Is art important to medicine?

Art vs. Science, commerce vs. culture; call it what you will, but call it wrong. Jefferson Medical College is selling Thomas Eakins' painting of The Gross Clinic for $68 million dollars to a Wal-Mart heiress who will take it to Arkansas in 2009.

Isn't that a little like selling your soul to the devil? Couldn't Jeff issue bonds in the usual fashion and go into debt like any respectable university?

Says Bob Barchi (University President), "We're not a museum. We're not in the business of art education" and in two sentences betrays his failing grade on his Two Cultures book report , a crushing ignorance of the centrality of art to the human experience, and spins Jefferson's expansion as an Eakins rejection redux.

Heroic myth writ large (Homer) or small (Rocky Balboa, Luke Skywalker) inspires great things in real life, just as Eakins painting of Gross has inspired countless artists, physicians and patients. It is arguably Philadelphia's David. But Philadelphia is not Florence, and the Jefferson Board no Medici.

The sad irony is that Wal-Mart heiress Alice Walton is funding this on the backs of an uninsured and exploited workforce run by a corrupt management culture. She's never been held to account for her drunken driving or vehicular manslaughter of a pedestrian in 1989, but has instead been lauded by those who receive 'her' largess; she is, after all, one of the largest individual sources of contributions to 527 groups.

Since 9/11 I've thought plenty, if shallowly, about the symbolism of our built environment and possessions generally. Can you put a fence around Independence hall without destroying what it stands for? Can destruction of the Buddha's destroy Buddhism? Of course not. Similarly, Jefferson's sale will not destroy the university. But the sale and announcement (Federal holiday Friday afternoon - can you san PR graveyard?) does reveal the price of its values.

As an alum I suppose I thought they were worth more. Sigh.

Philadelphia is beautiful

Can I say that without invoking sympathetic groans from anyone not familiar with the place I call home?

I've been driving my Mini Cooper on a different path to work every day for the past few weeks in search of my holy grail*, and have been rewarded in every instance with new discoveries about the city that I thought I knew. Wissahickon park's Forbidden Drive is amazing this time of year, as are the trees near Lemon Hill. The centennial exposition residua are still a stately, if a too quiet reminder of what happened here in 1876.

Get off your mental interstate and enjoy the show around you. You won't be sorry.

*Can a person get to work without encountering an intersection with a stop light?

Flu Vaccine distribution

Breathless posts are flying in from physicians throughout the country to the AAFP 'prez' list (private, moderated) describing broken promises of delivery of flu vaccine.

Post themes:

1. Little guy suffering at the hands of the big guy.

"I paid for 500 doses with a guaranteed delivery of Sept 30 and got 100 on Oct 3 with the balance who knows when. Meanwhile, [fill in bigbox retailer here] is advertising in my town and my patients are all reporting they've gotten their vaccine from them."

2. This one small minimally profitable task is pulled out of our hands by the market in the name of 'public health' while other less profitable (or frankly money losing) but more important public health problems are pushed into physicians offices.

3. Splintering of the medical home.

4. Revisits and rework for flu clinics/visits scheduled and now rescheduled.

5. Conflation of health with consumerism in the market.

6. Does the early push by big box retailers push the vaccine window too early?

CDC Podcasts (including flu vaccination information)
CDC Flu Pages

If choice leaves you unhappy, make your own happiness

If you haven't figured it out I love TED talks. Great ideas from interesting people. Dan Gilbert's work on happiness was posted just before Barry Schwartz' choice conundrum (see below.) If choice causes problems, then Dan Gilbert explains how we can make ourselves happy with what otherwise seem poor choices. Is this how we rationalize our healthcare mess?

The Choice Backlash

I've always been vaguely uncomfortable when universal coverage discussions turn to 'patient choice' of coverage, provider and plan. Now I know why. Watch Barry Schwartz' discussion of 'The Paradox of Choice'.

The cost of recruiting

This summer I attended the AAFP's national conference of residents and students for the umpteenth time with some of our program faculty and residents to kick off the recruiting year. This annual August affair is quite the sight. A fellow faculty mate along for the trip estimates that the 14 programs recruiting resident applicants in our immediate vicinity spent nearly $100,000 for the three day exhibit fest. All that for a chance to meet a handful of students who might want to apply to your residency.

Seems like there should be a less expensive, more direct and targeted way to achieve the end: recruiting medical students to the specialty of family medicine.

Now that recruiting season is really heating up I can't wait to see how this year's version of future family physicians will play out as they walk across the recruiting stage. More later.

Podcasting in healthcare

A recent dust up with administration at the medical school where I teach tangentially involved this question: do our patients have iPods? I could see innumerable advantages to dissemination of patient information in this way, as do many others, like Kevin Payton at his Health Tech blog and Hans Oh at his eHealth Blog: Podcasting in Healthcare - Revisited 2006.

AAFP is podcasting

The AAFP announced two podcasts this week. One, a free CME podcast isn't exactly the most riveting audio experience, but the live panel discussion from this years' National Conference is a much better start.

The audio quality could be better, and the range of offerings isn't that great, but I'll always take the 'ship then improve' model over the 'wait until it's perfect and includes the kitchen sink' model (google Microsoft Vista for example of the latter.)

RSS feeds:
In iTunes, select the "advanced" menu, and then choose "open stream" or "Subscribe to Podcast" and past the URL of the RSS feed below. You can also search for the podcast in the iTunes music store podcast section.

AAFP News Now podcast
AAFP Podcasts: Americans in Motion

Flattening Health Care

Thomas Friedman's The World is Flat posits 10 forces that are flattening the world. Some of these are evident in the US healthcare system, but not enough for my taste.

The first flattener: the fall of the Berlin wall and within six months the shipping of Windows 3.0. It's difficult for those of us who remember the cold war to convey the change embodied by the phrase "I scored some pirated software in China." And we thought only Nixon could go to China. Health care impact: more IMG's are entering medicine in the US than ever before, draining many countries of much needed talent. Meanwhile tele-radiologists and video-intensivists have arrived. Can a Wal-Mart effect be far behind?

Hospitals began outsourcing food services and housekeeping years ago. But will they homesource a call center?

Patients already 'see' their chart online. When will they be able to register themselves, make co-payments online, request referrals and prior-authorization online directly from the insurer?

Inpatient primary care medicine

I just finished two weeks as attending on our inpatient service, which was notable to me for a couple of recurring themes.

1. I'm getting old. My residents started theophylline on a patient with asthma and not one had ever used it before.

2. If I could get paid a fraction of the hospital costs I could save by providing patients with prescription medicine upon dischargeI 'd be a happy man. We admitted two patient who were recently discharged, only to fail outpatient life because they couldn't afford the medicines that had been prescribed during their previous admissions for asthma and hypertension, respectively.

3. The admission/discharge pace is frantic, with admitted patients rushed from one test to another to shorten their stay. Except of course on the weekends when the cost of staffing radiology for non-emergent cases doesn't make sense. I suppose not everything changes.

4. Scut has changed. In my residency we plated our own strep cultures (and incubated them), ran our own sed rates, spun our own hematocrits, etc. Scut these days is entering orders into a computer, text messaging by computer, checking email at the computer, etc. Lab scut is notable for what CAN'T be done. Indeed, there's not a microscope or lab on the floors at our two main hospitals. God forbid a resident would have to do a gram stain or wright's stain.

Did that sound as crotchety as it reads?

Why doctor's appointments are like airplane seats

My practice has struggled to balance patient demand for appointments with availability. I've done a lot of traveling lately so have had reason to consider the way that airlines market airline seats, carefully balancing my preferences and willingness to pay against the value in their various seats.

Mid-day flights cost more than early morning flights. Exit row seats cost more than other seats (at least on Northwest.) Frequent fliers get more and earlier choice in seats than non frequent fliers. Want to change flights? That'll be $ please.

Visiting the doctor is at least as expensive as a Southwest roundtrip, and often costs as much as a first class British Airways flat-bed to London. Flyers show up an hour or two early for their trip,queue on command, and print their boarding passes at home.

My QI mavens constantly use the airline quality programs as an example of how medicine should reduce errors. Should we also adopt the pricing and seat controls that airlines use?

Some offices already shunt frequent no-show patients to a special 'alternative probationary' schedule. Isn't this a reverse frequent flier program? Concierge practices charge thousands of dollars to ensure an experience that most of us aspire to provide to our patients anyway. Isn't that a form of 'first class'? Patients in many systems can make appointments online, but I don't know of any that show doctor availability to allow patients a choice of slot. Don't you think my patients would want to know if they're the last slot in a 17 patient session (like yesterday afternoon) vs. first in a 12 patient session (like this morning)? Don't you think they'd pay different for it?

Of course payment is the kicker. We are contracturally forbidden from charging different amounts for the same service to different patients. We are also in the unusual circumstance of not knowing in advance what service will be required before we see a patient. My office visits are one kitchen renovation after another, with the same "Well I didn't know I'd find rotten joists when I agreed to retile your wall" conversations with patients.

Would you fly if you didn't know the fare, didn't know how long it would take to get there, and had no basis to judge the experience of the flight crew or seat comfort on the airplane?

We ask our patients to do that every day.

P4P in primary care

Family Practice Management has an update article on pay for performance in their July/August 2006 issue, including some interesting statistics and graphs on the rise of P4P programs in primary vs. specialty care and among public and private insurers. There's also a nice checklist for docs to consider before signing up for their local P4P.

I've written before on why performance measures don't work well in primary care; attempts to focus on individual disease markers in patients with multiple comorbid conditions is a byproduct of specialist "disease oriented" rather than "patient oriented" care. The result of this thinking is P4P programs that promote physician behaviors that detract from the demonstrably valuable task of balancing complex competing co-morbidities to achieve improved outcomes. Want more? See Barbara Starfield's editorial in Annals. This unending focus on disease rather than patient is one of the greatest failures of US healthcare.

The New York Times has written about P4P. It's also all over the blogosphere:

Retired doc's thoughts: To see what P4P is really all about, look at the Seattle Blue Shield experience

Roy Poses, a decision analysis maven and fellow generalist: Health Care Renewal: Implementing P4P in the Real World: the Case of Regence BlueShield

KevinMD's thoughts

And even some specialists are aggravated by P4P: Aggravated DocSurg: A(nathe)MA, part the second

Bayes' Theorem in the attention economy

Nothing like lecturing in the fourth hour of a five hour conference morning on Bayes' theorem in the guise of screening for coronary artery disease to a room of bottom line learners. I've put the pdf of my keynote presentation here. The 2002 ACC guidelines for exercise testing mentioned in the talk are here. My proudest accomplishment in preparing this talk was finally finding a still of Sigourney Weaver floating over Bill Murray from the movie Ghostbusters to illustrate the concept of guidelines. : )

Presentations 101

I'm a medical school professor, so I give and sit through many lectures. Despite 20 years of trying I still can't get them right, but I'm trying. These three sites might help you with your presentations - they've helped me.

Presentation Zen is my latest favorite. Less is more. Make sure to visit the popular posts and presentaiton tips on the links bar.

Guy Kawasaki describes his 10/20/30 rule, which I've never been able to achieve. While he makes reference to venture capital pitches, the rule is applicable to nearly any stand and deliver presentation, especially if you're projecting something. I had a chance to meet Guy at a Lexington, KY computer show back in the 1990's (pre-internet.) I'll never forget that he used a slide carousel and not a computer LCD projector. At the beginning of his talk he noted that he didn't trust computers with something so important, that he was suspicious of slides too (he had overhead transparancies just in case), and that he'd be just as happy giving his presentation with no visuals at all. In that brief encounter he gave me permission to hate technology for it's shortcomings while still loving it for it's promise.

Lastly is Ian Parker's Absolute Powerpoint piece in the May 28, 2001 New Yorker (I link to a web based text version) that should be required reading for all powerpoint users.

Gordon's Notes: All the vulnerable people: eFraud, aging and special needs

John Faughnan is a family doc who I've been acquainted with since the late 1980's via our common interst in tech. He has the chops, which is why I follow his blog. He's one of my tier one mavens for things medicine and tech.

His take on spam and reputation managment in these days of HIPPA and privacy concerns is more pertinent than anything I've read in the medical journals.

We're going to have to evolve new systems of defense, trust relationships, identity management and reputation management. Developing these systems will be a major social challenge over the next few decades. In the meantime, encourage your parents, and your vulnerable family members, to consult about their financial decisions. From: Gordon's Notes: All the vulnerable people: eFraud, aging and special needs

Future of Family Medicine extended

I've put a pdf of the Keynote presentation that I gave yesterday at our grand rounds on my file sharing page (download it here - 2.5MB.) It's a long way from my original resident conference I presented in 1988, but in many respects the themes are remarkably similar.

Addendum:
I realized that many links I visited in the talk aren't in the slides. Why would they be? Slides are, after all, so very 1995 : )

Here they are, plus a few extras as your reward for visiting:

A mashup for locating doctors in berkeley.

Ratings of doctors. Not quite digg or slashdot, but the rival doctor shopping networks are fighting it out as you read this.

Another doctor mashup. Want a real 'monetizer' for web sites? Get health system marketing dollars pointed at these mashups, buying preferential placement for their docs and hospitals. Did I say that out loud?

Penn's patient blog site for checking on inpatients

Rob Centor's blog - president of SGIM, faculty at UAB

One of many examples of a personal health record.

An example of a virtual conference that I recently 'attended'. Why doesn't STFM or AAFP do this in addition to their 'regular' conference? Much of the networking value (though not all) without the travel costs.

If you know about 'flash mobs' then you won't be surprised that others are holding what amounts to 'flash conferences'. The prototype is here. This is another idea that medicine needs to adopt. It's certainly more convenient (for me) than the bulletin board next to the registration desk with handwritten notes on it for whomever happens to stop by.

One of many social networking sites that our applicants use to discuss the interviewing process. Yes, I'm reading you!

Graphical browsing - enter a website and see what's connected to it and what it connects to. The underlying concept and code is used by many sites as one example of 'conceptual mapping'. See here for other examples to numerous to list.

The point to this site isn't the story, it's the "big picture" link that allows graphical browsing of the related stories. Let the entire page load then click the 'Big Picture' link in the red bar on the right of the page. Any news story you visit on cnet news can be browsed the same way.

Like graphical browsing? See here and here for more examples. Now imagine this technology used to visualize medical concepts. We're getting close but aren't quite there yet. The Krafty Librarian post from last month talks about this.

Drug Quilt is an example applied to the drug industry. It certainly makes it easier for me to see the relative relationships between companies and products.

The future of lipid therapy

I'm about to deliver this presentation at the NJAFP annual scientific assembly in Atlantic City. It's a pdf of the keynote file that I used to present. I also have a powerpoint version if you want to email me for it. Feedback is welcome.

Should US Med Students train abroad?

A recent NEJM podcast notes interest in US students travelling overseas to gain international experience. "In 2003, 1 in 5 US students participated in an international experience" the moderator states.

One of the students interviewed comments on their experience: "The most important question asked in Uganda was whether they had money to pay for medicine. If so, they were given medicine, if not, they weer sent home to die...It Taught me the importance of perspective in global health."

Given the recent spate of articles describing how the US healthcare market is 'stealing' nurses, physicians and other health care workers from developing countries I wonder whether this 'send student doctors back' phenomenon will help stem the tide by opening the minds of medical decision makers to international training.

I know that in the residency that I direct I have little ability to pay for residents to travel or train overseas. Do other payors feel they're getting their money's worth? Anyone up for a cost-benefit analysis of exchange training?

Contextual advertising

One of the problems facing product manufacturers who want to get their product in front of your eyes is the tension between grabbing your attention by inserting ads in an entertainment experience vs. making the information 'so valuable' that someone actually seeks it out - e.g. 'must watch media' vs. 'must watch ads'.

Of course the 'watch' metaphor in today's attention economy isn't the right verb for the ADHD generation. You know the type; a teenager doing homework while simultaneously holding online chats, playing a MMORPG, talking to someone else on the phone, answering mom who's calling for dinner and playing poker (and winning).

That's why ads in SecondLife (product placements if you will) or other social networking venues work so well. They take advantage of an alreay established social network to interject their product in context; if there is real value in the product there will be real value in the network, with all the viral marketing implications intact.

Call Center homesourcing

Tom Friedman's book (The World is Flat) includes the forces that are flattening the world. One that stands out to me is homeshoring. We have a small call center in our department that has equipment and people in cubbies. Office Space cubbies. All expensive, all calls tracked relentlessly by a system that tells us everything we could ever want. Unfortunately, we rarely use the call metrics. Instead we continue to ignore them. The result is a continued 15-20% abandoned call rate, in part due to busy Mondays where we don't have staff to cover the phones.

Why don't we contract for our high demand days on some volume/quality basis to qualified and trained folks who work from home? If Jetblue can do it why can't we?

Bibliometric Analysis in promotion decisions

My chair has challenged me to come up with metrics that go above and beyond publication number or 'impact' as measured by ISI citation index. Promotions here and elsewhere betray their own peculiar mix of culture, politics and tradition. Here are my thoughts.

The basic premise is that academic productivity ought be judged on the basis of defined principles. Boyer's categories of discovery, integration, application and teaching have been quantified by promotions committees in traditional terms such as publication volume, publication influence, patents, grants, courses taught and advising undertaken. The context for these discussions is often one of promotion or tenure in academic environments, concepts themselves with questionable external validity that are increasingly under scrutiny.

While variation in and of itself isn't a problem, not examining the variation is certainly problematic. What I'm most concerned about is decisions where the lack of analysis dampens innovation or worse, hampers scholarship.

Computing and communications advances have created novel means of visualing qualitative and quantitative relationships in real time, which in turn brings variation in promotion and tenure decisions within and between organizations into sharp relief. Unfortunately I don't have answers, but did come up with some questions for myself.

Will Google Scholar replace ISI's web of science? Should professors be blogging? The editor of the Scientist thinks so, as does the Unversity of Chicago Law School. How do you cite a blog? Should you be able to tap into the attention filter of mavens? Does doing so alter the nature of their maven role? Are Boyer's categories of scholarship congruent with maven-ness, connecting, or selling? What's the role of personomies in promotion decisions?

If the nature of scholarship is changed by how it's measured, then scholarship in a web 2.0 world has more to do with the new tools to measure it. Visualizing the role of an academic and the relationships in academia over time takes on new meaning when you can do so in real time. Why don't promotion committees use academic tag clouds? Is ISI really a snobbish technorati? Where's my touchgraph ?(You must have java for the touchgraph applet to launch - what's a touchgraph?)

The Krafty Librarian

Information sciences meets medical search meets web 2.0 at the Krafty Librarian. I don't know what the future of medical education looks like but the future of scholarship will incorporate much of what is discussed here.

Pennsylvania Health Care Reform

Handing over the reins of my PAFP presidency was painless, though I almost missed the inauguration of my successor. The ceremony (which I mc'd) was to begin at 6 pm and I found myself waking up from a power nap at 5:47 still having to get into my tux and navigate 8 floors in elevators hijacked by teenage band members who acted as if they'd never seen an elevator before.

The big discussion in our house of delegates was about the competing versions of health care reform in play in Pennsylvania. SB 1085 got the most discussion, a full bore universal coverage single payer system that has all the elements to actually work, and therefore all the elements to petrify every stakeholder into opposing it. It's being pushed by a group that includes a lawyer, doctor and businessman (all with progressive leanings) and democratic sponsors in the legislature, making chances of action nearly nil. Reminds me of Star Trek:

Kirk: I take it the odds are against us and the situation is grim.
Picard: You could say that.
Kirk: You know, if Spock were here, he'd say that I was an irrational, illogical human being by taking on a mission like that. Sounds like fun!

Plenty of other blog discussion on SB1085 here and here. A hearing would be nice but seems unlikely at present. Still, the primary is only a few days away and the elections are coming up in November, making for a lame duck sine die session that's already building steam.

Other legislation in play: a Maryland like "make walmart pay their fair share" plan that's pretty white bread to me. A no-brainer "don't let insurers retroactively revoke payment four years after they cut the check", not to mention a few more.

New Mexico - Amazing

I recently went on a road trip with the family to New Mexico to explore the region. Pueblo indian culture at Bandelier, atomic energy museum at Los Alamos, browsing Santa Fe galleries, driving back roads to Roswell, then a side trip through Hondo Valley to White Sands before circling back to Albuquerque via Tularosa and Carrizozo.

Most amazing aha's? The stunning Hondo Valley drive in the spring. White Sands national monument: we never expected it to be that great. A great 2003 Sangiovese (Sangiovese!) at Tularosa Vineyards. And if you're ever in Carrizozo make sure to get a green chile cheesburger at the Outpost. Honest food, honest setting. Great all around.

Marketing Metrics meets Public Health

I listened to David Reibstein of the Wharton School* on this Knowledge@Wharton podcast (free registration required) last night while riding home, and it got me thinking about the Press-Ganey surveys we do in our health system. Do we inflate our satisfaction scores by only surveying people bold enough to stay with our practice? I know how to calculate MDRD-GFR. Why don't I know these common marketing metrics? Aren't they a better predictor of what I'm being paid for?

More importantly, how do the metrics like 'market share' relate to similar public health/epidemiology concepts? If patient satisfaction/practice satisfaction is associated with adherence, and adherence with health outcomes, then it would seem we're not paying enough attention to doing right by the patient. Anyone who's navigated my practice's 'automated voice attendant' probably knows what I'm talking about.

*disclaimer-I'm employed by Penn but don't know Dr. Reibstein and am not getting a cut of his book, but would be happy to : )

AAFP now has RSS feeds for news now

Periodically I send Leigh McKinney (Director, Online and Custom Publishing Division AAFP) an email about AAFP publications and how I'd like to bring them into the 21st century. The academy is already the leader in pushing electronic medical records, and they've won awards for some of their online sites, but as a geek I can't help but consider how the academy can more successfully compete for the attention of its members by using new media tools that take advantage of the social networking that is the strength of the academy.

Today Leigh sent me a message to note that the academy has added an RSS feed to their valuable news service AAFP News Now. wOOTt!

Now how about an AAFP RSS aggregator that pulls feeds of interest to the AAFP into one spot (like David Ross' and Jacob Reider's medlogs.com)?

Contracting resources for residents

Had a nice chat with my residents this morning about looking for a job. Stark ("what's that?"); restrictive covenants; need for lawyers, etc. This is an area where it's important to personalize the advice to the person involved, hence my inclincation to point residents to resources and have them identify their own learning issues and approach. Guided discussion is one way to do this but it's not as active as it could be and doesn't take advantage of the 'teachable moment' that every resident feels when they first get a glimpse of what life could be after residency.

Here's a collection of articles on contracting from FPM for residents seeking employment. Also contracting services and demystifying contract terms. FPM is a good general resource but [small print lawyer disclaimer language here] "can't substitute for legal counsel."

Why quality measures don't work in primary care

I've written in my PAFP Keystone Family Physician column about my dissatisfaction with pay for performance measures in primary care. Now Barbara Starfield weighs in. I couldn't agree with her more.

This isn't the first time I've been impressed with her work this week. She presented a plenary at last weeks society of teachers of family medicine meeting that introduced me to the world health chart website and application.

The world health chart is amazing, but clearly in its infancy with regard to the integration of graphic display of quantitative information as it relates to public health. I'm anxious to see local versions of google-map mashups with useful information like the availability of medical assistance dermatology appointments in the Philadelphia area. Alternate mash-ups: physician by appointment availibility, physician by blog, physician by contribution to neighborhood economy, physician by contribution to community health measured by primary care characteristics - availability, comprehensiveness, coordination of care

Anyone up to the task?

Independent Pharmacies still exist

The version of this pharmacy that still exists here in Philadelphia is Davis Pharmacy on Baltimore Avenue in West Philadelphia. Nice story.

Brain Rain Barrels

Do you use a mind mapping software program? Inspiration is my current dumping ground, and it's fine for my casual use, but something that makes it easier to group and connect similar ideas would be nice, not to mention something a little prettier to look at. Tinderbox, OmniOutliner and some of the opensource programs at the wiki mind mapping page seem to be candidates. I use Mac OS X and am a casual GTD beginner, using a backpack account for my various lists. Quicksilver is gold. Stickybrain doesn't do it for me.

My typical inspiration use: jotting notes directly into the diagram view using rapidfire mode. Outline view doesn't do it for me.

What do you use? Why?

Albuterol and Pharma

So why are albuterol inhalers rapidly disappearing from the market? Are CFC's really to blame or is the market transition to HFA inhalers with their higher cost and higher margins to blame. Call me cynical, but this seems to me to be another failing of the current health care system. It takes doing the right thing (eliminating CFC's) and turns it into a profit making - patient hurting debacle.

What am I missing here?

Hello

No the world doesn't need another doctoring blog, but as you'll see if you read for long it's really for me. A place to brain dump all the otherwise forgotten thoughts that enter my too full head. If I put one more thing in I'll forget how to drive.

OK, I suppose it's also an effort to preserve the patience of my colleagues, who would otherwise have to listen to me rant even more than they already do.