020 Discussing Healthcare: A look at end of life care
Gloria Lewis, EdD, MSN, MHA, RN, CCMGloria Lewis, EdD, MSN, MHA, RN, CCM currently works as a per diem palliative care nurse at the John Muir Medical Center in Walnut Creek, California. She is also a faculty member at the University of Phoenix where she teaches in the nursing and health science program. Gloria earned her RN (registered nurse) degree in 1986 and after working in many roles as a nurse she obtained a BSN (bachelor of science in nursing) in 2001. She continued her education and went on to earn her MSN (masters of science in nursing) and MHA (masters of healthcare administration) in 2007 and most recently in 2013 obtained her EdD (doctorate of education) with a focus on nursing education. Her dissertation was titled “Burnout and Stress: a phenomenological study of ICU nurses experiences caring for dying patients.” She is also a Certified Case Manager (CCM). Gloria’s experiences in nursing include: medical/surgical, critical care, same-day surgery, long-term care, home health hospice, palliative care, and case management. If you are a young adult and think that you are immune to death, then I want you to remember some recent cases that have been publicized in the news. The first is a 13-year-old female who is now brain dead after a dental procedure. Then second is a 33-year-old female who was pregnant and had a spontaneous brain hemorrhage and was also brain dead. Neither of these young ladies expected to suffer life-threatening medical conditions, but they did, suddenly and without warning. Their stories are very different, but both came to the same decision point…their families were left to decide what path to take for their medical care. Undoubtedly, this is a difficult decision for any family to make, but it is done every day across our country.Death is inevitable. It is a part of life that most of us would rather not consider until it is upon us. But, we all deserve a to die with our dignity. Unfortunately, it does not always happen. Impending death can often bring the worst out in patients and their families. Issues that have been swept under the rug often resurface creating emotional, social, and financial turmoil. Medical diagnoses and potential treatment regimens can be difficult to understand and confuse the patient and family. Family members frequently have a difference of opinion when considering withdrawal of care for a terminally ill patient.All of these issues related to end of life care create a very difficult situation for the patient, families and healthcare providers. Fortunately, there are physicians and nurses that provide end of life care for patients. They are able to address all of these issues and more while preserving the patients dignity and allowing them to die peacefully.Gloria Lewis, EdD, MSN, MHA, RN, CCM is an experienced nurse who has spent the past 10 years caring for patients in the end stages of their lives. She has helped many patients and families deal with the very difficult issue of dying. Gloria has been part of a palliative care team that cares for patients in the hospital during the end stages of life. She has also worked in hospice.It is important to understand some of the terms that are associated with end of life care, such as: Palliative care – a holistic team approach to support care of patients and families with life threatening illnesses. Hospice – a philosophy and way to care for patients and their families in the last 6 months of life in hopes to prevent suffering and address the emotional and spiritual needs of the patient and loved ones. Comfort care – medical care given to a patient in hopes of keeping the patient comfortable by treating the patient’s symptoms and addressing the emotional needs of the patient and family. Care for the underlying medical problem(s) is stopped. Advanced directive – legal documents that state your wishes for end of life care. Often, this document will include a living will which will tell your family and physician what kind of care you would or would not like in certain medical scenarios. Also, a durable power of attorney is often included which gives a loved one the ability to make medical decisions on your behalf. There are relatively simple steps you and your loved ones can take to ensure you receive the care you want at the end of your life: Discuss what kind of care you would like in a life-threatening situation: Do you want CPR given? Do you want life saving medications given? Do you want to be shocked, if needed? Do you want to be on life support Ventilator (breathing machine) Tube feeding (liquid nutrients given by a tube to your stomach) Do you want life saving surgeries? Obtain advanced directives Living will (to document your answers to the questions above) Durable Power of Attorney (to give someone you trust the right to make medical decisions on your behalf) The advantage of having these discussions with your family is that you save them heartache and turmoil in the event you become gravely ill. Families often have guilt about the decision that is made in relation to end of life care of a loved one. The decision maker is left to wonder if he/she made the right decision. If the above conversations are documented on paper and signed then the family has no choice but to honor the patient by letting the physician know what the patient wanted. This relieves the patient’s loved ones of any guilt associated with the care given or withheld and it allows the healthcare providers to honor the patient’s wishes and treat the patient with the dignity and respect that is deserved.
25 Mar 2014
026 Discussing Healthcare: Why are physicians frustrated? (Physician rant part 2)
In the News Capital punishment: In Oklahoma last week a prisoner was put to death by way of lethal injection. Unfortunately, there was error in the process and the prisoner didn’t die until 43 minutes after the injection. Since then there has been debate about lethal injection and capital punishment. There should be debate about capital punishment and the methods that we use to carry out an execution. However, in this case we should look at the process of how lethal injection is performed. Here are the basics about IV catheters and the drugs used in the Oklahoma case. Intravenous catheters (IVs) are used thousands of times every day around the world. Sometimes when an IV is placed there can be problems. The IV is placed in a vein with the goal of injecting medication or fluids directly into the vein. The medication is then spread throughout the body for the desired effect. An IV can come out of the vein if the catheter is not in far enough, if someone accidentally pulls on the catheter, or if a patient moves in a certain direction. It is difficult to tell if this happens because the catheter can still be in the skin. Medications and fluids can flow into the surrounding tissues and the desired effect of the medication will not occur. There are other complications that can occur with IVs, but the point is that an IV is not perfect and problems can occur. The medications that were used in the Oklahoma case were good medications. By report Midazolam (Versed), Vecuronium and Potassium were administered (in that order). The effects of all three drugs depend on the dose given and the individuals ability to metabolize the medication. The first drug given, midazolam, is used to sedate a patient. In large enough doses it renders a patient unconscious and removes any memory of the event. Vecuronium was given next and is a paralytic. Paralytic medications paralyze the muscles. After receiving vecuronium the patient cannot breath until the medication dissipates. Vecuronium is a long acting paralytic. It takes about 3-5 minutes to start working and lasts 30-60 minutes. Lastly, potassium was given. Potassium is needed in our bodies to help perform normal function and it is vital to keep the heart beating. There is a very fine balance of maintaining just the right amount of potassium in the body. Too much or too little will result in death. So, potassium is given in a large bolus to cause cardiac arrest. In theory these medications should have worked without incident. Many physicians use these medications every day and they are widely accepted as safe for patient care. I use midazolam and vecuronium on a regular basis and have never had a problem with them. SO, WHAT HAPPENED? Well, likely the medications were not given in the vein, rather they were given into the tissue around the vein. The medications then are absorbed unpredictably and the amount of medication absorbed from the tissues was less than when given directly into the vein. This created a situation where the patient had a prolonged death as a result of medication that was not put in the vein. HOW CAN IT BE FIXED? This is currently under review by the Oklahoma government. But, there are longer IVs that can be placed where the medications can be administered into the vein more predictably. Or, the medications can be given through 2 different IVs at the same time. The likelihood that both IVs would have complications is quite small. I have never taken part in capital punishment, nor do I know the protocols that are in place for lethal injection in Oklahoma or any other state. But, these protocols should be reviewed and adjusted to prevent events like this in the future. MERS-CoV: Indiana has claimed the first confirmed case of MERS-CoV (Middle East Respiratory Syndrome Coronavirus) in the United States. This is a big deal as this virus has claimed the lives of many in the middle east. MERS-CoV is a virus in the coronavirus family. The most famous of the coronaviruses is the virus that causes SARS (Severe Acute Respiratory Syndrome). MERS-CoV causes a similar illness. Although the infection is not completely understood most of the confirmed infections have had pneumonia like symptoms. The patients can become quite ill and about 33% (93 of 254) of the confirmed cases have resulted in death. All of the cases have had some connection to the middle east. The virus is believed to have originated in Saudi Arabia, as this is the location of most of the infections. However, there have been confirmed cases in Jordan, Kuwait, Oman, Qatar, the United Arab Emirates, France, Germany, Greece, Italy, the United Kingdom, Tunisia, Egypt, Malaysia, the Philippines, and now the United States. The origin of the virus is unknown. There have been positive tests for the virus or the virus antibody in animals, such as the camel. This has lead to the idea that this could be an animal infection that has crossed over to humans. However, more work needs to be done to figure out the origin. It is thought that there is human to human transmission, but no one knows how it is transmitted. There is no need for hysteria about MERS-CoV, but you should be aware of the infection if you are traveling or around individuals from the middle east who have been sick recently. Pay attention to the news for ongoing updates. Physician rant (part 2) Mimi Zipser, MD Mimi Zipser, MD is an emergency physician. She, like many other physicians, is frustrated with her career. She sat down with me to discuss her frustrations. This is the second half of the interview (see episodes 25 for the first half of the interview) which was based on the following writing by Dr. Zipser: I apologize for the ensuing rant but these are thoughts weighing heavy on my mind tonight…I am saddened by the fact that my profession as a physician has seem to become a field where instead of respect for the 11 years I spent in higher education obtaining my degree, I am overshadowed by celebrities and well meaning but poorly educated parents telling me I have no idea about the true ramifications about vaccinations. I am told time and time again that a patient has diagnosed themselves via Google and doesn’t understand why I am not treating them for x,y, and z. I am told frequently that if I don’t order a certain test or imaging, that I will be sued if I miss something. I am berated by patients who tell me I am causing them harm by not refilling their narcotics for chronic pain or giving them narcotics for even a simple bladder infection or an antibiotic for their “cold”. I am overshadowed by hospital administrators judging my quality and worth as a physician based not on how accurately or well I care for a patient medically but on how high my “CUSTOMER SATISFACTION” scores are. And in that same breath they are telling me customer service is a key factor, they strip away more and more of my time away from my actual patients by placing me in front of an electronic medical record system so I can place all my own orders, spend more time charting my interaction with the patient then I actually have physical time with the patient and then spend more time answering emails about how a “Customer” was dissatisfied with their ER visit. I AM A PHYSICIAN. I studied hard so I could help care for others in their time of distress and need. So I can tell someone how best to treat their condition based on evidence supported medicine. So I could possibly save a life of someone I may or may not know. So I could be an empathetic bearer of bad news to the family of those that I could not save. I AM NOT a secretary, a waitress or a salesperson helping you get the shirt in the size you want. There is not a single thing wrong with any of those professions, but it is not MY profession. NOT what I went to school for. I am not in the customer service industry. My job is not to satisfy people. The customer is NOT always right in my profession because PATIENTS ARE NOT CUSTOMERS. Patients are people with illnesses and pain or injuries who seek my help because I may be able to provide them some respite from their ailments. Patients once upon a time actually listened and physicians used to garner some respect…or at least that is what my job used to be…I feel that administration and misconceptions about how the medical field should be run has tainted what used to be a truly altruistic field. I love what I do. I love my job. But it is getting harder and harder to maintain the love with the constraints and disrespect administrative and social roles have placed on my profession…again, sorry for the tirade. I don’t usually post things like this but felt like I needed to get these thoughts off my chest. Dr. Zipser’s views are shared by many practicing physicians. Most of us are frustrated with the changes that are occurring in healthcare. There is concern that the changes are not improving medical care. Patient care is now put on the back burner as we are forced to be concerned about things like electronic medical records and patient satisfaction. The idea of electronic medical records is great, but the reality is that the software development and user interface are not beneficial to patient care. Rather, physician and nurse charting has become onerous and complicated. This will likely work itself out in the coming years, but for now it is impeding on the physician’s ability to care for patients. In a 2012 JAMA article patient satisfaction lead to increase healthcare costs and a 26% increase in mortality (death). It seems crazy that we would continue focusing on patient satisfaction with the results of this study. If this were the results of a drug study the study would have been stopped early and the drug would never make it to the market. So, why do we continue pushing for high patient satisfaction? Healthcare is changing…and it should. But, we need to be careful about the changes we make. Patients should be at the center of every decision that is made about healthcare. Physicians should have a hand in making decisions about how healthcare will be delivered in the future. However, it seems like the two voices that matter most are now muted. Corporations and government are now in control of our healthcare system. The profits and expenditures for these entities control most healthcare decisions and the physicians and patients are left to argue about it.
7 May 2014
025 Discussing Healthcare: A Physician Rant
In the News NBC News reported about an outbreak of gastroenteritis (vomiting and diarrhea) at a conference about food safety. It is ironic that a food related illness infected a large number of people at a food safety conference. However, food related illnesses are common and have affected most of us at least once in our lives. Physician Rant Mimi Zipser, MD Mimi Zipser, MD is an Emergency Physician. She has seen a transformation in healthcare that has her concerned about her profession. She is frustrated with the business mentality that is taking over medicine. One of her main concerns (along with many other physicians) is that patients are now being valued as customers and not patients. Patient satisfaction surveys are now more important than appropriate patient care. Patients expect certain diagnostics and treatments based on information from the internet and other sources. Some patients are not willing to accept a different viewpoint and become upset with physicians who do not comply with the patient requests. Dr. Zipser’s concerns are valid and supported by many physicians in practice today. She recently wrote a rant about her frustrations with the healthcare industry. Here is Dr. Zipser’s rant: I apologize for the ensuing rant but these are thoughts weighing heavy on my mind tonight…I am saddened by the fact that my profession as a physician has seem to become a field where instead of respect for the 11 years I spent in higher education obtaining my degree, I am overshadowed by celebrities and well meaning but poorly educated parents telling me I have no idea about the true ramifications about vaccinations. I am told time and time again that a patient has diagnosed themselves via Google and doesn’t understand why I am not treating them for x,y, and z. I am told frequently that if I don’t order a certain test or imaging, that I will be sued if I miss something. I am berated by patients who tell me I am causing them harm by not refilling their narcotics for chronic pain or giving them narcotics for even a simple bladder infection or an antibiotic for their “cold”. I am overshadowed by hospital administrators judging my quality and worth as a physician based not on how accurately or well I care for a patient medically but on how high my “CUSTOMER SATISFACTION” scores are. And in that same breath they are telling me customer service is a key factor, they strip away more and more of my time away from my actual patients by placing me in front of an electronic medical record system so I can place all my own orders, spend more time charting my interaction with the patient then I actually have physical time with the patient and then spend more time answering emails about how a “Customer” was dissatisfied with their ER visit. I AM A PHYSICIAN. I studied hard so I could help care for others in their time of distress and need. So I can tell someone how best to treat their condition based on evidence supported medicine. So I could possibly save a life of someone I may or may not know. So I could be an empathetic bearer of bad news to the family of those that I could not save. I AM NOT a secretary, a waitress or a salesperson helping you get the shirt in the size you want. There is not a single thing wrong with any of those professions, but it is not MY profession. NOT what I went to school for. I am not in the customer service industry. My job is not to satisfy people. The customer is NOT always right in my profession because PATIENTS ARE NOT CUSTOMERS. Patients are people with illnesses and pain or injuries who seek my help because I may be able to provide them some respite from their ailments. Patients once upon a time actually listened and physicians used to garner some respect…or at least that is what my job used to be…I feel that administration and misconceptions about how the medical field should be run has tainted what used to be a truly altruistic field. I love what I do. I love my job. But it is getting harder and harder to maintain the love with the constraints and disrespect administrative and social roles have placed on my profession…again, sorry for the tirade. I don’t usually post things like this but felt like I needed to get these thoughts off my chest. Dr. Zipser’s frustration is evident. Physicians value the relationships we have with our patients. We enjoy the challenge of diagnosing and treating patients. However, our jobs are difficult. Now, we are given added non-clinical tasks of charting in inefficient electronic medical records while ensuring every patient is “satisfied” with their care. It seems almost impossible at times to balance all of the responsibilities put on a physician by the healthcare system. Dr. Zipser is not the only physician frustrated with the current trends in medicine. Check out these articles as well: A Doctor’s Declaration of Independence How Being a Doctor Became the Most Miserable Profession A growing number of primary-care doctors are burning out. How does this affect patients? Are Physicians Just Complaining? Physicians, like most human beings, often resist change. So, are physicians just complaining about change or do they have valid concerns? I would say a little of both. Certainly there are valid concerns about the direction we are going in healthcare. Take patient satisfaction surveys, most physicians loathe the thought that patients are given a survey to rate the physician interaction. Patients often are not satisfied with the physician for many reasons. Patients often want antibiotics and pain medication inappropriately. They want CT scans and labs that are not warranted. In the emergency department they want to be admitted to the hospital when there is no clinical reason. Even after spending time and energy explaining why these things are not needed some patients expect them anyway. They leave the physician’s office, the emergency department or the hospital angry, upset and frustrated and give the physician a less than flattering rating on a survey. In 2012, JAMA published an article called “The Cost of Satisfaction.” This was an original research paper that studied the affects of patient satisfaction in relation to patient outcomes. In short, the study showed that satisfied patients used the emergency department less, but had higher healthcare costs, payed more for medication and had a 26% increase in mortality. That’s right a 26% increase in mortality. Now, what do you think about patient satisfaction? Yes, we as physicians should want our patients to be happy. But, at what cost? We are bending over backwards to make sure patients are “satisfied.” Physician pay is increasingly partially based on patient satisfaction scores. It just seems that the healthcare system is not worried about the things that really matter most….patient outcomes. Would you rather be happy or healthy? On the other hand, physicians need to help change medicine for the better. The healthcare system spends too much money. Physicians are greatly responsible for the cost of healthcare. Although physicians do not control the cost of medical technology or medication, we certainly have some control over what an individual patient consumes within the healthcare system. There is little focus on preventative care. In my mind, the best way to control costs is to avoid the diseases that cost the most. Many of the diseases we face in the United States are preventable and a lifetime of better choices can lead to decreased healthcare costs. We physicians should take a central role in the prevention of chronic diseases. Healthcare is changing in this country. The biggest stimulus for change is the Affordable Care Act. This law has some aspects that will improve the healthcare system. But, there are also areas of concern with this law that need to be addressed. Whether you support or disagree with this law, the biggest question we need to answer is “should the government control healthcare?” I don’t know the answer, but I do know that in general physicians are not happy with the trends in medicine. We feel devalued. We are losing our autonomy to care for patients in a manner that we see best fits each patient. We are pressured to keep patients “satisfied” instead of healthy. We are asked to see more patients, never make mistakes, chart using software systems that are inefficient and labor intensive, keep patients happy at all times, and smile while doing it all. The word is out…life as a physician is not as satisfying as it was in past years. Physicians are retiring early. They are leaving their current practice to start cash pay businesses in hopes of practicing medicine in a more personal and simpler manner. They are seeking business opportunities outside of medicine. Why? Because healthcare is headed down a road that physicians never wanted to travel.
29 Apr 2014
024 Discussing Healthcare: Kevin Pho, MD (KevinMD.com) talks about social media and online physician reviews
Kevin Pho, MDKevinMD.comKevin Pho, MD operates one of the most respected blogs on the web, KevinMD.com. He is a practicing internal medicine physician who is an expert in social media and physician online reputation. Dr. Pho has dedicated himself to advancing the practice of medicine by utilizing the technologies that most of us use everyday…computers and the internet. The practice of medicine is rooted in tradition and before Dr. Pho innovators in medicine were known for discovering new treatment modalities, describing a new disease process, or curing an incurable disease. Dr. Pho has leveraged his knowledge as a physician and is applying his skill to popular culture by giving medicine a voice in social media. There are many physicians who blog and create content on the web, but none have been as successful as Kevin Pho, MD.Dr. Pho understands that physicians need to reach patients where they live and interact everyday. There are over 1.2 billion people on Facebook alone. Dr. Pho feels that physicians should make an effort to reach people on social media platforms such as Facebook. He believes that patients in the future will partly obtain healthcare remotely by use of computers, the internet, or live video. How social media will be utilized in the future of healthcare is unknown, but we as physicians should take control and help shape that future.Kevin Pho, MD has co-authored a book titled “Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices.” The book title explains the basic premise of the book. But, there has not been an authoritative document on these topics prior to the release of this book. Dr. Pho has helped outline how physicians can take advantage of the resources available on the interenet to further their practice. No doubt an invaluable tool for physicians.Kevin Pho, MD (KevinMD.com) can be found in the following places: KevinMD.com Facebook Twitter LinkedIN Google+ Book: Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices South Korean Ship and HypothermiaThe horrific sinking of a ship off the shores of South Korea on Wednesday April 16th will likely result in the death of over 200 people. 475 people were on board when the ship started to sink. There are reports that crew members on the ship told the passengers to stay where they were and as a result many passengers were trapped as the ship submerged. There is still a rescue effort underway. Authorities are pumping oxygen into the ship in hopes that there will be survivors. People have survived in air pockets of sunken or overturned boats. However, as the rescue effort continues the death toll is rising.The question is, can anybody survive in that ship? Well, the answer is yes…maybe. There are really two major factors. The first is oxygen. As we all know, without oxygen survival is limited to minutes at best. There are extreme cases of humans surviving under water for hours, but most will die within minutes. Many of the people on board that ship will die from drowning as they are trapped under water without access to air (oxygen). The second major factor is temperature. The water in that part of the ocean is around 50 degrees Fahrenheit on the surface (colder as you go deeper). The average person can only survive 1-6 hours in 50 degree water even if they have access to air. There are definitely factors that can improve a person’s survivability in cold water, but surviving longer than a day at that temperature is highly unlikely. So, in order to survive there must be an area of the ship that has maintained a dry environment with plenty of air to breathe. I hope the passengers were able to find a part of the ship that fits those requirements, but it is unlikely a large number of people will survive.
21 Apr 2014
Most Popular Podcasts
017 Discussing Healthcare: Why are physicians changing to concierge medicine? (part 2 of 2)
The New York Times published an article titled “New Law’s Demands on Doctors Have Many Seeking a Network.” The article is about 2 primary care physicians and their choice to practice in 2 different environments. One physician chose to join a hospital network and is now an employee. His job is less stressful, although he remains busy, the hospital system now takes care of the business part of his practice so he can focus on patient care. The other physician has chosen to remain as an independent practitioner in her own clinic. Running the business is a burden for her, especially in the current healthcare environment with decreasing reimbursement and increasing overhead. It is an interesting look at how healthcare is changing in our nation. A gentlemen in Mississippi was pronounced dead…but did he really die? Well, I’m not sure. But, he did come back to life prior to embalming. A strange story, indeed. Dead Mississippi Man Begins Breathing in Embalming Room, Coroner Says Mark Sexton, MD Mark Sexton, MD Part 2 In the first half of the interview (episode 16) Dr. Sexton began a discussion about the reasons physicians are choosing to change their practice to concierge medicine. The discussion was prompted by a TIME article titled “My Doctor, the Concierge,” where the author wrote a commentary piece and concluded that physicians are not taking the Hippocratic Oath seriously by practicing concierge medicine. We discussed many of the underlying reasons for physicians to choose to leave the third party payer system and practice medicine independently, charging cash instead of billing insurance companies. Two topics that were discussed specifically were 1) there were and perhaps are a large percentage of physicians who are trying to get out of medicine, 2) the cost of medical education is outrageously high. Here are some links to articles that support both of these claims: Claim 1: Physicians want to leave the practice of medicine – Doctor’s Attitudes on the Future of Medicine: What’s Wrong, Who’s to Blame, and What Will Fix It Report: 36% of Physicians Plan to Leave Medicine Within 10 Years Survey Shows a ‘Silent Exodus’ of Physicians Claim 2: Medical school costs are outrageously high – $1 Million Dollar Mistake: Becoming a Doctor Estimated Cost of Medical School 2014-15 at the University of Wisconsin-Madison Think About Medical School Tuition Debt Before Becoming a Doctor AAMC Tuition and Student Fees Report 2013-14 Medical School at $278,000 Means Even Bernanke Son Has Debt Dr. Sexton was always drawn to critical care and emergency medicine, but trained in family medicine. He once worked as a primary care provider, but changed his practice to emergency medicine. Much of his decision to practice emergency medicine was based on his desire to be in a more acute care setting. But, he states many reasons why he left primary care, from dealing with the everyday business of running a clinic to dealing with the bureaucracies of the government and insurance companies. In his current work environment he can focus more on patient care and less on the other aspects of practicing medicine. He claims that physician satisfaction is not based on money, rather a combination of factors that have more to do with patient care and autonomy as a physician. Dr. Sexton did refer to decreasing number of applicants to medical school. Although he did not give a specific time period there is data available from 2001-present. The data over this time period actually shows an increase in the number of medical school applicants from about 34,000 to about 45,000 applicants per year. Please refer to the data from the AAMC – applicants to US medical schools from 2001-2012. However, I did not find data prior to 2001 and medical school applications may have been down during that time. Both the cost of medical education leading to extraordinary education debt and decreasing reimbursement for primary care doctors is leading to the decrease in the number of medical students seeking training in primary care fields. This has resulted in a decrease in primary care providers. And further, those primary care providers that are changing their practice to concierge medicine are further decreasing the available number of primary care doctors. This is a recipe for disaster.
4 Mar 2014