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Statues of Exeter

Posted on October 3, 2015 at 11:40 AM Comments comments (0)


In the 21st century it is time to carve a new name with pride

If you ignore the saintly carvings on the cathedral wall, you can count the number of statues in Exeter on the fingers of a deformed hand. Yet one member of this elite group and possibly the most prominent figure isn’t even an Exeter man. I pass Redvers (pronounced Reevers) Buller almost every day on my way to work, sitting proudly on his horse adjacent to Exeter College, but at times he is a sorry site. A few weeks ago he was garlanded with a blazing orange tutu and carried the best part of a rowan tree over his shoulder. His horse, ‘Biffen’ sported the ubiquitous traffic cone on his ear. It might seem like a cruel fate for such a senior ranking British army officer, but there was a time when he was described as ‘…one of the bad jokes of Victorian military history’ because of his tactical ineptitude in the Boer war. The positioning of his statue now seems like another strategic blunder, parked on the main route between Exeter city centre and the university campus. The challenge to mount the pedestal of Cornish granite, scramble up Biffen and plant a trophy on Buller’s noggin must seem irresistible to students returning from their nighttime revelry.

The Buller family seat was originally in Morval in Cornwall and they owned extensive land in both that county and Devon. His home was in Downes, Crediton and it must have been a blow for the ‘Kirtonites’ of 1905 to see the statue unveiled with Biffen’s rear end facing their hometown. He fought in many campaigns including; the second opium war, the Ashanti campaign, the Xhosa wars, the Anglo-Zulu war, the first Boer war, the Egypt campaign, the Madhist war and the second Boer war. He was awarded the highest military honour for valour during the British defeat at the battle of Hloabane during the Anglo-Zulu war. However, his heroism as a junior officer was overshadowed by later failings, he was described by one historian as “…an admirable captain, an adequate major, a barely satisfactory colonel and a disastrous general”.

Even so, you may feel that the students should show more respect to a war hero. For all his failings as a military leader, you don’t get awarded the Victoria Cross for doing nothing and more recent historical texts suggest that his skills as a military leader have been harshly judged. But I suspect he is a stranger to most of the passing students, representing a time of Empire, colonialism and stark social division. Perhaps it is time to replace him with a contemporary and true Exeter hero, but who? It is a real struggle to think of suitable candidates. My vote would be for another military man: Trooper Jack Sadler born in Exeter and killed in the war in Afghanistan in 2007. This might seem a strange choice for a statue on a major student thoroughfare and there are many who may feel that his sacrifice was in vain, but not me. He fought men who believe that women who aspire to improve themselves through education need a bullet in the head rather than a place in college. He was 21 years old when he died, so by virtue of age alone he would be a recognizable figure for the passing students. Also he was an old Exonian, whereas Buller was an old Etonian. His statue would be a fitting tribute to the brave young men and women who have been killed in this conflict and from what I have learned about Jack, he would definitely see the funny side of a traffic cone on his head.


Western Morning News  October 3rd 2015


Fight the good fight

Posted on September 23, 2015 at 12:00 AM Comments comments (0)


What is it about cancer? Hardly a week goes by without a newspaper headline telling us that some celebrity has ‘lost their brave fight’ against it. We are encouraged to raise money to finance ‘the war against cancer’ helping researchers ‘battling’ to find cures. It seems almost impossible to use the word ‘cancer’ without linking it to a military metaphor, but when did this all start and is it appropriate?

Most sources credit US president Richard Nixon with firing the first shot in ‘the war on cancer’ when he introduced the National Cancer Act of 1971. But he never used this expression in his State of the Union address or any related speeches and the words are not included in the act itself, which boosted cancer research in the USA by $100 million with the stated aim ‘to conquer this dread disease’. It appears that the war metaphor was conjured up by contemporary journalists - and it has stuck. Cowboy actor John Wayne stated his intention to beat the ‘big C’ when diagnosed with lung cancer in 1964. He survived removal of one lung and four ribs, but ultimately succumbed to stomach cancer in 1979. His posthumous web site still encourages us to; ‘saddle up and help bring courage, strength and grit to the fight against cancer’. Many cancer victims feel duty bound to declare their intention to fight their disease. This is all very odd, because cancer is one of the few diseases where an individual can do very little to affect the final outcome. If your aim is to live longer, fighting is not required; submission is best. Better to yield to the surgeon’s knife, submit to the oncologist’s venom and expose yourself to the radiotherapist’s rays. Once diagnosed with cancer, your chances of survival are not improved by lifestyle modification or a positive mental attitude.

Also the one thing that cancer consistently does is debilitate its victims, who usually don’t feel at all like fighting. While receiving treatment for oesophageal cancer, Christopher Hitchens says in his book ‘Mortality’ “… you feel swamped with passivity and impotence: dissolving in powerlessness like a sugar lump in water.” And for those overwhelmed by this torpor, the failure to fight leads to frustration and depression in sufferers and relatives alike.

Recently the British Heart Foundation launched its own military campaign: ‘Fight for Every Heartbeat’. It seems that these days every charity needs a war cry to successfully raise funds. “We're fighting cardiovascular disease through world class research”, they claim. Conjuring up a vision of laboratory workers clad in battle fatigues and armed guards protecting their secrets. Yet nothing could be further from the reality of medical research whether it is investigating a cure for cancer, heart disease or any other ailment. The systematic testing of new treatments, the rejection of failed therapies and the cautious introduction of new ideas could hardly be described as a war. And I have yet to meet a medical researcher who feels that they have enlisted in an army.

Unlike cancer sufferers, you seldom hear people with heart disease speak of fighting their illness. But strangely this is a disease worth fighting. If you stop smoking, lose weight, take more exercise, eat a healthy diet, overcome your distaste about taking regular medication and you can significantly prolong your life expectancy. This is just one example of many illnesses where a change in lifestyle and mental attitude can result in a positive outcome both in terms of preventing disease progression and improving quality of life. Sadly, cancer is not one of them.

That’s not to say that you cannot achieve great things following a diagnosis of incurable cancer. Take Kate Granger for example. Based on her own pitiful experiences she has launched a highly successful Twitter campaign (#hellomynameis) to encourage health care workers to introduce themselves by name when they first meet their patients. I was amazed when she told me this hardly ever happened when she was treated as a patient in the hospital where she also works as a doctor. Her campaign “…to encourage and remind healthcare staff about the importance of introductions in the delivery of care” has swept across the country and been adopted enthusiastically by most hospitals in the South West including my own in Exeter. She goes on to say; “I firmly believe it is not just about knowing someone's name, but it runs much deeper. It is about making a human connection, beginning a therapeutic relationship and building trust. In my mind it is the first rung on the ladder to providing compassionate care” But Kate is not really fighting her cancer, just making the best of what life is left to her. And isn’t that what we all should do, cancer or not?

Western Morning News 23rd September 2105

Private practice is unethical and doctors should give it up

Posted on May 5, 2015 at 11:15 AM Comments comments (0)


Profit rather than need is a poor driver of clinical decision making, writes John Dean. Private practice also directly affects the care that NHS patients receive, he says—which is why he’s stopped doing it

Ask any smoker: the last person they want to be with when lighting up is someone who has just quit. I sense a similar discomfort among some of my colleagues now that I have given up private medical practice. Like a lapsed Catholic shunned by the priesthood, I have become an apostate.

I have always been ambivalent about private practice, and I had become increasingly uncomfortable about my own involvement. I realised that, in all conscience, I could not go on with it. No matter how high I set my own moral and ethical standards I could not escape the fact that I was involved in a business where the conduct of some was so venal, it bordered on criminal—the greedy preying on the needy.

The business of medicine and the practice of medicine are at odds. Private medicine encourages doctors to make decisions on the basis of profit rather than need. When confronted with a choice between two treatment pathways in equipoise—one that earns the doctor no money and the other with a fat fee attached—that conflict is stark. I cannot say, with hand on heart, that I have never chosen the second option.

Money is at the root of it all

So why did I do it? To begin with, I decided that I needed the money to renovate the house, educate the children, and so on. And I was sure that I could keep the private work separate from my NHS work. I saw private patients after hours and slotted in operations in my free time. But it became increasingly difficult to keep the lid on the private jar as the contents expanded, and some spillage was inevitable.

I wasn’t so much earning a living as earning an earning. Of course, the rewards from private practice were not entirely financial; I could spend more time with these patients, and I met some colourful characters and made good friends, which would not have happened if I had restricted myself exclusively to NHS work. But the inescapable fact is that money was at the root of it all. This is strange, because I never hankered after a Maserati car or a chalet in the Swiss Alps. And I’m not attracted by the promise of “fine dining”—I’m more of a chicken balti man.

Private work also has direct adverse effects on the NHS. A consultant cannot be in two places at once, so time spent in the private sector deprives the NHS of a valuable resource. Private medicine is a lonely place; you do not have the support of a team, as you have in the NHS. It is also difficult to discuss problems with colleagues—after all, the problems are yours, and you are being paid to sort them out. In the private sector your NHS colleagues are usually your competitors.

And, let’s face it: the whole business is largely a con. Patients think that paying must mean higher quality medicine, but—like paying more for shampoo with added vitamins—the promise is far greater than the reality. Rich and famous people may use private facilities to shelter from the public gaze; for most “ordinary” private patients, though, the main advantage is simply to jump the NHS queue. Private hospitals are like five star hotels, but for the most part they are no place to be if you are really sick.

Cognitive dissonance

The most pernicious aspect of private medical work, however, is the indirect effect it has on a consultant’s NHS practice. It is difficult to justify subjecting private patients to unnecessary tests and treatments if you avoid doing the same to NHS patients. So, to ease the stress of this cognitive dissonance, you have to operate the same system in both wings of your practice. Also, private practice creates a perverse incentive to increase your NHS waiting times—after all, the longer they are, the more private practice will accrue. Hence, specialties with short waiting times, such as oncology, offer little private work. Jealousy over private income is a major source of conflict between consultants in many hospitals.

I know what some will be thinking: what’s wrong with doing extra work in your own free time? If I had done a paper round or taken a Saturday job, wouldn’t that have been the same? Well, the work might have worn me out, but there would be no other conflict with my main business.

I don’t miss private practice. The release of the burden is liberating. And I find that the time I have gained is much more valuable to me than the money was. Is it a crass hypocrisy, though, for me to sit atop the pile of money I earned and pretend to have the moral high ground? Maybe, but I wish I hadn’t done it. Perhaps it would have been easier if I had not been allowed to. Perhaps the rulers of healthcare should draw an uncrossable line between private and public medicine and tell doctors to choose: namely, that they cannot work on both sides of the divide.


BMJ 2015;350:h2299 5th May 2015



Postscript

Opposition from the medical profession to my BMJ article seems to take two forms; firstly (and most commonly) there are those who believe it is perfectly possible to behave ethically in private practice. They almost all accept that conflicts exist and can name doctors who have abused the system, but it does not happen to them. Many express either pity or scorn for me that I lacked the moral fibre (which they hold in spades) to resist the substantial financial incentives.

Secondly, there are a few who simply cannot understand my misgivings. Private practice is a business. And like any business, the name of the game is to make as much profit as possible. As long as the police and the GMC are not interested in your affairs, what’s the problem? Go ahead and make as much money as you can.

I do not hold strong views on healthcare models in other countries apart from the general comment that anyone who consults a doctor working on a fee for service basis faces a dilemma, whether the doctor’s main focus is on the patient’s health or their chequebook. This statement is often greeted with outrage but it seems self-evident to me. I accept that most patients across the globe face this dilemma.

Also I am not unduly concerned about doctors who devote all their time to private practice. My main point is that it is difficult to work in both the private and public sectors at the same time. There are two further reasons why I believe this to be unethical, but did not have space to mention in my article. Firstly, it divides the profession, splitting us into the ‘haves’ and the ‘have-nots’. Is it purely coincidental that the specialties that have the greatest recruitment problems are those where the opportunity for private work is very low or non-existent? And yet these disciplines (emergency medicine, geriatrics, acute medicine, palliative care etc.) are exactly those that desperately need more doctors to cope with the ever-increasing tide of emergency admissions to hospital and care for our aging population.

Secondly, it divides the medical profession from the allied professions (nurses, radiographers, ODA’s etc.). A consultant carrying out a private procedure in an NHS hospital will receive a substantial fee, whereas the team assisting him will be paid standard NHS rates, even if this procedure is done outside normal working hours. A bag of doughnuts doesn’t really address this imbalance.

My comment that private practice ‘…is largely a con’ has proved particularly inflammatory, I cannot see why. For sure, if you want to have your piles fixed in a facility with a private room where you can order a bottle of claret with your evening meal, you will not get this on the NHS. But if you really believe that private hospitals offer safe, quality care I would urge you to read the https://chpi.org.uk/wp-content/uploads/2014/08/CHPI-PatientSafety-Aug2014.pdf" target="_blank" rel="nofollow">CHPI report  and think again.

Referral Mismanagement Centres (Dirty DART)

Posted on November 22, 2013 at 9:45 AM Comments comments (2)


 

The evidence seems quite clear. Referral Management Centres (RMC) do not improve access, they increase rather than reduce costs and they preferentially target high referrers from primary care, not the low ones1. I bet you if you challenge your local RMC with these facts, they will say; “yes, but we are different”. But they’re probably not.

 

Referral rates to 2 week wait clinics can vary tenfold between GP’s working in the same practice. It drives those of us who work in these clinics nuts. The rapid access chest pain assessment clinic (RACPAC) I help run has rules that are clear and simple, they are printed on the referral form...send us patients with recent onset chest pain, suspicious of angina. But the majority don’t have symptoms that sound remotely like angina, some have had them for years (and been thoroughly investigated), and some have no chest pain at all. I feel like a greengrocer whose customers keep asking for half a dozen pork chops. What’s worse, when I recently queried a referral from a GP, I discovered that it was never his intention to send them to RACPAC at all. The RMS did what it was designed to do and redirected the referral, “against my wishes” and quite inappropriately. But, that is only half the problem. Who is hunting out the low referrers hoarding scores of imperfectly treated patients who should be offered the opinion of a specialist?

 

I have yet to hear a satisfactory answer to the question “what’s wrong with GP’s sending referrals directly to named consultants?” The smart GP soon twigs that the specialist with the shortest waiting time isn’t necessarily the most efficient. But to the managers we are all the same, no one is primum inter pares. The RMS distorts communication between health care professionals, but rather than hang their heads in shame, they seem rather proud of it.

 

Last year I paid my local RMC (Devon Access and Referral Team or DART) a visit and was introduced to the six band 3 clerks who man the phones for cardiology referrals (no really, six, for cardiology). They were clearly dedicated to their work and told me how difficult they found it to tell patients who ring up that their appointment to see the cardiologist won’t be for 3 months “but ...I’ll be dead by then”. I left downhearted. DART costs about £1.5 million a year to run and it’s reasonable to ask if this represents value for money. I think not. How easy it would be to improve our hospital service for GP’s and patients alike if this call centre were closed down and the funds redeployed to the front line.

 

Perhaps I’m just jealous of their riches? But whether by accident or design a fault line has opened up between primary and secondary care and I can feel the weight of the RMC hammer driving the wedge in further.



BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7014 (Published 22 November 2013) Cite this as: BMJ 2013;347:f7014



Ref 1. http/www.kingsfund.org.uk/publications/referral-management

 

The language of medicine

Posted on November 17, 2013 at 5:55 AM Comments comments (0)


Last week I lived the dream. A visit to the library doesn’t sound like much of a dream, but I was off to lay my hands on William Harvey’s original text on the circulation (Ref 1). The importance of this book, marking the dawn of clinical science, had inflated in size in my mind’s eye to that of a mighty tome. In reality it is tiny, like the pocket sized reference books I kept in my white coat pocket as a junior doctor. The librarian warned me that the book was badly foxed, but the discolouration of ageing was not the reason I found it difficult to read – it is, of course, written in Latin. Fortunately, she had the good sense to leave me a copy of the English translation published a few years later.

As a registrar I worked with an academic who devoted his life to anglicising anatomical nomenclature. So, atria became atriums. “We don’t wait for the croci to bloom in spring, do we?” was a typical challenge. The fossa ovalis became the oval fossa (but why not the oval ditch?). It was a bold effort, but one that has (so far) largely failed.

So it’s hardly surprising that Latin is still part of the everyday lexicon of medicine. I occasionally see ‘discharge mané’ written in the notes. (The acute accent presumably to distinguish the Latin for morning from the hair on a horses neck).

Every profession has it’s jargon and I can see how discussions between doctors must seem arcane to the outsider. My own job involves regular meetings with clinical geneticists. It’s like talking with a group of Norwegians - they are perfectly capable of speaking excellent English but when they speak amongst themselves, the language is impenetrable.

But there is a new language of medicine that many doctors struggle to comprehend - management speak. Woe betide those who cannot translate it, you might miss the vital meeting to discuss allocation of junior medical staff, hidden in the email entitled; ‘Human resources: blue sky thinking and horizon scanning event’. In the management speak world we ‘revisit’ places we have never been to. We are given ‘toolkits’ to ‘drill down’ in ‘workshops’ but there isn’t a spanner to be seen. Undefined acronyms (UNAC’s) are liberally sprinkled into the mix. The end result is an indecipherable word salad of mixed metaphors and gobbledygook that is rarely challenged. I once introduced myself at a management meeting as ‘director of cardiovascular enablement and excellence’. Some nodded sagely, no one stopped to ask what on earth I was talking about.

In Harvey’s day Latin was the international language of medicine, an aid to universal communication. Management speak appears the polar opposite. Despite it’s comic absurdity it represents a pernicious and conceited attempt to manufacture a technical lexicon by those with no specific skills. Or am I just picking the low hanging fruit?

Ref

1. Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus, William Harvey,1628, Frankfurt (see it for yourself at www.rarebookroom.org/Control/hvyexc/index.html)

The generals strike

Posted on November 11, 2013 at 6:05 AM Comments comments (0)


Like dinosaurs, there was a time when general physicians ruled the earth, or at least the acute hospital. A consultant’s power and status was proportional to their involvement in the medical take. But the climate changed, medicine became increasingly complex and specialists bred prolifically so now the generalists have become an endangered species.

From the brink of extinction, the society for the preservation of the generalist (aka The Royal College of Physicians), has come up with a master plan. It’s time for the generals to strike back.

Conscious of the impending perfect storm of an ageing population, ever increasing hospital medical admissions and an inability to train sufficient numbers of acute physicians and geriatricians to look after them (REF 1), the RCP set up the Future Hospital Commission (REF2).

Chaired by a retired general physician, supported by a team heavily represented by general physicians and with an operational lead who is professor of respiratory intensive care in a hospital that only admits patients with heart and lung disease (but still identifies himself as a general physician). Their solution to the crisis looming in acute hospitals is ... yes, you guessed it, reincarnate the general physician.

Opinion is divided. Advocates of this proposal point to the USA where a new species of ‘hospitalists’ has been successfully created to fill the void in generalism in their hospitals (REF 3), but this is a country where by and large ‘primary care’ is what patients get from the first specialist they visit. Comparisons are difficult and If we plan to model the new NHS on healthcare delivery systems in the USA, we really are in trouble.

One fellow of the College wrote “I have always believed in seeing a doctor first, specialist second”. Brave talk. I would like to see him shooing away the cardiologist when he is admitted with a heart attack.

So who will become the generalists of the future? Answer; everyone who trains as a hospital physician (Ref 4). If you thought becoming a dermatologist would allow you to escape GIM, think again. Scrap your plans to become an oncologist if you mistakenly believed your future would be spent looking after patients with cancer. You will be expected to do your share. It’s a bit like the task of cleaning out the latrine; very few really want to do it (REF 5), so we all need to roll our sleeves up and get stuck in. So, all physicians will have to be accredited and maintain competence in their speciality and GIM.

However, as a patient your outcome is likely to be better if you are cared for from the outset by a relevant specialist (REF 6). So why not concentrate the acute facilities in a smaller number of hospitals to allow larger teams of specialists (including geriatricians and acute physicians) to provide the front door service for the acutely ill? Unless politicians loosen their grip on the NHS this will not happen. MP’s will instinctively oppose hospital closures in their patch regardless of any health gain that might accrue from doing so. Perhaps dinosaurs really do still rule the earth.


Refs

  1. Hospitals on the edge
  2. The Future Hospital Commission
  3. BMJ 2012;344:e652
  4. www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf
  5. BMJ 2012;344:e2240
  6. http://www.bcs.com/documents/37E_BCS_Press_release_March2013.pdf

Mandatory Moaning

Posted on October 9, 2013 at 11:55 AM Comments comments (0)


The contrast could not be sharper between the pleasure I get from teaching junior doctors and medical students, and the ennui I often have to endure in the training sessions I am compelled to undergo to help them learn. Recently, I attended a two hour session of mind numbing tedium, one of five I will have to complete to be deemed competent as an educational supervisor. But there will be no measure of my skills on completion to assess how much this experience has improved me.

The facilitator’s narrative had an anaesthetic effect on many of us, it was as if someone had sucked all the oxygen out of the room. My fellow consultants suffered this torment in many ways, some simmered slowly with rage, like lids rattling on saucepans. Others tried to break the spell of paralysis by speaking out—but this just prolongs the suffering for the rest of us. A few looked terrified that at some point the facilitator might ask them to dance the word “education.” I was left wondering why it was that those who are charged with teaching the teachers often do it so badly?

The next day I met my ELF. I asked her how long she had been a fan of Tolkien, but the “essential learning facilitator” said she that she was here on serious business and handed me a list of the trust’s mandatory training sessions that I have failed to complete this year—three out of 23. But look on the bright side: consultants are not expected to complete the clinical waste management module this year. Just as well. What would the public think about their money being used to pay brain surgeons to witness a demonstration on the correct way to flush a toilet?

Mandatory training is a growth industry, and after Francis’s inquiry, how long will it be before we must take an online module in compassion awareness? The subjects are limitless and have become increasingly intrusive into consultants’ clinical work.

My solution: set aside the last 10 minutes of every session for whingeing. This could be about the relevance of the session or how to improve the delivery, but equally we could branch out into moaning about hospital management or even the state of the NHS. Come on: let it all out; vent your spleen; no topic should be off-limit. How much of this essential learning has a real impact on the care we provide for patients? And that the session on how to lift a box of paper towels was rubbish.

Mandatory moaning . . . there, I feel better already.


BMJ 2013;347:f5968  9th October 2013

Bibliotherapy

Posted on July 25, 2013 at 6:35 AM Comments comments (0)


I probably shouldn’t do it at my age, but I do love music festivals. Sure, my interest in sex, drugs and rock & roll has been whittled down to two but the eclectic mix of music, poetry, comedy, dance and the outright zany always hits the spot. This year as I strolled around the fields of Latitude in my festival attire and spray on monkey tattoo, I stumbled on an old ambulance, a relic from the 1960’s. At first glance it looked like a scene from one of the medics’ reviews that I remember so well, I fully expected a medical student to explode from the back of the vehicle armed only with speculum, sigmoidoscope and excessive profanity. But no, this is the bibliotherapy clinic - serious business. I booked an appointment and arrived at the allotted time, but like any proper doctors’ surgery they were running 20 minutes late - I understood. Eventually I was ushered into the back of the ambulance by the nurse-receptionist and was greeted by the ‘doctor’ poised like a latter day fortune teller.

The therapist in the white coat (hasn’t she heard?) was Ella Berthoud from The School of Life and co-author of ‘The Novel Cure: an alphabetical list of ailments with their literary remedies. After a potted life history and résumé of my current ailments, Ella gave me a prescription of reading material. No, not an unreadable stack of information leaflets, but 5 novels.

I have dabbled in bibliotherapy myself. I once suggested to a patient keen on homeopathic treatment for her heart disease that she read ‘Bad science’ by Ben Goldacre. She retaliated with ‘Bad Pharma’ by the same author. Touché!

To help me deal with my melancholia, Ella suggested I read Mikhail Bulgakov’s ‘A Country Doctor’s Notebook’. Perhaps reading about a doctor’s life in early 20th century Russia might make mine in the 21st century NHS seem less arduous. As a balm for my spiritual uncertainties; a dose of ‘Quarantine’ by Jim Crace. And the antidote for middle aged medical blues; some scalpel sharp Finnish wit from the pen of Arto Paasilinna in ‘The Year of the Hare’. All of these treatments can be bought over the counter and some are available in tablet form.

This is good medicine; there are no unwanted side effects to worry about and it seems unlikely any harm will accrue from exceeding the prescribed dose. But, as always, you should not take someone else’s medicine for your own self diagnosed maladies. I was warned that “...when read at the right moment in your life, a novel can - quite literally - change it”. So don’t read my books, that’s my prescription. Get your own.


July 25th 2013


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