Members of the American Geriatrics Society,

We request your participation in a brief online survey about your experiences working with socially isolated and vulnerable elderly patients.


Purpose:  The “AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults”1 hich proposed policy and practice guidelines for patients who are “unbefriended” or at risk for becoming so.  We want to learn more about your experiences working with such patients and the strategies you have developed.

 

Information about the survey:

  • It’s completely voluntary.
  • Your answers will remain anonymous – no identifying information will be collected about your or your patients.  Your IP address will not be collected. 
  • It will take about 15 minutes to complete. 
  • The survey is being distributed to the AGS membership nationwide (approx. 5,000 members).
  • At the end of the survey, if you are interested, you may enter a drawing to win a free iPad.
  • The project has been reviewed and approved by the Research and Institutional Review Board Committees of VA Boston Healthcare System and the Ethics Committee and executive board of the American Geriatrics Society.
  • The project received funding from the Guardianship Policy Institute.

 

We are eager to gain your valuable perspective on these important issues.

 

Sincerely, 

 

Timothy Farrell, M.D., AGSF

University of Utah School of Medicine

VA Salt Lake City Geriatric Research, Education, and Clinical Center

 

Eric Widera, M.D.

University of California, San Francisco

San Francisco VAMC

 

Aanand Naik, M.D.

Baylor College of Medicine

Michael E. DeBakey VAMC

 

Jennifer Moye, Ph.D., ABPP

New England Geriatric Research Education and Clinical Center

Harvard Medical School

 

Casey Catlin, M.A.

Boston VA Research Institute, Inc.

Boston VAMC

 

1Farrell, T., Widera, E., Rosenberg, L., Rubin, C.D., Naik, A.D., Braun, U., Torke, A., Li, I., Vitale, C., Shega, J.; Ethics, Clinical Practice and Models of Care, and Public Policy Committees of the AGS.

AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults. Journal of the Am Geriatr Soc. 2016 Nov 22; doi: 10.1111/jgs.14586. PMID:27874181.



We will use the following definitions from the AGS position statement.  Some find these problematic – we’ll ask you more about this later.


DEFINITIONS:


An "unbefriended older adult" is a person who: 

(a) lacks decisional capacity to provide informed consent;

(b) has not executed an advance directive;

(c) lacks a legal surrogate (e.g., is without a family / friends - isolated, estranged, bereaved - and there is not a professional acting in that role)

 

An "adult orphan" is an older adult at risk of becoming unbefriended who: 

     (a) currently retains decisional capacity;

     (b) has not executed an advance directive;

     (c) lacks a legal surrogate (e.g. is without a family / friends - isolated, estranged, bereaved - and there is not a professional acting in that role)


Therefore, both a person considered "unbefriended" and an "adult orphan" are isolated and lack advance directives.  The difference is that the term "unbefriended" is used to describe a person who currently lacks capacity, whereas an "adult orphan" retains capacity.



What is the clinical setting you work in most often?
1e03d2eb9a62466ca26b21db9aa8b1ce Outpatient - home or clinic based 
1e03d2eb9a62466ca26b21db9aa8b1ce Outpatient - other 
1e03d2eb9a62466ca26b21db9aa8b1ce Inpatient - acute care 
1e03d2eb9a62466ca26b21db9aa8b1ce Inpatient - rehab / subacute 
1e03d2eb9a62466ca26b21db9aa8b1ce Inpatient - long term care 
1e03d2eb9a62466ca26b21db9aa8b1ce Inpatient - other 
What is your panel size (outpatient) or average daily census (inpatient)?

If your primary work setting is INPATIENT, please answer the questions below, #3 - #12.

If your primary work setting is OUTPATIENT or LONG TERM CARE, please skip to question #13.  

If you work in both INPATIENT and OUTPATIENT or LONG TERM CARE, you may answer all questions if you wish.

 

Definition Reminder.  An "unbefriended older adult"

> No decisional capacity

> No advanced directive

> No legal surrogate (family or professional)


Before this survey, had you heard of the term "unbefriended"?

1e03d2eb9a62466ca26b21db9aa8b1ce Yes 
1e03d2eb9a62466ca26b21db9aa8b1ce No 
In the past year, how often have you cared for an "unbefriended" older adult?
1e03d2eb9a62466ca26b21db9aa8b1ce Weekly (>1 time per week) 
1e03d2eb9a62466ca26b21db9aa8b1ce Monthly (1-3 times per month) 
1e03d2eb9a62466ca26b21db9aa8b1ce Quarterly (3-4 times per year) 
1e03d2eb9a62466ca26b21db9aa8b1ce Annually (1 time per year) 
1e03d2eb9a62466ca26b21db9aa8b1ce Never 
Have your unbefriended patients/ your team faced any of these problems?
NeverRarelySometimesFrequently
Prolonged hospital stay, past a medically necessary point
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Delay in treatment or surgery
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Delay in appropriately transitioning the patient to hospice or end of life care
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Unable to provide the patient something that may improve quality of life
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Delay in authorizing charges/coverage for care
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Loss of rehabilitation ability/potential in patient
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
We had to continue with what seemed like medically non-beneficial care
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
I experienced personal distress because of an inability to act in my professional role
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
The patient was in physical or psychological distress
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Other: describe below
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
If Other, please describe - also any additional comments?

Please briefly describe a recent example of a situation you encountered with an unbefriended older adult. What was challenging about working with this patient? How did you proceed?

For example:  “An adult with dementia and without known family or friends  lacked consent capacity.  Nursing home placement was recommended to facilitate rehabilitation from a hip fracture.  The nursing home would not accept the patient without a legal surrogate.  The patient remained in the inpatient setting for 68 days.  It was difficult to manage him on the inpatient setting due to his wandering and other dementia-related behaviors.”
What practices, strategies, or resources have you used to meet the needs of unbefriended older adults in your practice/ institution?

Many find the term “unbefriended” to be stigmatizing, undesirable, or not adequately descriptive. Alternatives are often wordy (e.g., “incapacitated, isolated, and unrepresented”).  Do you have suggestions for a different term to describe an older adult who lacks decisional capacity, lacks advance directives, and lacks a legal surrogate?

Below is a list of possible alternative terms for “unbefriended” (adult who lacks decisional capacity, lacks advance directives, and lacks family or friends able to serve as surrogate).

Please rank your top three choices (1-most desirable) for an alternative term.
Top ChoiceSecond ChoiceThird Choice
      1            2            3      
Unrepresented adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Incapacitated and alone
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Vulnerable isolated adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Unaccompanied adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Solitary adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Incapacitated adult without advocates
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Surrogate-less
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Proxy-less
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Proxy Vacans (Latin for "vacant proxy")
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Non Advocatus (Latin for "no advocate")
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Non Surrogatus (Latin for "no surrogate")
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Non Amicum (Latin for "no friend")
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Adultum Solum (Latin for "alone adult")
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
None of these - I prefer the term "unbefriended"
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
What is your highest professional degree?
1e03d2eb9a62466ca26b21db9aa8b1ce MD/ DO 
1e03d2eb9a62466ca26b21db9aa8b1ce PA  
1e03d2eb9a62466ca26b21db9aa8b1ce NP 
1e03d2eb9a62466ca26b21db9aa8b1ce RN 
1e03d2eb9a62466ca26b21db9aa8b1ce PhD 
1e03d2eb9a62466ca26b21db9aa8b1ce PharmD 
1e03d2eb9a62466ca26b21db9aa8b1ce MSW 
1e03d2eb9a62466ca26b21db9aa8b1ce Other 
What U.S. state do you practice in?
Optional: If you would be interested in participating in a future focus group or interview to discuss these topics in greater depth, please leave your name and contact information (email address or phone number) so we may follow up with you.

OUTPATIENT & LONG TERM CARE survey begins here



 

Definition Reminder.  An "unbefriended older adult"

> No decisional capacity

> No advanced directive

> No legal surrogate (family or professional)


Before this survey, had you heard of the term "unbefriended"?
1e03d2eb9a62466ca26b21db9aa8b1ce Yes 
1e03d2eb9a62466ca26b21db9aa8b1ce No 
In the past year, how often have you cared for an "unbefriended" older adult?
1e03d2eb9a62466ca26b21db9aa8b1ce Weekly (>1 time per week) 
1e03d2eb9a62466ca26b21db9aa8b1ce Monthly (1-3 times per month) 
1e03d2eb9a62466ca26b21db9aa8b1ce Quarterly (3-4 times per year) 
1e03d2eb9a62466ca26b21db9aa8b1ce Annually (1 time per year) 
1e03d2eb9a62466ca26b21db9aa8b1ce Never 
Which clinical situations have brought a patient’s unbefriended status to your attention?
RarelySometimesFrequentlyN/A
Consent for medical procedure
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Concern re: medication self-management
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Concern re: safety
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Concern re: driving
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Elder Abuse/ Adult Protective issue
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Advance care planning process
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Other: please describe below
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
If other, please describe - also any additional comments?
Please briefly describe a recent example of a situation you encountered with an unbefriended older adult. What was challenging about working with this patient? How did you proceed? (Note: do not include any identifying information).
For example:  “An adult with dementia and without known family or friends lacked consent capacity.  Nursing home placement was recommended to facilitate rehabilitation from a hip fracture.  The nursing home would not accept the patient without a legal surrogate.  The patient remained in the inpatient setting for 68 days.  It was difficult to manage him on the inpatient setting due to his wandering and other dementia-related behaviors.”

What practices, strategies, or resources have you used to meet the needs of unbefriended older adults in your practice/ institution?
Many find the term “unbefriended” to be stigmatizing, undesirable, or not adequately descriptive. Alternatives are often wordy (e.g., “incapacitated, isolated, and unrepresented”). Do you have suggestions for a different term to describe an older adult who lacks decisional capacity, lacks advance directives, and lacks a legal surrogate? 
 
Below is a list of possible alternative terms for “unbefriended” to describe an older adult who lacks decisional capacity, lacks advance directives, and lacks family or friends able to serve as surrogate.

Please rank your top three choices (1-most desirable) for an alternative term.
Top ChoiceSecond ChoiceThird Choice
      1            2            3      
Unrepresented adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Incapacitated and alone
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Vulnerable isolated adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Unaccompanied adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Solitary adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Incapacitated adult without advocates
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Surrogate-less
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Proxy-less
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Proxy Vacans (Latin for “vacant proxy”)
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Non Advocatus (Latin for “no advocate”)
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Non Surrogatus (Latin for “no surrogate”)
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Non Amicum (Latin for “no friend”)
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Adultum Solum (Latin for “alone adult”)
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
None of these – I prefer the term “unbefriended”
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce

ADULT ORPHANS:


These final questions seek your input on ways to prevent “adult orphans” from becoming unbefriended. 

 
 

Definition Reminder.  An "adult orphan"

> Has decisional capacity

> No advanced directive

> No legal surrogate (family or professional)


Are there things you do to identify adult orphans in your practice / institution?
1e03d2eb9a62466ca26b21db9aa8b1ce Yes 
1e03d2eb9a62466ca26b21db9aa8b1ce No 
1e03d2eb9a62466ca26b21db9aa8b1ce Unsure 
If you have instituted or could envision a process, please describe:
What would your practice need in order to better identify adult orphans and prevent them from becoming unbefriended? Check all that apply (if any).
6c4eb1b5e3c84f9fb47ba431dc4d2df6 Time 
6c4eb1b5e3c84f9fb47ba431dc4d2df6 Advance care planning supported by Medicare reimbursement 
6c4eb1b5e3c84f9fb47ba431dc4d2df6 Care manager 
6c4eb1b5e3c84f9fb47ba431dc4d2df6 Social worker 
6c4eb1b5e3c84f9fb47ba431dc4d2df6 Pathway to partner with community or volunteer agency 
6c4eb1b5e3c84f9fb47ba431dc4d2df6 Other 
Many find the term “adult orphan” to be stigmatizing, undesirable, or not adequately descriptive. Do you have suggestions for a different term to describe an older adult who retains decisional capacity, has not executed an advance directive, and lacks a legal surrogate?
Below is a list of possible alternative terms for “adult orphan” to describe an older adult who retains decisional capacity, has not executed an advance directive, and lacks a legal surrogate. Please rank your top three choices (1-most desirable) for an alternative term.
Top ChoiceSecond ChoiceThird Choice
      1            2            3      
Elder orphan
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Isolated vulnerable adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Lone elder
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Isolated adult at risk
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Adult without advocates
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Unprotected adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Companionless
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Solitary adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Solo adult
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Proxy Vacans (Latin for “vacant proxy”)
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Non Advocatus (Latin for “no advocate”)
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
Non Surrogatus (Latin for “no surrogate”)
1e03d2eb9a62466ca26b21db9aa8b1ce
1e03d2eb9a62466ca26b21db9aa8b1ce
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Non Amicum (Latin for “no friend”)
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Adultum Solum (Latin for “alone adult”)
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None of these – I prefer the term “adult orphan”
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What is your highest professional degree?
1e03d2eb9a62466ca26b21db9aa8b1ce MD / DO 
1e03d2eb9a62466ca26b21db9aa8b1ce NP 
1e03d2eb9a62466ca26b21db9aa8b1ce PA 
1e03d2eb9a62466ca26b21db9aa8b1ce RN 
1e03d2eb9a62466ca26b21db9aa8b1ce PhD 
1e03d2eb9a62466ca26b21db9aa8b1ce PharmD 
1e03d2eb9a62466ca26b21db9aa8b1ce MSW 
1e03d2eb9a62466ca26b21db9aa8b1ce Other: specify: 
What U.S. state do you practice in?
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