Boreal B[l]og

Twenty years ago, medical director of a hospital, I took a call from a woman who wanted to know how many Abdominal Aortic Aneurysms (AAA) her husband’s surgeon had repaired the prior year at our facility.  She asked a good question, because the surgery is difficult, fraught with risk, even when done electively, which in this instance it would be.  Too often, it is done after the aorta ruptures.  My cousin’s husband died of a ruptured AAA; I have dealt with the issue emergently, and it is difficult to control the bleeding while simultaneously repairing the vessel.

I didn’t know the answer.  Therefore, I had no idea her husband’s chances of survival, how long he would likely be hospitalized, or his condition six months later.  We didn’t track that.  It took me four years to get the hospital to track outcomes from cardiac surgery, after I exploded one night in the ICU saying that I had been consulted 26 times in 270 open heart cases in one year.  Consulting a neurologist after a heart case usually doesn’t bode well.

I mention this, because AAA is one of the outcome measurements Leapfrog uses in determining how well a hospital performs.  So is Aortic Valvular Replacement.  The Tucson hospitals that used Leapfrog scored no better than “C”; one scored “D”.  Some of these hospitals had marketed themselves as being “one of America’s top 100 hospitals.”  It seemed that they were not quite as good as they thought they were.

Leapfrog tracked drug errors, too, and no hospital in Tucson scored better than “C”.  On 2 May 2002, I met with administrators at University Hospital in Tucson to outline my reporting program to reduce medical errors.  A year earlier, I had met with their cardiac surgery program to help track outcomes better.  I can’t believe I was so naive to think that I, who had practiced, been an administrator, had a Master’s in statistics, and 2 months earlier had written an op-ed on an error reporting system we needed in medicine would take on Big Hospitals.  Capitals mine.

Both groups wanted to know, in an unfriendly tone, who I was.  Being from the same city was a minus; had I been from outside, I might have had more credibility.  It would have helped if I were good-looking, exuded charisma, and showed glossy paper with colorful bar graphs, rather than having sound ideas and a quiet demeanor.

Needless to say, the cardiac surgery program wasn’t interested, and I was assured, that second of May, that University Hospital had “one of the best safety records in the country.”  They gave me no data.  They wanted to know what software I would use. I didn’t need software; I needed reports of errors in order to understand them better.  Unfortunately, computers and charisma mattered more to them.

Leapfrog was initiated by a group who had the smarts, the looks, the networking ability, and the leadership skills I lacked.  My ideas were ahead of theirs.  In 1974, I was counting outcomes in medicine when I was an intern.  I was selecting my surgeon to do carotid surgery in the mid-1980s, based upon his outcomes.  I raised concerns about our cardiac surgery program in 1990.  I wasn’t surprised that hospitals were graded “C.”

Every member of my immediate, now small family, has suffered from a medical error.  People make mistakes.  I accept that.  People should learn from them, too, which they often don’t.  For years, we had lousy data and lousy tracking systems.  No, we had no data and no tracking systems.  We hadn’t a clue, and we let Big Medicine, called the Joint Commission, dictate what hospital quality was.  I met with the Joint Commission, too, on 14 August 2001, in Chicago, at my expense.  They were quite interested, so they said, but I never heard again from them.  No e-mails, no calls, no response to my written requests, nothing.

It takes 30 seconds to compose and send an e-mail saying one is not interested.  They weren’t  too busy.  They were rude, arrogant, and wrong, as wrong as Condoleezza Rice had been 8 days earlier and the Bush administration would be four weeks later.  The only difference is a lot more people die from medical errors every year than died on 9/11.  We just don’t know how many.  Our estimates are bad, and the margin of error of those estimates is seldom given.  That violates a basic rule of statistics.

We should be tracking outcomes of common procedures in medicine.  When I broke my hip in an accident, the surgeon had no idea I had done well until I wrote him.  I fractured my fifth metacarpal, had a cast for four weeks, and told that alcoholics often took off their casts with no sequelae.  When I was told I needed two additional weeks of the cast (which did not change the angulation of my metacarpal), the comment my father made was “that is what your doctor learned to do where he trained.”

“Why?” I asked, “don’t we know whether somebody with a broken metacarpal even needs a cast?  Why don’t we know the optimal time? Do metacarpals heal depending upon geography?”  This is not a rare injury.  If we don’t need a cast, wouldn’t that save money and time?  How many other conditions don’t we know the results?  Perhaps some shouldn’t do certain procedures, like colonoscopy, lumbar punctures, bronchoscopy or angioplasty.  How many of these have you done, doctor?  And what happened to the patients?

We physicians like to say we are scientifically trained, and non-physicians don’t have data to show they make a difference.  Where are the numbers?  What should they be?  And what are we doing to achieve those numbers?   Too many ideologues argue using rhetorical questions, which I find annoying.  A statistician’s job is to ask questions.  Ours are good questions, answered with data, uncertainty and appropriate inferences.

We don’t need high speed computers to measure outcomes.  Pen and paper work just fine, with a lot of curiosity, and an open mind.

“Dr. Smith, lay to the bridge.”

John, my hall mate back aft on the O3 level, cringed, and then let loose with a few epithets.  He and I had the two aft staterooms separated from the rest of “Officer’s Country” by a door.  It was colder there when it was cold, like off Korea in March, and it was hotter there when it was hot, like in the Philippines in June.  But we were mostly left alone, had an exit door aft, with a good view of the ship’s wake, when we weren’t working.

The numbering system for decks started with the Main Deck, then 2,3,4 going below or down.  Going topside or up, it was O1, O2, O3, to the uppermost deck, our bridge on the O4 level.

John cringed, because “lay to the xxx,” was used only to call enlisted personnel. “Your presence is requested to xxx”  was for officers.  Put succinctly, it was a breach of etiquette. The Navy was polite.  As coarse as the day-to-day language was, contributing to my current curse word vocabulary well into three figures, there was politeness.  I had to salute senior officers once a day on board, but only if I were covered, or wore a hat.  At sea, hats were not required, although most of us wore ball caps.  Navy men never salute uncovered.  Covers were not allowed in sick bay; they were required on the bridge.  In port, in uniform, one was always covered outside.  I learned these rules fast; I had to.

Coming aboard, one saluted twice, once aft, where the colors (flag) flew, and once to the officer of the deck, concomitantly saying, “request permission to come aboard.”  The procedure was reversed when one disembarked.  One needed an ID ready, too.  Ashore, one saluted any senior officer, holding it until the salute was returned. We called senior officers “Sir,” but on board, the executive officer was “XO,” the Captain was “Captain,” or plain “Cap’n”.  He didn’t mind.  When the Captain appeared, the first person spotting him said, “Attention on deck,” and we all jumped up.  The Captain would say “at ease,” and we would sit down.  This was formal stuff.  When the XO appeared in Sick Bay, I stood up.  It showed respect.

In correspondence with junior officers or enlisted men, we wrote, “Your attention is directed to xxx.”  To senior officers, we wrote, “Your attention is invited to xxx.” To this day, I take that and three other things with me from the Navy: short hair, my shirt buttons lined up with my pants zipper, and use of the word “Sir.”

I mention all of this, because the other day at the local pharmacy, where I get my medications, I stood inside the privacy line, painted on the floor.  Privacy is a big deal these days, except everybody knows everything about me, so I don’t really believe in it.  I may not see a prescription, but even with bad ears I hear what people are getting.  In any case, I was chided with a “Get back behind the privacy line.”

Gee, sorry that I am old, new in town, and honestly didn’t see the line, since the letters were faded.  I got half my medicines, since one was still not ready, five days after I dropped off the prescription, another problem with today’s “just in time inventory.”   I decided to return the next day.  As I left, I heard , “Thank you, Michael,” and cringed.

I don’t like strangers, especially the young, calling me by my first name, and I don’t like it when people on the phone with whom I speak ask me how I want to be called.  You call people Mr., Mrs., Dr., or Ms.  It is default.  You don’t ask, you do it, and you ought to know that.  I still call the former head of neurology where I trained “Doctor.”  He is in his 80s, and he has always been “Doctor” to me.  The past Executive Director of the Medical Society always called me “Doctor,” although we spoke on a lot of issues as friends.  It’s a sign of respect.

I don’t push the issue, but maybe it’s time to.  If you are too polite, you will be given an honor (yes, it is) to call someone people by his or her first name.  One should not put people in an uncomfortable position of asking how they want to be called, which happened with me with AARP.  How about “Mr. Smith”?  It is always in style, never wrong.

Thirty years ago, I flew over to San Diego to attend my Chief’s retirement.  I stayed in my stateroom one last time. I could have called both the Captain and the XO by their first names, for I was a civilian.  I could have called my chief by his first name, too.  But I didn’t.  I never had.  These people were “Captain,” “XO”, and “Chief”.  They were, and they always would be.

I discovered in civilian life that “Sir” is a powerful word showing respect for the office or age, but properly pronounced may be used to show distaste for the individual or task.  I learned the last to more than one lawyer’s chagrin, when he thought he was dealing with an arrogant doctor: my use of “Sir” with the appropriate tone was devastating.

“Sir, could you please step behind the privacy line?  Thank you.”

“Thank you, Mr. Smith. Good-by.”

“Mr. Smith, may I outline the benefits of our program?”

Notice the “Sir,” “please”, “Thank you,” “Mr.” and “may I”. These seven words exude politeness.

Many gun owners have told me that gun ownership will create a polite society.  I disagree.  I didn’t think the 19th century was so polite, the 20th or especially this one, while gun ownership has increased rapidly.  People must be scared of something.  Congress won’t even fund the CDC to find out why.  If we had 25,000 people dying from a new virus every year, you bet the CDC would get money.

Ironically, one of the most polite places where I worked was one where rifles were locked up, we enforced the Uniform Code of Military Justice with Captain’s Mast (non-judicial) more than courts martial, and fights were almost always with fists, even in liberty ports.   I treated a lot of STDs; I honestly can’t remember treating even a knife wound.

But please, dear reader, bear with me, for my memory is no longer good.  I might be mistaken.  But not about gun violence.

April 15, 1994, was a memorable day:  The executives of tobacco companies stood before a congressional hearing, under oath (Italics mine), and said these words, among others:

“Cigarettes may cause lung cancer, heart disease and other health problems, but the evidence is not conclusive.”

At one point during the hearing, Rep. (now Sen.) Wyden presented data from medical groups and a 1989 Surgeon General’s report on the health consequences of smoking, asking each executive if he believed that cigarettes were addictive. Each answered no.  I saw that on TV. (Italics mine.)

“What the anti-tobacco industry wants is prohibition,” said one. “We hear about the addiction and the threat. If cigarettes are too dangerous to be sold, then ban them. Some smokers will obey the law, but many will not. People will be selling cigarettes out of the trunks of cars, cigarettes made by who knows who, made of who knows what.”

I know what: carcinogenic and addictive substances, same as now.

Despite earlier denials, a Philip Morris study that suggested that animals could become addicted to nicotine was suppressed in 1983 and 1985.

Wow, if cigarettes are banned, only outlaws will have cigarettes, and as bad as firearm lack of regulation in our society is, the magnitude of deaths is at least 20-fold more in the case of cigarettes. (Italics mine.)

The executives stated that tobacco companies could control the amount of nicotine in cigarettes, using these blends for flavor.

Or to addict people.  Turns out smoking is not a character flaw, but is an addiction, like high fructose corn syrup, but the latter is for another time.

Pressed by the subcommittee’s chairman, Mr. Waxman, and Representatives Wyden and Synar, (all Democrats), the companies agreed to supply many private company papers, including all the research done by the Philip Morris researcher whose scientific paper on addiction was blocked from publication by company executives.  (Italics mine.)

When one executive said that all products, from cola to Twinkies, had risks associated with them, Mr. Waxman replied, “Yes, but the difference between cigarettes and Twinkies is death.”

“How many smokers die each year from cancer?” Mr. Waxman then asked.

“I do not know how many,” was the reply, adding that estimates of death are “generated by computers and are only statistical.”

If computers are banned, then we won’t die, I guess.  (Italics mine.)

Mr. Waxman asked, “Does smoking cause heart disease?”

“It may,” Mr. Johnston said.

“Does it cause lung cancer?”

“It may.”

“Emphysema?

“It may.”

Could the world be flat?

It may.  (Italics mine).

The term “only statistical” underpins science. We stopped the study on the effectiveness of polio vaccination because of statistics proving the vaccine was effective.  I am polio-free today because of that.  I received the Salk vaccine when it was first available; I was in the first cohort who received the Sabin vaccine.  We have confidence intervals stating with high (not complete) confidence that global climate change is occurring.  I have never seen one CI saying that it isn’t.  (Italics mine.)

We didn’t regulate tobacco enough, allowing “market forces” and “getting government out of business” to handle such issues.  The result has been as many deaths from tobacco-related illnesses every year (Italics mine) as the number of Americans who died in World War II.  Stalin said that “One death is a tragedy, one million a statistic.”  Yes, it is a tragedy when it involves a death at 40, or 53, my father-in-law, or my brother.  This should be a national outrage.  Wow, I can make a case for anti-government being in line of Stalinist thinking.  (Italics mine, but reasoning probably faulty.)

The incredibly rich tobacco company executives lied in front of Congress, suppressing evidence that went back decades.

That, Mr. Boehner, and Mr. Cantor, and Mr. Joe Tea Party, is why we need federal regulation.  Without it, people DIE.  (Italics mine.)

We regulate, because left to their own devices, people make a mess of the world.  We learn that early in school when “today, on your break, you will stay quietly in your seats, because a few people abused the privilege by jumping on their desks and screaming.”  You can use whatever you want for what you couldn’t do, but the first seven words in the subordinate clause stay the same throughout our lives. (Italics mine.)

I unsuccessfully tried to regulate medicine.  With no regulations, doctors did piecework and expected to be paid for it.  I remember a few of these doctors.  Those were the “golden days” of medicine, when “Doctor” was “God,” surgeons threw instruments, people cowered, nurses and medical students abused.  I was verbally abused to the point of tears by many doctors and had a retractor slammed on my thumb once.  “The Giants” made mistakes, because they were human.  Their mistakes were covered up, not investigated so we could learn from them. because to rat on a colleague would result in ostracism and no referrals.

My colleagues operated on carotid arteries, with frighteningly bad results, worse than the natural history of the untreated disease.  I counted these and presented the statistics.  I was screamed at and told I had no business to interfere. I was unpopular; however, I did notice that 12 physicians who became my patients never referred their patients to me.  (Italics mine.)  I thought that interesting. We allowed rods and fusion for low back pain, without adequate evidence that they did any good, which with few clear exceptions, they didn’t.

We failed to do what was proven effective to decrease post-operative infections:  inject a specific antibiotic for clean case infections 30-120 minutes before incision.  Easy, right?  In my hospital, we did it 25% of the time, and physicians refused to change.  We couldn’t even mandate the right antibiotic, promoting resistance to stronger antibiotics that some surgeons insisted upon using.  (Italics mine.)

After many years, we finally mandated that only pulmonary physicians, not general internists, could manage ventilators, because the former had better results.  That was strongly resisted, but it was one powerful group against another, not a dweeby neurologist (Italics and individual mine.) trying to change the profession through data and outcomes.

Politically powerful physicians who brought money into the hospital had special treatment.  Facts, outcomes, right or wrong were too often subsidiary.  It had to do with money. (Italics mine.)

My point is simple:.  Every law, every regulation, came because of a reason.  Maybe the law could have been better written, but the fact that there is a law speaks to a reason.  Some person said, “There ought to be a law against…..”

Don’t like regulations?  Neither do I.  Then self-regulated your group, your peers, your city, your country.  Want government out of your life?  Then figure out how 310 million people can each do what he or she wants without upsetting somebody else.  (Italics mine.) Hear that, Mr. Boehner and Mr. Cantor?

I don’t miss second hand smoke.  Nor does my body.  

(Italics mine.)

Despite difficulties with the Affordable Health Care Act, I have had no problem with Medicare, “big government” medicine.  I have, however, had problems with one private insurance company.  I will call it “X,” to avoid any semblance of libel, although I am not telling an untruth.  Part D was enacted by the Bush administration, and while a step forward, I expected perfection, since Bush was a Republican.  I did not expect a “doughnut hole,” cost overruns, and failure to negotiate with pharmaceutical companies.

Anyway, I signed up online with X and a local pharmacy for my two prescription medications.  I used my Arizona address, because at the time I lived there. I soon discovered that I got what I paid for.

I take Drug “A,” 2 mg, 2 pills twice a day, 240 mg monthly.  Drug A has 3 sizes:  2, 5, and 10 mg.  Representatives from company X told me that Medicare regulations limited the number of pills per month to 90, in order to prevent falls, a potential side effect.  This restriction was not true, I later learned.  Rather than to ask my physician for an emergency authorization to take my usual dosage, I procured a prescription for 5 mg, 60 a month, although I needed to take my daily dosage in a different fashion.  It wasn’t ideal, but I could live with it.  Notice that I could take 300 mg a month.  That was a tipoff that Medicare restrictions were not the issue, private business restrictions were.

I called a special number to X and had a 3-way conversation with their clinical pharmacist and their sales representative.  I had no problem with Medicare’s restriction; I did have an issue with the monthly allowed dose, which made no sense.  Knowing the answer, I asked my next question:  How many 10 mg pills may I take a month?  They both answered: “120”.

I continued:  “So, I can’t take 120 pills of the 2 mg dosage a month, or a total monthly dosage of 240 mg, right?”  They agreed.

“But,” I continued, “I can take 120 pills of the 10 mg dosage a month, 1200 mg total, 6 2/3 times the allowed 2 mg dosage, right?”  I teach high school math; I knew this stuff when I was about 6.

There was sudden silence on the line, then, “we need to talk to our supervisors.”  In other words, apparently somebody at X realized the restriction of dosage for the smaller amount did not obviate the issue of prescribing a larger number of pills for the larger dosage.

That is Part 1.  On 7 March, I went to the pharmacy to get my prescription, only to be told I had been “disenrolled” from X on 28 February.  No reason was given.  Nobody at X answered the telephone on the weekend, so now I was without Part D coverage.  Suppose I were 75, on chemotherapy, needed a key anti-arrhythmic, didn’t have money, and had moderate dementia?  These things occur, even to elderly Republicans.

Becoming concerned about coverage, I called AARP-recommended United Health Care, spoke to a person, and enrolled, effective 1 April.  I will have no coverage during March.  Fortunately, I have enough medication.  If I didn’t, and the medication were expensive, I would be in trouble.

One may change address for coverage of drugs under Part D, and I planned in March to inform X that starting in April, I would be living in Eugene, not Tucson.  I don’t know how X got my Eugene address, except private information is easy to find nowadays.  Amazon, most of West Africa, and every medical organization worldwide appears to have mine.

On 14 March, I received a letter from X, dated 7 March, saying “Your Prescription drug coverage ends soon” .  In fact, when I got the letter, I was already two weeks without coverage; when the letter was written, I was already a week without coverage. Given the letter was written in the future tense, I wonder how X treats the past.

I quote part of the letter, my comments in bold:

“Thank you for letting us know about your change of permanent address”  (I didn’t.  I would have in March, had I not been disenrolled.)

“You now live outside X Prescription Drug Plan service area. To be a member of our plan, you must live in X’s service area, although you may be out of the service area temporarily for up to 12 months. How did you know the address wasn’t temporary? For that reason, we’ll disenroll you from X’s Prescription Drug Plan on 02/28/14.  “Because” is a better word than “for” in this instance.  The tense was wrong, they waited several days to send the letter, it was dated a week after the fact and took 7 days to travel 2000 miles.  

X did nothing illegal.  On page 107 of my coverage document, the wording was quite clear.  It wasn’t in fine print, but I wonder how many people go through these documents word by word, especially elderly folks, who may not understand a lot of these terms.   The individuals involved at X did not appear to know the English language, judging by the tenses; further, they did not mail the letter in a timely fashion, I had no chance to appeal, and without warning, I lost my coverage.  That was not mentioned on page 107.

While the Affordable Health Care Act has become a whipping boy for all that is wrong with medicine, this is an insurance company issue. The one organization that has worked is Medicare.  I suggested two decades ago that we would do well to expand Medicare to cover everybody:  It would be a one page bill, solving many problems. Costly?  Sure.  What cost can one place on not having insurance and being ill?  A lot of people pay that cost, especially the ill person.  Is that what America is about?

Perhaps X is a good company.  In my experience, however, they drop people suddenly, then later use the future tense.  I teach English online to people in 90 different countries and know the difference between the past perfect and future.  Their letter was signed:  “The X Enrollment Team.”  I am old enough to remember the jokes about “the 20 Mule Team.”  This would be funny, if it weren’t so potentially dangerous to the elderly.

I must be careful; “scorn or ridicule” are part of the definition of libel.

When I was a first year medical student, I worked for a neuroanatomy professor 31 years my senior, who became a good friend.  He was still the professor, however.  When I once became upset, he became stern and calmed me down.  When I called a co-worker  “Little man,” (a college nickname), the professor, with the same last name as I, took me aside, told me my comment was demeaning and never to use it again.  I haven’t.

I offered suggestions in his research but never corrected him otherwise. Dr. Stuart Smith greatly influenced me, never knowing he was a big reason I became a neurologist. In 1981, I sent him a card announcing the opening of my practice.  His widow wrote me he had died two weeks earlier, at 63, from a ruptured aortic aneurysm. I wished I had written sooner. I can still hear his booming laugh.

I am now older than he lived to be and have had different experiences with those in their 20s.  One posted an article on Facebook about a scientist who had found a possible breakthrough that “might” help Alzheimer’s patients.  The individual wrote that the man deserved the Nobel Prize, hoping a grandmother, afflicted with the disease, would be helped.

I posted that the key word was “might,” and there was a long way from the lab to clinical practice.  I was measured in my response, not commenting, as I could have, that my grandmother also had Alzheimer’s, my mother died of a rapidly progressive dementia, and that doctors like the limelight, too, so any possible breakthrough is often taken directly to the press, rather than waiting to see whether it will work.  I didn’t add that I had evaluated thousands of Alzheimer’s patients and had seen many possible “cures” appear and disappear.  In short, I tried to inject a dose of needed reality into hope. Taking away hope is bad; giving false hope is worse.

The young person quickly retorted, “No, MIKE (caps added), the key word is hope.”

I am fairly informal about being called by my first name, but the Internet has allowed the young to call elders by their first name and slam them, because it is easier to write something nasty than to say it directly to somebody 40 years your senior.  On the bus, I am often called “Sir”; that is rare online.  I chose to remain silent, showing both restraint and wisdom.  I found the comment disrespectful and am not particularly eager to communicate again with the individual, whom I suspect would not notice.  I was once that age; the person has not been mine.

I never would have dreamt to correct Dr. Stuart Smith by using his first name and thinking I knew more than he did. He would have slammed me verbally, and he was one of the best English grammarians I ever met. Times have changed.

Many scientists want to report they have discovered a possibility that may lead to a possibility that possibly some day might possibly help somebody.  The use of the same base word here is deliberate, for new, safe, effective drug production is a long process.  There are few “miracle drugs” in medicine.  In my training, I learned an adage: “to write anything positive about treatment of multiple sclerosis is a good way to ruin your career.”  Forty years later, the adage is not far off the mark.  I have no doubt we will eventually prevent, stop, or cure MS, but that day is not yet visible to me.

The young person might feel I was too sensitive to take the comment as an insult. As both as a neurologist and as an older person who has seen and experienced far more, I was insulted.  Hope mattered a lot to the person, which I understand; realistic hope, however, based upon a great deal of experience, matters more to me.  Others in their 20s have said worse to me, but they were from other cultures, not familiar with mine, so I gave them more leeway when they said or did things I found appalling.

I can count on the fingers of both hands the numbers of patients in my practice I called by their first name.  I was formal.  I used “Mr.”, “Mrs.”, “Ms.” or “Dr.”    Thirty-five years after I met him, I still call the retired chairman of neurology where I trained, “Doctor.”  I always will. My parents resented being called by their first name.  I was furious when my dying father had a chest X-Ray performed by a technician, referring to Dad as “buddy.”  My father began his career as a science teacher and became superintendent of schools in three cities.  He wrote two science textbooks and could fix cars.  At 90, he was interested enough to see the Sandhill Crane migration; the following year, he explained to two young women why a lunar eclipse occurred and traveled alone to his 70th college reunion.

I think a key difference today is that the young have equal access to information that I have.  They don’t, however, have the same life experiences as I; many do not have critical thinking skills necessary to carefully analyze “breakthroughs.”  In my youth, every cashier could correctly make change, not now.  We learned grammar and how to hold a pen and write, uncommon today.  We called adults “Mr.” or “Mrs.”, less now.

Perhaps I should have apologized for being too old, sensitive and experienced to write what I considered a careful response.  I certainly know how to apologize, but felt then what I did was appropriate.  If not, I’ve had a lot of practice apologizing.  That comes from age, too.

Also from my parents, my wife, and Dr. Stuart Smith.