Anyway, really nice to see someone echo the feelings of my PA friends.

    Comment by Anon | 1 October, 2012 | Reply

  12. Thank you from a PA and fellow medical provider for this wonderful post! Feels great to be appreciated!

    Comment by Ashley | 26 September, 2012 | Reply

  13. Hello again doctor,
    I just want to know whether or not you could keep to your sleep schedule of going to bed at around 8. I’ve tried experimenting with my sleep due to me feeling rather unconcentrated and tired in the evening after school. I tried waking up at 2 however the prospect of waking up to face 4 or 5 hours of studying wasn’t very pleasant plus the grogginess accompanied with it if you did not go to bed at a regular time due to it being pushed back due to other things that needed to be taken care of. And do you think it’s wise to change sleeping schedules because maybe I would be required to change it to adapt to a working schedule and then sometimes adapting it to a studying schedule of going to bed early. And other difficulties going to bed at around 8 would be that my bedroom is right next to the room where my brother and father watch television seeing how football in england is usually broadcasted at around 8 until 1 in the morning.

    Thank you again for taking the time to answer to my replies and writing helpful articles.

    Comment by New Ifield | 8 March, 2012 | Reply

    • To New Ifield:
      If you change anything that has to do with sleeping, do the change gradually rather than in one step. You have to give your body chance to adjust to a new system.

      Comment by drnjbmd | 8 March, 2012 | Reply

  14. Thank you again doctor for your timely advice. I’ve also asked my pharmacy teachers about how they memorized the different drugs and they also came up with the same advice that you gave namely putting them into groups, seeing if there are any “hints” to the brand or generic name and the group and they also said that you learn the drugs through familiarization by reading over and over again the drugs to get used to them. I guess I just needed to hear the advice from a different people.
    Thank you again doctor for sharing your wisdom and advice.

    Comment by New Ifield | 23 February, 2012 | Reply

  15. Hello again doctor,
    I hope you don’t mind me bringing back the question on drugs.
    YOu see in the subject were we are required to memorize drugs, the drugs are grouped according to their classification in the MIMS. Like Antiasthmatic and COPD preparations, Cough and cold drugs and so on and you would have around 30 drugs under each group. Sometimes I would try to find a common prefix or suffix to the drugs like-lol or -tinate but many groups posses those name properties and it’s easy to get confused. Rote memorization doesn’t work for me nor do flash cards. Mnemonics like the method of loci and associations helped and are what I currently do but to create the associations based on the name is time consuming. I’m just wondering how were you able to do it and did you forget things like how do you know what group a drugs is in for if I memorize through rote I have no idea where it belongs and how were you able to balance the memorization with your other studies and how many were you able to memorize, for it takes me hours on end just to memorize a couple of drugs and even then I forget things and the stress resulting from this inefficiency just causes me to procrastinate.
    I’m terribly sorry doctor for asking this question so many times but I just can’t get my head around how to do it. And I just feel like giving up…

    Comment by New Ifield | 22 February, 2012 | Reply

    • To New Ifield:
      If you look at memorization as something that you have to reproduce word for word, then it takes longer to accomplish this. You likely need to know your pharmaceuticals not rote but relatively which means that you need to organize your information in related packets so that you can get this mastered. Getting material into your long-term memory means that one needs to relate new material to material already mastered. To do this, you need strong organizational materials that work for you as an individual. Your test/professor may organize materials in a manner that is different than you can individually master the material thus you must make organizational changes that work for you.

      If you are “procrastinating” then you need to find a method that will enable you to get to work and get your work done. For some people, this amounts to setting a schedule and checking off tasks as they are completed. Just be sure to make your schedule realistic. You are not going to be able to “memorize” 300 pages of material in one sitting so divide and conquer. Take frequent breaks (see my study skills elsewhere on this blog). Make sure that your study area is away from distractions such as the Internet/telly etc. Study in different locales (coffee shop, library (public & school) mall) so that your mind learns to focus on your work and not distractions. Take frequent breaks (no more than 10 minutes at a time) and do something different such as walk around, stretch, leave your study area but come back and get down to work immediately.

      Finally, get plenty of hydration (water not coffee/caffeinated beverages), exercise (aerobic) and regular restful sleep (minimum 7 hours). Take things like “clubbing” out of your life until you get to “holiday” when you can enjoy them without interfering with your studies. Constant and consistent study practices get results. Having to play “catch-up” isn’t going to work well. Good luck.

      Comment by drnjbmd | 22 February, 2012 | Reply

  16. And did you ever employ mnemonics to memorize complex names of drugs or bodily structures ?

    Comment by New Ifield | 28 January, 2012 | Reply

    • To New Ifield:
      I was not a fan of mnemonics as with the huge volume of material to be learned, I found that additional memorizing of mnemonics added additional material for me. Others in my class used them but I didn’t.

      Comment by drnjbmd | 28 January, 2012 | Reply

    • Thanks Dr.

      Comment by New Ifield | 28 January, 2012 | Reply

  17. Hello againn Dr. , I just want to clarify by what do you mean by ” i studied the lectures that were presented on the day and then previewed for the next lecture “. By this do you mean that you studied the subject lecture of the day then previewed the next lecture in the same subject or do you mean you previewed for the lectures tomorrow. If the former didn’t it take alot of your time along with all the others things that you have to do ?

    Comment by New Ifield | 28 January, 2012 | Reply

    • To New Ifield,
      Look at my study skills lectures (there are five on this blog listed as “study Skills 1-V) for how I handled learning the huge volume of material in medical school. I fully explain my techniques there.

      Comment by drnjbmd | 28 January, 2012 | Reply

  18. Hi Dr NJBMD, Your posts have been inspiring and also a guide for me on my own path to being a doctor. Currently I’m a pharmacy student and I have been having difficulty with my courses mainly pharmacology and the memorization of drugs. I remember reading somewhere of your experiences with the course but it was brief. I would be forever grateful if you could teach me how you went about mastering the course and how you memorized the different drugs.
    Thank you, Kris

    Comment by New Ifield | 21 January, 2012 | Reply

    • To New Ifield:
      I actually put the pharmaceuticals in families (with the help of Pharm Recall by Ramachandrian) and invited them to my party. With each drug group, I remembered the bad actors. I also found that learning the Autonomics helped me review neuro and learning the CNS helped me review the neurotransmitters. In short, I put things in small chunks and learned them as they were more manageable that way. Good organization of the material is the key to pharm.

      Comment by drnjbmd | 21 January, 2012 | Reply

      • Thank you so much for the reply when I truly needed it.
        And I want to thank you again for creating this site. I believe many a person has found what they really needed
        by reading your articles.

        Comment by New Ifield | 22 January, 2012

  19. This is wonderfully helpful! Thank you very much for it.

    Comment by doctobe | 15 January, 2012 | Reply


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