Tomorrow will be my first attempt at bringing the health care providers from my community together to discuss how we can change our practices to make health care more affordable.

I approach it with some level of trepidation due to the fact that doctors can be pretty defensive about change.  Nevertheless in many one on one conversations I’ve noticed that all of us are to some extent disgusted by how much health care costs, and by the fact that this means that many people don’t have access to good care.

So what will I say to a group of internists, nurses, family practitioners, radiologists, orthopedists and surgeons (if they show up)?

I hope that it won’t be me talking at them, since I already know what I think.  But I will have to get the whole thing rolling.

I am co-facilitating this with a radiologist who is motivated to change our doctors’ ordering habits for radiological procedures so they are at least ordering the right tests and not repeating tests unnecessarily.

I intend to say:

I’ve talked to many of you over the last months about the costs of health care. I’ve been doing thinking and research on the subject, and I think that, although we do a good job with our patients, the whole process costs way too much.  Some of that is because we order too many tests when we are busy or because we are worried about malpractice, and some of it is because there are so many demands on doctors that we have trouble organizing our efforts.   Many of us have adopted computerized medical records, and though they improve the quality of followup and documentation, they are sometimes distracting, and slow us down and focus us away from our patients. Technology and pharmaceuticals have exploded since most of us finished our training, and it is hard to keep track of which medications or procedures are really worth the time and expense.

The result of these factors is that our patients end up going to emergency rooms or quick care offices for things that could be better handled by their primary care doctors, and end up with testing that is expensive, and often unnecessary. We spend much of our time keeping track of preventive medicine recommendations and being glorified record keepers and ineffective nags in the service of smoking cessation, weight loss, colonoscopies, mammograms, pap smears and other preventive strategies.

We have very little knowledge of what the things we order cost our patients, and so they end up with huge bills that often profoundly affect their finances and so their overall social health.

There has been much talk about health care reform, and I have paid attention to a good bit of it.  What I see is that legislators have lots of ideas for improving access, though they don’t necessarily agree with each other, but they really do not know how to address reducing costs, which is the basis for most of the debate.  In some ways this is good.  If legislators make rules to reduce medical costs, they are liable to be rules that don’t make sense from our standpoint. I think reducing costs is something that we, as providers, can do best.  There are limitations to what we can do as a small community, but this is our community and it is a place to start.

What I would like to do today is sit together and talk about what we do that is effective in our practices, and what things we see happening, or do ourselves, that contribute to the high cost of health care.  I would like for us to come up with some concrete ideas for ways to improve our efficiency, our and our patients’ well being and move medicine in the direction we want to see it take.

Steve Chapman talks to Janice about his life as a farmer.

The landscape differences never strike me harder than when I go to the High Plains. Whether I’m driving or flying into Lubbock, TX the view is staggering.  From the sky, you can make out circles where crops are planted.  On the highway, you notice the dramatic change in altitude as you drive up onto the Caprock.

But for the last several years, my amazement with the landscape has been matched with the welcoming feelings I’ve felt on my visits to the biggest cotton patch in the world.  Cotton has been my “bread and butter” for a long time and the High Plains has become a place I feel so comfortable in.  That’s in part due to people like Steve & Melinda Chapman who farm in Lorenzo, TX.

Lucky enough to call Chappy (Steve) a friend, I was excited to hear the new ideas around our blog while in Lubbock.  I grabbed my cameras and headed out to his farm to see if he’d mind me getting my farmer perspective blogs off to a start.  He was a perfect subject because he is so easy to talk to and I know how passionate he is about sharing information about farming. I’ve seen him tour bankers, tourists, members of the media, scientists, etc.

I had been in Lorenzo just a month or two earlier and that’s when I found out that Steve’s dad, Robert, had passed away this summer.  His dad always had a big smile for visitors and it was the first major farm event he wasn’t there to help host.  It seemed a fitting time to talk about the background of the family farm a bit and Chappy was willing to provide insight on how the farm came to be, how conservation practices  employed and more.

From there, the connections to the rural landscape and the sense of community seemed automatic.  And the connections Steve has to the area, is something that he is passionate about.  While he took a short break to live “in town” and decided he’d be better off in the wide open spaces.  Lots of houses in the area are gone though, and Steve’s one of the farmers who have taken on additional acres in order to stay on the farm full-time.  The sense of camaraderie is unique and appreciated.

He gave me more food for thought as I boarded that plane and we took off.  I tried to spot Lorenzo and that shop that we visited in… but I got distracted by the harvest activity underway.

Marc treats historical artifacts with respect

Greetings from La Guardia airport! Your highly esteemed (ok, ridiculed) co-blogger is sitting on the floor with her dog and her laptop, bored and cranky because her flight has been delayed two hours due to, get this, the anticipation of rain. Not even real rain. What the hell is that? The airlines aren’t even trying anymore.

I just watched a small child drop a piece of cheese on the airport floor, pick it up and then feed it to her father. Ew.

In honor of this ridiculous travel holiday and the highly caloric meal that follows it, Marc has agreed to do a Thanksgiving-themed Either/Or. I provide the subjects, he makes hasty and uninformed opinions. Everybody wins. Well, except the Indians.

Buckles on Hats vs. Buckles on Shoes

Buckles on hats are nice, but are they anything more than a passing fad among a group of uptight Puritans? Is that who I want to be associated with? Absolutely not. Buckles on shoes, on the other hand, have been around for centuries, maybe more. I wouldn’t be surprised to learn that Jesus had buckles on his sandals. They are timeless and practical. Putting metal on your hat isn’t practical. It’s just the fast track to getting struck by lightning.

Smallpox Blankets vs. Sending Everyone to a Reservation

Well, ignoring the white elephant of abject genocide, I’m going to go with sending everyone to a reservation. If you’re trying to contain a population, smallpox just isn’t the way to go. It may be confined to a few blankets at first, but you never know how fast the disease is going to spread. You could end up taking out your allies and trading partners. It might even spread to YOU. A reservation allows you to keep track of where everyone is and what they’re doing. You can encourage them to farm the stony rocks you’ve given them, or produce casinos for their benefit and your debauchery. I’d rather be an imperialist jackass than a murderer.

Thanksgiving Dinner vs. Leftovers

I’m going to wager that, like me, every one of you has thought about this question before. Dozens of times. You probably haven’t come to a clear conclusion, so I’ll save you the trouble. It’s Thanksgiving dinner.

The thing about leftovers is that they’re great, but they’re really all about one thing: that giant, amazing turkey sandwich. And man, it is ever amazing.  You pile on that cold turkey, throw some dressing or cranberry sauce on it, toss it between a big Kaiser roll and you’re stuffed for hours. It’s great.

But look, at the dinner not only do you have the turkey and the sauce, you also have all the amazing sides. Mashed potatoes, corn, fill-in-the-blank casserole and fresh rolls. That’s the kicker right there, isn’t it? Sure, you have the sides with the leftovers but they’re not fresh. Everything is fresh at Thanksgiving dinner, especially the rolls. Not to mention that after dinner you’re probably heading for the absolute King of Naps, the post-Thanksgiving slumber. To put the nail in the coffin, what night did we all hate as children? Leftover night. Check and mate.

Gelatinous Cranberry Sauce vs. The Kind With Real Cranberries in It

There is something inherently amusing about a cranberry sauce that comes out of the can in a solid, gelatinous cylinder. There is also something inherently disgusting about that. I generally don’t like my sauces to involve jiggling, so I’m going to go with the real thing here.

Note from Claire: False. Gelatinous is better, especially when it slides out of the can as one solid mass: Thhhwwuuuk!

Thanksgiving Football vs. Thanksgiving Movies

Ignoring the fact that you can do both of these quite easily (that’s what she said!), if I had to pick I would go with the football. Yes, Thanksgiving movies are typically a fun, family outing. You still have to deal with traffic, parking and all the other families that are going to see the exact same movie. You will inevitably struggle to find seating together. And if you blunder into picking the wrong movie, well shit. You’ve just wasted 2-3 hours of your life and $8 that could have bought booze.

Thanksgiving football almost always involves a horrid game played by the Lions, a mediocre game played by the Cowboys and a wildcard. And you have the option to take the best nap of the year at any time, something your movie cannot offer you. I’m going with sports and naps.

Black Friday vs. Black Tuesday

One of these is the death of fun, the other is the fun death. There’s a surprisingly small amount of difference between the two. Each mass hysteria, loads of money exchanging hands and at the end of the day the loss of most of your savings. The bonus to Black Friday is that you’re killing on the ridiculous sales, and most likely someone is buying YOU presents. The bonus to Black Tuesday is…well there aren’t any bonuses. That was the whole point; everyone lost all their money. Black Friday wins.

Growing Corn vs. Starvation

Remember Bubba, from Forest Gump? That’s me, except with corn instead of shrimp. Also, I’m white and I didn’t die in ‘Nam, but details. If you didn’t know, corn is god’s food. There’s cornbread, corn on the cob, creamed corn, corn chowder, corn syrup, popcorn, candy corn and dozens of other concoctions. There are ways to prepare corn that I don’t even know about. Hell, you can even power your car on it. If you were starving, and all you had was a boatload of corn, you could turn it all into ethanol and drive yourself to a grocery store. It’s simply amazing.

Pumpkin Poo jokes vs. Turkey Breast Jokes

This photo was sent to us by Janice

Case closed.

Christmas Decorations in October vs. People Who Don’t Like Christmas

Ugh. Putting up Christmas decorations pre-Halloween is an absolute joke. First of all, it completely overshadows and disrespects All Hallows’ Eve—or Candy Day as it is more widely known. Secondly, you still have Thanksgiving to contend with. And finally, it makes you think about having to go shopping for Christmas presents. I do not want to think about that in October. I want to think about football, eating candy and delicious holiday pies.

People who don’t like Christmas: The Grinch, Ebenezer Scrooge, Mr. Potter and the Jews. One guy loves dogs and ends up saving Christmas; one guy is massively wealthy and ends up saving Christmas; one guy is just massively wealthy; and the Jews, well, they love presents so much that they have eight days of them instead of just one. Even the people who don’t like Christmas actually like Christmas. I’m going with them.

Dying on Thanksgiving Because You Choked on a Turkey Bone vs. Dying on Thanksgiving Because You Were Attacked by a Balloon in the Macy’s Thanksgiving Day Parade

Wow.

I’d like to think that choking on the turkey bone means I have already enjoyed a delicious meal and am polishing off the turkey by ripping apart the bone like a greedy dog. I’d also like to think that being attacked by a balloon means I am in the parade, like Mr. Pitt in Seinfeld. That would certainly be very exciting. I don’t know these things, though. What I do know is that my death by turkey bone would ruin Thanksgiving for my whole family, and that’s simply not fair to them. If I were killed by a Macy’s balloon however, it would be immediate national news. I would live in infamy, and might even usurp the name “Balloon Boy”. Or even better, some people would think the real Balloon Boy was the one who died. I can already picture the Time cover with a deflated balloon, my legs sticking out and a “WHOSE FAULT IS IT?” headline. This is just too good.

Thanksgiving with Marc’s Dad vs. Thanksgiving with Janice

This one needs a brief preface. We all know about Janice and her wonderfully endearing, quirky ways. What we don’t know is that my father, in many ways, is just as quirky and bizarre as Claire’s mother. He once washed his shoes accidentally, then continued to wear them even though they had shrunk an entire size. He once added a cell phone on his plan and mailed it to my brother, so that he could talk to him for free. This is the man that asked me if he could take cough syrup for his cold, despite the fact that the bottle in question was not cough syrup, and it was 16 years expired. Needless to say, he’s an odd cat.

That said, around Thanksgiving, my dad is fairly normal. He smokes a good Turkey, talks his way into doing nothing and eventually takes a nap. Pretty standard fare. In Janice’s corner we have the fact that she just recently sent Claire a recipe that turns your Turkey into boobies. I’m going with Janice.

Every year we tell the story of pilgrims, coming to a new land to seek religious freedom, nearly wiped out by hunger and disease, and saved due to their resolve and some good advice by native Americans. I will not speculate on how much of that is true, but it is our story. We then tell the story of a meal shared to celebrate and express gratitude for their survival.

The original Thanksgiving feast was probably not much of a spread. We have gone far in the last 200+years to make amends for that. I personally never remember a Thanksgiving celebration when it was possible to fit all of the food I wanted on one plate.

Corn was one of the reasons that our predecessors survived. It grew easily, was forgiving of nasty weather and inadequate soil, and now is our major cash crop. We produce huge amounts of it, and so we make all kinds of stuff out of it, and instead of scrawny pilgrims, we are now round, well fed, and increasingly diabetic.

We continue to be a resolute and industrious people, and have fixed the problem of inadequate food supply, in spades. We make plenty of cheap food, and though starvation is by no means wiped out in the US, more of the poor are injured by access to cheap and abundant corn-based carbohydrates than are from inadequate calories. Like Scarlett O’hara in “Gone with the Wind’, we will “never go hungry again.”

I have gotten a bit behind with my write-ups on Flash Forward since I have been out of town. I visited the Walt Disney Family Museum in the Presidio in San Francisco on Friday and will be blogging about that over the next few days.

Jeff “Doc” Jensen of Entertainment Weekly has some theories about Flash Forward. I loved to read his theories on LOST each week, so I am leaving you with his latest musings on Flash Forward.

Enjoy!

In the new issue of Entertainment Weekly now on newsstands, you’ll find a story written by yours truly in which I geek out on my new TV obsession, the ABC sci-fi drama FlashForward. If you’re new to the show, here’s what you need to know: On Oct. 6, the planet blacked out and for 2 minutes and 17 seconds, and everyone on earth saw a brief vision of their respective futures. The saga’s center is FBI agent Mark Benford (Shakespeare In Love’s Joseph Fiennes), who during his brief quantum leap saw himself investigating an elaborate conspiracy behind mankind’s perplexing power nap. The day glimpsed in all the flashes: Thursday, April 29, 2010. (Yep, the show will air that night.) Will Mark’s faithful wife Olivia (Lost’s Sonja Walger) find herself in bed with another man? Will vaguely sinister scientist Simon Campos (Dominic Monaghan, another ex-Lostie) strangle a dude to death? And will FBI agent Demetri Noh (Star Trek’s John Cho), who saw only darkness during his flash, be (gulp) dead? “The high concept pitch is simply this: if you were given a glimpse of your future, what would you do with it?” says FF’s exec producer David S. Goyer. “If you see something bad, can you change it? If it’s good, how do you make it come true?”

One of the things I love best about the series is the explicit and implicit references to science, literature, philosophy, and pop culture. When investigated, these references suggest all sorts of possibilities about what’s really going on in the saga, or at the very least add some cool or ironic shading to the story. For example: we’ve been told that Agent Noh will be killed on March 15. That also happens to be the date of Julius Caesar’s murder. More on the nose with FlashForward: Shakespeare’s Julius Caesar, in which a seer tells the Roman leader to “beware the Ides of March,” i.e. March 15. Is that just the writers having some smarty-pants fun—or are they planting a cue that a Brutus-like colleague will betray Agent Noh?

Here’s another example—a little more tenuous, but if you follow my Doc Jensen work on Lost, you know that making pseudo-intellectual leaps are part of what I’m all about. In FlashForward’s third episode, Agent Benford traveled to Germany to interview a Nazi war criminal who claimed to know something about the true nature of the global blackout. The old Nazi was being held at Quale Prison, and as it happens, the word quale is directly linked to a philosophical term dealing with—in wikipedia’s words—“the subjective quality of conscious experience.” (The fact that FlashForward would name a prison after such a heady concept is pretty provocative. Is the show trying to suggest that objective reality is unknowable and mankind is fundamentally at odds with each other because we are locked into our unique, idiosyncratic perspectives of the external world?)

Are you with me?! I hope so, because in the weeks to come, I plan on doing even more obsessing about FlashForward here at EW.com, beginning with a complete TV Watch recap of the next episode, airing Dec. 3. Until then, here’s are some additional references (legit and perceived my crazy eyes) that FlashForward has made during its first nine episodes—and some theories about what they could mean.

Lost
Of course, Dominic Monaghan (Charlie) and Sonya Walger (Penelope) are living, breathing embodiments of Lost. Both actors played characters linked to Desmond Hume. During the show’s third season, the ex-Hatchman became super-charged with The Island’s electromagnetic energy and began having flash-forwards of Charlie’s death. He also went back in time and tried to change his destiny. David Goyer—a big Lost fan—slipped a billboard for Oceanic Airlines into the pilot, inspiring fans to wonder if both shows exist in the same universe. At the very least, they may share a similar philosophical idea: that no matter how much you try to change predestined events, fate will get what it wants.

“Across The Universe” by Rufus Wainwright
Like Lost, Cold Case and so many other shows, FF has a penchant for episode-ending slow-motion montages, set to rousing score or a thematically loaded pop song. One of my faves was Wainwright’s cover of this classic tune by The Beatles, heard in the Oct. 29 episode “Scary Monsters and Super Creeps.” In the 1999 Robert J. Sawyer novel that inspired the series, the blackout/flash-forwards are caused, in part, by an anomaly in deep space—literally “across the universe.” Coincidence? Nay! I say: Synchronicity! As in…

“Ghost In The Machine” by The Police
Agent Benford is a fan of the band and wore a T-shirt featuring this album’s artwork to an undercover operation—infiltrating an underground club catering to “ghosts,” people in the FF universe who didn’t see anything in their flash forward and thus believe they are destined to die before that date. According to band lore, the album was inspired by Sting’s fixation with Arthur Koestler, an egghead who postulated that people, events, and time are psychically linked via the concept of Synchronicity described by Carl Jung. (The Police song “Synchronicity,” from the album of the same (also inspired by Koestler), is a FlashForward theory unto itself; check out the lyrics here.) Koestler’s books include The Ghost In The Machine, The Roots of Coincidence (a book that has had a big influence on sci-fi, fantasy, and comic book writers), and Janus: A Summing Up, an exploration of systems theory that says that a larger whole or “holarchy” is make up of individual components called “holons” that also contain systems within themselves, or something like that, or maybe nothing at all like that, and yes, I don’t have any clue what any of this means. Bookmark that Janus name—we’ll be coming back to it in a minute.

Jericho
In FlashForward, Jericho is a military contractor that provides private armies to the highest bidder. Their soldiers apparently played a role in the attempted killing of Aaron Stark’s daughter, Tracy, in Afghanistan. I also suspect they are providing goons to the conspiracy that perpetrated the global blackout. Of course, Jericho was also the title of the short-lived, intensely loved cult drama that imagined the aftermath of a cataclysmic nuclear attack on the United States.

David Baldacci
Trying to make sense of Jericho’s treacherous attack on his daughter, Aaron likened the situation to a “Baldacci novel.” David Baldacci is the best-selling author of hugely successful books like The Collectors and Absolute Power, political potboilers that usually involve elaborate government conspiracies. Application to FlashForward: I’m thinking President Segovia (played by Peter Coyote)—who is (or was) tight with Assistant Director Wedeck (Courtney B. Vance)—knows much more about the global blackout than he’s telling. And remember Senator Clemente (Barbara Williams), the congresswoman who was leading the subcommittee investigation into the flash-forward event? She was no friend to Segovia and Wedeck, yet the president made her his new vice president—presumably to stifle her persecution of Wedeck’s Mosaic team. No, it’s not very realistic that a president would appoint a hated political rival as his No. 2—unless, of course, Segovia and Clemente aren’t the bitter enemies they appeared to be. I’m thinking that yes, Senator Clemente is in on the conspiracy, too. So what’s the conspiracy? Here’s the clue that sketches the big picture:

“D. Gibbons”
The “bad man” from little Charlie Benford’s spooky vision and one of many cryptic clues gleaned from Agent Benford’s flash forward. The name undoubtedly refers to Dave Gibbons, co-author of the subversive superhero saga Watchmen, whose intricate mystery plot concerns (SPOILER ALERT!) a conspiracy to encourage world peace by staging a fake alien invasion. And like FF, Watchmen stuffed coded clues and tell-tale non-sequiturs in the margins of its story. I’m thinking that the power players behind the global blackout were attempting to do something similar—usher in a new era of world peace by staging a global cataclysm designed to cause everyone to rethink their lives, the way they live their lives and the political, religious, and philosophical barriers that divide us. The bipartisan union of President Segovia and Senator Clemente is symbolic and representative of the narrative the conspiracy was/is trying to promote throughout the world. The two-faced, double-edged nature of this scheme to engineer planetary rebirth via planetary catastrophe is reflected in our next clue…

Janice/Janus
Janice is the name of the FlashForward character who saw herself having a baby on April 29… even though she’s a lesbian who is currently not in relationship and had been deeply ambivalent about even having kids until recently. Janice sounds exactly like Janus, the two-faced Roman deity of open gates and closed doors, of beginnings and endings. Janus is a deeply ironic, very paradoxical dude—both hopeful and ominous. That’s very Janice. Speaking of double-sided clues…

Beilby Porteus
Mosaic’s search for “D. Gibbons” led him to Pigeon, Utah, where he encountered a mystery man, coined “The Chess Player” by fans, in an abandoned doll factory. Before escaping, the chess player said, “He who foresees calamities, suffers them twice over.” That’s a famous quote from Porteus, an 18th-century English clergyman and noted abolitionist. His other major claim to fame was introducing something called “The Sunday Observance Act,” a “blue law” that regulated the ways people in England could spend their recreational time on Sunday. This is could be a double-faced clue. On one hand, we have an ostensible bad guy, quoting a guy linked to a righteous cause (ending slavery) and famous for forcing a righteous way of life on society (the Sunday Observance Act)—another possible proof on the aforementioned world peace conspiracy. But is The Chess Player part of The Blackout Conspiracy—or working to subvert it? The Porteus quote is darkly ironic. And coming from The Chess Player, it sounds like a warning or threat. Possibilities: If The Chess Player is trying to promote the conspiracy, he might have been trying to tell Benford that trying to solve the mystery of the blackout calamity will only produce another calamity—the ruin of its peace-promoting effect. But if The Chess Player is trying to fight the conspiracy, he might have been trying to tell Benford that flash-forward event had backfired—or will backfire when it reaches its fulfillment on April 29. FYI: Porteus is associated with another ironic quote that could be applied to FlashForward and my “Conspiracy of Peace” conspiracy theory: “War its thousands slays; peace its ten thousands.”

White Queen
The Chess Player left behind some clues for Mosaic, including a chess piece—the white queen, which provocatively intersects with all sorts of fantasy and geek pop. The White Queen is a character from Through The Looking Glass—a scatter-brained figure that lives her life backwards and struggles to live in the present. (“Jam-yesterday or Jam-tomorrow, but never Jam-today.”) That’s fitting for a show whose people got mind-scrambled during the global blackout and are now playing out futures that may have already come to pass—who are constantly being reminded and challenged to bravely defy fate by “living in the now.” However, “White Queen” is the handle of several prominent characters in comic book land, including the morally ambiguous X-Men foil Emma Frost (who can see into other people’s heads) and another baddie, Sat-Yr-9, an unhinged femme fatale from an alternate reality Earth. Yes, it is unlikely FlashForward was deliberately trying to forge a connection to the latter character. But she does embody a high concept theory in quantum physics that was explicitly referenced by Dominic Monaghan’s Simon Campos character: the idea that all possible realities actually exist. (See: the Schrödinger’s Cat thought experiment, used by Campos to seduce the blonde lady on the train.) I won’t beat this dead (Schrödinger’s) cat further by bringing this full circle and explicating the link between Alice In Wonderland and quantum mechanics, or how the whole notion of white and black chess pieces illustrate the binary either/or dynamics of alternate reality logic. However, and fittingly, I will ask you to entertain at least two possibilities: 1. That what everyone saw in their flash-forward was actually a peek into an alternate reality; and 2. That per the implications of Schrödinger’s Cat, which says that reality isn’t created until directly observed by the viewer, that the future sketched by the flash-forwards is now locked into place as a result of being directly observed by everyone in the past via the global blackout. Got that? Thought so. Also see: A Christmas Carol SPOILER ALERT! David Goyer says Charles Dickens’ classic novel—about a grinch who’s shown a vision of his (possible) future—looms large in the Dec. 3 episode.

If you’ve been watching the news, you may have seen some historic changes in recommendations about cancer prevention.  There have been news releases regarding a change in the recommendations for mammogram screening by the US Preventive Services Task Force (USPSTF). Women in the 40-50 year old age group are now only encouraged to have regular mammograms if they are at increased risk of breast cancer, due to the fact that this test often finds non-existent of unimportant abnormalities in this age group that, on the whole, makes them less, not more, healthy. This will save women thousands of dollars and countless hours of time and energy at a time in their lives when that time and energy is a real gift.

Today I read that the American College of Obstetrics and Gynecology now recommends starting pap smear screening at 21 for most people, and reducing the frequency in that first decade to every 2 years. I have studied evidence based recommendations for pap smears for years, and the formula that makes sense is somewhat more complex than this, but in most cases our standard yearly pap smears are not necessary. This is based on the fact that some of the treatments for abnormal pap smears can make a women less healthy, less fertile, and that the whole process is expensive enough that  honing it down to what is truly necessary makes excellent sense.

Cost is certainly not the only issue here, but diversion of significant money from womens’ health funding in directions where it does no good hurts all of us. Google tells me that a mammogram costs around $100, and may cost as much as $200, and a pap smear runs about the same price. The cost of these tests in terms of comfort and dignity is not insignificant.

By Andrea McCallum

SINGING sensation Susan Boyle today (fri) prepared for the launch of what is expected to be her multi-million selling debut album launch on Monday – by going shopping in Bathgate.

And showing the celebrity status hasn’t gone to her head she even travelled the short distance from Blackburn by bus, stopping off at her favourite store to buy a new outfit before her appearance on this weekend’s X-Factor.

Casually dressed in a rain coat and black trousers, and sporting her signature Burberry scarf and a splash of red lipstick, SuBo showed no sign of nerves as she wandered along the West Lothian town.

The star walked confidently from her house past the local primary school before being called over by a friend outside the newsagents.

The blonde bespeckled woman, in her 50s, shouted across the street to SuBo before walking over to have a chat.

Laughing and smiling, the pair talked for a couple of minutes before Susan said goodbye and continued on her way to the village’s Mill Centre.

Walking confidently, she said she was “busy” and couldn’t stop for a chat.

But she had time to mention her upcoming trip to London and the States, suggesting that as famous as she is, she still gets excited about her new lifestyle.

Moving on to Blackburn’s main strip, the singer popped into the Mill Centre.

Home to just a few small shops and the local library, Susan found a way to pass the time as she wiled away an hour inside.

On her way out, she was approached by an elderly woman who gave her a big hug.

Ruffling the star’s hair, the OAP looked as though she was teasing the singer before she rushed across the road to catch the bus.

She flagged down the 11.49am number 557 bus to Bathgate outside the Mill Centre.

Mobbed

Squeezing into the busy small single decker vehicle run by local company E&M Horsburgh, she made her way into town for her shopping spree.

Alighting in the town centre, the international celebrity sauntered around the streets, stopping at the bank on her way to her favourite shop.

Those stopping her in Bathgate were more fans than friends, and she graciously smiled and said hello.

During the hour she spent in local department store M&Co, more fans gathered outside, taking snaps of the singer on their mobiles as they waited for her to come out.

Eventually, the star emerged from the shop clutching a bulging bag of purchases.

According to staff, she had bought a longline cardigan and a couple of pairs of trousers.

The bus Susan jumped on

Janice Hendry, the shop manager, said: “She’s been a customer with us for years so it was no surprise to see her coming in. She was quite funny when she was in, laughing and joking with the staff.

“A few people were asking her for autographs and she was great with them, posing for photos and everything.

“Other than that she is treated as a normal customer.

“I said to her today ‘why are you still shopping in M&Co now you’re famous?’ and she said to me ‘nothing wrong with that’.

“We wish her well with everything in the future; her album is already a hit. It’s quite phenomenal.”

Smiling to those waiting, she started to walk down the street when the two most determined admirers called out to her.

Susan ambled back to the builders in fluorescent vests and posed with them as they took photos on their mobiles.

After a five minute chat, she wandered off smiling at passers by.

I Dreamed a Dream

She had been splashing the cash ahead of her album’s debut on Monday, but with sales from the expected sales of the CD, she will soon be able to visit any designer emporium she wants.

Amazon reported earlier this week that the album had already sold more copies than any other pre-order.

And bookies and so certain that she will top the album chart next week that they are refusing to take bets.

With an appearance on the X Factor on Sunday and a raft of publicity events lined up in the States next week, todays (Fri) shopping trip was a relaxing break for the singer.

See more of our pictures at our Flickr site and videos at our dedicated channel,  Deadline TV.

As a fourth generation Memphian and the third in the line of women who went to what is now the University of Memphis, I rarely thought of agriculture growing up.  And my guess is the farmers portrayed in movies or on television were a general stereotype… I didn’t think much about it being inaccurate or accurate.  That started to change when I got a job that involved me contacting farmers directly.  And it didn’t take long for me to realize I had stumbled into a great industry — one that is made up of people who are willing to share their knowledge in the most genuine ways sharing themselves and their stories.

Although I grew up city, my path has taken some unique turns from attending a small college in Oklahoma, grad school in Memphis, working at an agency in metro New York and living in the Mississippi Delta for more than a decade.  Travel around the US and the world has allowed me to meet a lot of people and learn so many incredible things.  I find myself still working in agriculture not just because it’s a job, but because it has become one of my passions.

The openness and honesty from farmers and the passion I have for agriculture is what I hope to bring to this blog.  And wherever possible, I’ll let farmers tell their own stories by video, audio or quotes…. I want to hear a bit about each farm and some of the things that farmers have on their minds whether that be the successes or failures associated with crop production or what it’s like to be in rural America.  And hopefully I can provide some additional insight I’ve picked up along the way from talking to the people upon whom we depend to produce for our food and fiber.  And while I’m a Southern girl who loves cotton and will certainly talk to people nearby about topics I have some experience with but I’m also looking forward to meeting farmers that can help me better understand other areas of agriculture.

Three articles in the most recent New England Journal of Medicine describe more new medical technology, and have made me curl my toes in mental conflict.

1. A pacemaker that goes into both the right and left chambers of the heart, rather than just the right side, preserves heart function better, according to ultrasound tests.  It is a much trickier (read inaccessible, expensive, desirable) procedure than the standard one, and the patients don’t actually feel any better or act any healthier than with the standard kind of pacemaker.

2. Giving an intravenous iron supplement that I’ve never heard of before (new) (they didn’t test the ones I have heard of before) can improve heart function and health in patients who have congestive heart failure and are iron deficient. How odd that they didn’t evaluate oral iron supplements which have been generic since before I was born and are the standard treatment for iron deficiency. Is it just possible that the new product will be the only product approved for treating congestive heart failure in patients with iron deficiency? Is it just possible that it will cost some jaw dropping amount of money?

3. In people who have heart failure so bad that they would need a heart transplant to survive, but they are not well enough to survive a heart transplant, use of a mechanical pump can prolong their life, and can be used somewhat indefinitely. Only 1/4 of these people will live a year with this technology, and 17% of those treated will have a major stroke. The cost of the technology wasn’t mentioned, and quality of life was not addressed.

We continue to move towards technology that is more expensive, more resource consuming and does not seem to improve quality of life, at least in clinical research. Frequently practice follows close on the heels of research. A good journal still publishes studies like the intravenous iron one that may influence practice without any evaluation of possibly equivalent less expensive and resource intensive alternatives.

Whence my internal conflict? Clinical science occasionally barks up the right tree, and contributes to the health and happiness of people.  It also burns money like it is nothing, as if resources were unlimited.

All our dogs were in costume and one of our dogs, dressed as an angel here, got adopted.
That’s me holding Lucy, now named Chloe because their other dog, a cairn terrier, was also named Lucy.

[click image for full size]

I was thinking more about the idea that not getting universal health care would cost tons of money because the 45,000 people who die every year from inadequate access to medical care have monetary value.  I forget what Steve said the estimated monetary value of a human life is, but I would bet it isn’t one of those numbers that have actual meaning.

How actually do you add that up? How could you come even close to getting a number for that? What about George Bush, who probably cost money, on the whole? or Ghandi, whose life probably created value, but whose death also created value? or do you just look at the big average of people living and divide the overall value they add to the universe by the number of people in the universe over an average lifespan? And if you do that, do you assume that humans are gradually trashing the planet, and therefore, in the long run that they have negative value? Or do you look at their value in communities over the short run? Or do you look at the devastating effect of a human’s death on the people who love them, and the lost productivity resulting from that?  And do you just assume that the lost productivity is the whole story, or do you think of, perhaps, the completely unpredictable positive consequences of a death, or the completely unpredictable consequences of life?

I’m still pushing for universal health care, but maybe not on the basis of humans as units of currency.

Hello everyone,

I have not posted anything to this blog since the beginning of August.  I told you all that my husband was having surgery and he did.  But like the saying goes, “When it rains it pours” and it did.  It poured and poured!

We all have good times and bad, unfortunately, the months of August, September, and October have been horrible.  I have had three deaths in the family and my husband is still trying to recuperate from his surgery.

I must admit with all the sadness in my life my husband and I had a 25^th anniversary party which was so much fun!!  My brother-in-law flew out from New England and my step-sister flew out from Oakland, CA.  We had our family and friends (friends that are like family) share our special silver anniversary celebration with us.

I have had people individually emailing me with macro questions and I have replied to them all.  I always, always, love to talk about photography!

This post will not be about how to photograph up-close.  It will be about me, Janice Sullivan, a person that loves her family and friends.   I just wanted to thank everyone that has supported me in my photography profession, especially my husband, my children and my best friend Pam.  To others that are reading this that do not know me…thanks for stopping by.  It’s nice to share myself with all of you.  This is a business blog, so today is a rare occasion for me to express my feelings to all of you.

Below is a photo of my father-in-law with his boys in Ireland, standing in front of what is left of the O’Sullivan castle. This is one of the things he always wanted to do before he passed away and I’m happy he did it!

YOU CAN CLICK ON THE PHOTOS TO SEE THEM BETTER, BUT TO GET BACK TO THE BLOG USE YOUR ARROW BACK KEY.

Below is my cousin with the family before she passed away from lung cancer.  She is still smiling, that’s Lisa!!

Lisa and our family.

I will also miss my Aunt Fern’s emails.  I am forever grateful for her wisdom and love.

Screen shot from my Aunt Kay:

The following photo’s were shot by my photographer friend Lindsey….

OUR YUMMY CHOCOLATE CAKE!!

After our vows….

Kevin and I never had a large wedding…so we decided to renew our vow with a small ceremony.  We had so much fun!  :)

SOME PARTY FUN WITH FAMILY AND FRIENDS:

My best buddy and her family!! (above)

Getting ready for dinner…  Marriane did you take the kids a run from the camera, lol! (above)

My awesome lawyer  and friends that go waaaaaay back! (above)

Family from my mom’s side. (above)

Family from my dad’s side. (below)

This photo was shot by my Aunt Kay…thanks Aunt Kay !

I plan to begin my post again on Macro & Close-up photography, so if you would like me to discuss a particular area, commit on this post or you can email me at INFO@SULLIVANJPHOTOGRAPHY.COM.

Cheers,

Janice Sullivan

Owner of Sullivan J Photography

http://archive.sullivanjphotography.com

If you work this Friday (Nov 13), please tell Janice when you are finished your shift. She has an early deadline for payroll and this will help you get paid on time.

Ken – you should probably mention to her on Fri morning that you don’t finish until 7pm and ask her what she would like you to do when you’re done.

Ever so briefly…

In the Annals of Internal Medicine I came upon an article:

Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation

by

• Aaron L. Nelson,
• Joshua T. Cohen,
• Dan Greenberg,
• and David M. Kent

The title was a little off-putting, but the message was sound. In medicine it very rarely happens that we invent technology that is less expensive and almost as good.  In all sorts of other fields we do that.  India invented the Nano, a small, very cheap, very fuel efficient car. Apple created the iPod shuffle. I don’t know who invented the amazingly warm, rock bottom cheap microfiber soft fluffy fabric that my bathrobe is made of, but my hat is off to them. In medicine we keep innovating, and we make these things that are a tiny bit better than the thing before them, and are much more expensive. If cost were of no consequence this would not be an issue. But when we talk about more expensive, the millions of dollars that get spent on these new technologies quickly adds up.

In this article the authors look at some of the rare medical technologies that are less expensive than the pre-existing technologies with which they compete, and come up first with the cardiac angioplasty, or PTCA. In this procedure a blocked artery around the heart is dilated open with a balloon rather than being bypassed surgically.  It is much cheaper to do it that way, but not quite as effective.  But the researchers fail to point out that this procedure also allowed all sorts of people who wouldn’t have been able to tolerate heart surgery to live free of heart pain or heart attacks for years.  So the technologies that are cheaper are, in a way, also sometimes better.

I merely point this out as yet another path toward responsible, successful, human centered medical care.

I just finished reading John Robison’s book Look Me in the Eye. It is his own story about growing up with Asperger’s syndrome.  People with Asperger’s syndrome are considered to be in the “Autism Spectrum” of disorders, which are conditions in which people have varying difficulties dealing with other humans.  They have trouble interpreting other peoples’ emotions, facial expressions or body language, and sometimes have intellectual abilities that are amazing.  The author got along horribly in school and with his parents, but eventually became spectacularly successful as a sound engineer, designing lights and effects and amplification for heavy metal bands including Kiss.  By paying close attention, our hero was able to figure out what he was supposed to say when a person said something incomprehensible like “How are you?” Eventually he was able to pass for eccentric rather than frighteningly bizarre. He used his considerable intellectual abilities to find ways to work around his rather profound social disabilities.

In Extremely Loud and Incredibly Close, Jonathan Safran Foer tells the story of a boy who goes on a quest for clues to the mystery of his family after his father is killed in the twin towers on 9/11. This boy, the narrator, is another beautifully drawn character with oddities in the autism spectrum. His quest brings him close to many strangers who enrich his life, and whose lives he in turn enriches, as he navigates New York city on foot, by bus and by taxi. During the narration the reader occasionally gets glimpses of how the world sees the narrator. He is a small boy, very verbal, who wears only white and usually carries a tambourine. He is not able to relate to children, but usually gets on well with adults when they overlook his oddities.

My nephew is such a boy.  As a baby he was easily disturbed by changes in routine, and let us know it with an incredibly high pitched Mynah bird screech. As he grew more verbal, he became progressively more obviously different, with intense dislikes of all but the simplest foods, and sensitivity to any irregularity of his clothing. He was difficult to discipline, resisting the expectations of his family on even the smallest of things. He never used a little word when a large one would do. He was incredibly annoying. As he has grown older, he has become more introspective, though he still drives his teachers and classmates completely nuts. He can really tell a joke. He doesn’t know which jokes are appropriate, but he can make anything funny. He has learned table magic, and none of us can figure out how he makes those coins disappear. He still dreams of world domination, but realizes that there is something about him that makes it difficult to make friends his age. He cares more about that now, and watches to find out what might be making him different.

Unlike some kids with Asperger’s, my nephew doesn’t rock, or repetitively move his hands. And yet he is undeniably odd, and though motivated to get along with other kids, hasn’t got much of a clue how.  He is finding his intellectual work-arounds, though. He can captivate people with magic. He can play a mean jazz piano. He can build a computer game.

As I watch my nephew and read these books that share insights into the brains of people with this autism spectrum, I wonder how common some degree of this is, particularly in some of the people who are close to me, people who are defined by their intellectual abilities. I look at the aging physicist I saw this afternoon, who rarely makes eye contact, has few close friends outside of her field and very different values than her peers.  As I look at my own hard-won facility in most social situations, I wonder how many of us actually live on some part of a spectrum whose far point is called autism.

Of course it’s true that preventing disease is less painful and less costly than treating disease.  Or is it?

Take the recent New York Times article (http://www.nytimes.com/2009/10/21/health/21cancer.html) addressing mammogram and prostate cancer screening. Apparently over the last 20+ years of screening with mammograms, we have been able to discover many more breast cancers that are small, and might never have been noticed, and probably never would have progressed to the point of hurting anybody.  This has given rise to alarming statistics, such as the one that breast cancer incidence has risen 40%.

We have long known that detecting prostate cancer early, especially in older men, finds many cancers that would never have caused any injury and would never have been noticed had we not screened the men.  When we find cancer, we usually remove it, and for women with breast cancer this means amputation of a breast or radiation therapy, and often chemotherapy.  For men with prostate cancer this means surgery on their very delicate private parts after which they often have trouble with bladder or sexual function.

But even if mammogram screening did detect cancer early, thus protecting women from getting more serious breast cancer, which honestly it sometimes does, is it really less painful and less costly than treating the disease? Mammogram screening, it is estimated, costs about $105,000 per year of life saved if we screen women yearly starting at age 40.  Because mammograms are somewhat difficult to interpret, many of those women have breast cancer scares, and all of those women get their breasts painfully smashed flat once a year. Encouraging them to get those mammograms is the job of doctors and nurses who might use that energy to provide other more life affirming activities.  The focus on the breast as the seat of cancer, rather than of, say, love or courage, puts women in the position of being at war with their bodies.

Let’s go back to the $105,000 per year of life saved.  I certainly love my women friends and relatives enough to believe that a year of their life would be worth $105,000, but isn’t it possible that if we spent that money on something a little different than mammograms, we might be able to buy more than a year of life? I could support a family, for instance, for a year on $105,000.

I do know and love people who have had screening mammograms, found breast cancer, had it cured, and are now healthy.  I think some of them might have died had they not had a mammogram.  I am not ready to say that women shouldn’t get screening mammograms.  It is, however, not necessarily accurate that preventing disease is less costly and less painful than treating it, at least in the case of breast and prostate cancer.

I have been cogitating and head scratching over the question of skewed costs in the delivery of medical care.  I have been wondering how Cat scans and MRI scans and colonoscopies and surgical procedures have gotten so amazingly expensive, when the technology hasn’t really changed that much  and why all new procedures, which are often simpler and use less actual resources, are priced higher than the more cumbersome procedures that they replace.

There are lots of explanations, but none of them has been truly satisfactory until last week.

I was at an educational meeting put on by Harvard Medical School for primary care internists like myself, and, between bites of roast onion and marinated mushrooms at the meeting’s reception, I heard a story of a beast so buried in obscurity that it’s sizable influence on this whole mess is not easily recognized.  The beast is partly camouflaged by a series of nearly impenetrable acronyms, making it all the harder to discuss. But here goes.

The first acronym is the RBRVS.  Years ago a system of standardizing payments for things medical was designed.  Based on what things cost, how much work they took, and how much they exposed one to the risk of malpractice, things that doctors did were evaluated on a  “resource based relative value scale,” which assigned relative value units (RVUs).  For instance, advising someone on the treatment for a bad sunburn might be one unit, and removing their appendix might be 12 units.  I’m just making those numbers up, but you get the idea.  The CMS (center for Medicare and Medicaid Services) and private insurance companies, use these units in determining payment for all services.

The next acronym is the AMA, the American Medical Association,  a powerful national group that represents all of its doctor members. The AMA apparently sponsors a group that updates these RVUs based on…whatever the 30 members decide.  The members of this group, the RBRVS update committee, or the RUC (pronounced like truck without the t)  are primarily subspecialists, so subspecialty services have very high  RVUs, leading to high reimbursement for a bunch of tests and procedures which (for other reasons) are also grossly overutilized.

To many non-physicians this may seem like an undignified cat fight between folks who really don’t know how good they have it.  Yes, primary care is relatively underfunded, but what does that have to do with the average dude? According to an article by the doc who has organized this meeting I attended, in most countries in the world, the physician work force is about 80% general doctors, but in the US only about 10% of the graduating medical students go into primary care internal medicine, one of the two generalist tracks out of medical school.  Family practice is the other track, and that attracts only about 20% of graduates.  Seniors, whose numbers are swelling with the aging of the baby boom and with more effective preventive medicine usually prefer internal medicine doctors because they have more experience in the complex problems that accompany aging.  The inability to make an adequate living and cover educational debt is one of the main reasons that young doctors are choosing to go into higher paid specialties.  Lack of satisfaction by primary care docs due to high demand and need to see ridiculous numbers of patients in a day also contribute to these choices. There is already a shortage of primary care doctors of all sorts, and as older ones retire, at this rate, there will be nobody to replace them.

So how is the beast to be slain? Perhaps knowing its name will be a start.  I will do a bit more research on the RUC, and push for its demise.

The link to Dr. John Goodson’s article is http://www.cms.org/DocCongress/LYNN%27s/RUC%20in%20JAMA%202007-11-21.pdf

As people age, their kidney function gradually goes down, usually keeping pace with overall needs. In people with longstanding diabetes or high blood pressure, though, sometimes the kidneys fail before the rest of the body does.  In this situation, various toxins build up in the blood and such a person gradually becomes weaker and eventually dies.

Enter kidney dialysis.

With a machine that runs the blood through a filter, much as the kidney is a filter, the toxins can be removed from the blood. Unfortunately all of the blood needs to be run through that filter, which is somewhat tricky, and it takes about 4 hours, and needs to be done about 3 times a week.

This is barely tolerable, but better than dying, usually, if you are pretty young, or only have to do it for awhile, as you wait to receive a kidney transplant.

If you are very old, though, dialysis is physically stressful.  The heart has to tolerate the movement of blood out of and back into the body, and all of the organs have to tolerate the rapid shifts in electrolytes and blood volume that are part of the process.

Not surprisingly, older folks, those over 80 for instance, don’t have much more in them than the 3 time a week dialysis sessions, and so don’t benefit in terms of energy from being dialysed, other than not actually dying of kidney failure. A study done at Stanford showed that, in fact, most nursing home residents lose their abilities to take care of themselves after starting dialysis, and within the year, almost half of them die anyway. But the over 80 crowd are in fact the fastest growing population of patients getting dialysis in the US.

Dialysis is a big business.  It is a procedure and therefore is reimbursed generously by insurance companies.  Dialysis centers are popping up like mushrooms, and must have patients to continue to make money. A single dialysis session will be billed at about $1200, sometimes more, and be reimbursed by medicare for maybe half that. Private insurance pays considerably better.  No matter how I calculate it, that is considerably over $100,000 a year.

In our small town there were no dialysis facilities available, so everyone who needed to have dialysis needed to travel at least 45 minutes to a dialysis center if they wished to have it done. With much wrangling and organizing, the hospital eventually put in a dialysis center, which seemed like it would probably not be very busy, since there just aren’t that many people living with kidney failure around here. They opened their doors a month ago, and then, as if by some kind of evil magic, there were two dialysis centers, in a town of 20,000 people. The second one is in a mini-mall at the edge of town. Competition is good, when it can bring down cost and increase quality, but costs for these things is based on what insurance will pay, which is static, and quality is pretty well controlled by standardization. Perhaps they will compete on the quality of the cookies they serve in the waiting room? The second dialysis center was started by a specialist who was not the proprietor of the first dialysis center, and figured he could hold on to his share of the patients by building his own.

Now perhaps I shouldn’t be fussing. What harm could it do if two companies want to open up and offer services that don’t really hurt anyone in town, and in fact potentially save lives?  What I’m worried about is the large population of over 80 year olds in town who will now most likely experience rather powerful marketing as both of these centers struggle to make ends meet.

These folks and their families will now be faced with the expectation that they should not let nature take its course when their kidneys quit, since dialysis is common and easily accessible.  If this made them healthier and happier it would be one thing, but I predict it will not go that way.

I like to joke about being a WASP, but it’s not an exaggeration. I really am that white. Although not white enough to realize that I could be de-activated from the Episcopalian Church. What the egg salad sandwich is that about?

Claire and Janice in Italy, 2006

Subj: Reactivating your church membership – permission por favor

Teddy & I stopped by [the Church of the] Holy Spirit late this morning-it is very very spruced up and much larger than it used to be -$$$infusion? from someone? I looked into activating my church membership and yours-then we can be listed in the members’ booklet, etc. Is that okay with you- ?-they will send you stuff- like time of Xmas services, etc. (Thank GOD-literally!-Episcopalians have an 11 o’clock Sunday service still. So maybe I’ll go some.) Okay, yes, they will also send a landfill of “send $$ now” letters, but I will cover you, modest donation wise. Saw many names from the past on the bulletin board. Looked like some of your school chums’ families are still there.
Of course, being Episcopalians, they could not find us on the computer system, but the Church Secretary is going to look into it , since I told her all of our records where still there and you had been confirmed there, so she will search and call me. The “Rector’s house” next door had a new Prius parked in it’s driveway – beige, of course. (How Epis. of them!!) This was part of our 2 hour walk- Teddy came home all energized. We went too the Church, the Bank, and the Library. He is locked up and I am having a cup of tea. Holy Spirit does a “Blessing of the Pets” every year in early October, so Tedster can join the Church too!!!! How you doing? Take care, Love, MOM

I just reviewed the blog stats on Alexandria, thanks to a post that I really couldn’t figure out without going to the attached links.  It was gratifying to note that Alexandria does get quite a few hits, regularly, and that, at one point or another, 70 people actually read something I wrote.  I didn’t think it was a particularly stand-out kind of piece, but even so…

The hits, though, really vary by day.  On one day in June there were thousands of hits, and on an average day, only in the mid hundreds.  The big banner day was when someone wrote a piece about Roman Polanski.  Later, I think, was a piece about the new Harry Potter movie, with pictures. That one still gets quite a fair share of the Alexandria hits, even months later.

I look forward to seeing if this post gets a bunch of hits, simply because the title has Roman Polanski and Harry Potter in the title.  Perhaps anything that is truly of such high literary value or so amazingly thought provoking that it really should have vast readership, should be linked to popular culture…