A Pandemic "Marshall Plan"​?

When World War II ended, a massive global recovery plan was initiated, and we enjoy the positive reverberations of that plan to this day. The dawning of 2021 and the ongoing COVID-19 pandemic call for nothing less than a similar worldwide initiative. Are we truly ready to collectively embrace this humanitarian call to arms?

A "Silver Tsunami" Among The Homeless

We all know that there are millions of homeless Americans of all ages. According to some recent studies, approximately 21 out of every 10,000 citizens is homeless. So, as the population ages across the board, how do we address the fact that a great number of homeless Americans are reaching the time when they should be retiring and enjoying the remainder of their lives rather than struggling on the streets?

Book Review: "Reflections From Common Ground"

"Reflections From Common Ground: Cultural Awareness in Healthcare" by Beth Lincoln, MSN, RN, is a timely and important guide to developing and strengthening cultural competence in the arena of healthcare.

Homelessness: Action or Complicity?

With the recent revelations that the homeless population in New York City is now at its greatest numbers since the Great Depression, we are again face to face with a public health crisis of astronomical proportions.

The Burden of Medical Bills

A recent study released by the CDC (and reported on Medscape and other sites) states the blunt fact that 20% of American households have difficulty paying their medical bills. And the National Center for Health Statistics states that 1 in 5 Americans has lived in a family that could not pay its medical bills in the last 12 months.

The Elderly and Medications: At What Cost Health?

Recently, my elderly mother moved from the Northeastern to the Southeastern United States in order to live closer to my sister. A widow for several years, she is on what would be classified as a fixed income, and her medical insurance premiums and prescription drug plans eat up a great deal of her monthly budget.

When it comes to some of the more pedestrian prescription medications, co-pays can range from just several dollars to perhaps $20 or $30 per month. But heaven forbid that an American elder needs a medication that is not quite so generic in nature, and the monthly payments for such drugs can skyrocket through the roof, wreaking havoc with even the most well-planned budget.

We have all heard stories of senior citizens having to decide between groceries and medications, or turning off their heat in order to pay their health insurance premiums. These stories are not uncommon, and although many of these elders may be under the media radar, we all know that there are still millions of Americans struggling to retain their health insurance, obtain health insurance, or simply get by without any coverage whatsoever.

While the debate about the new health care reform legislation rages on, we must remember that many seniors like my mother are regularly raiding their hard-earned piggy banks in order to pony up enough money to purchase costly (and admittedly life-saving) medications. While the need for pharmaceutical companies to earn money and support new research is understandable, vulnerable Americans like my mother cannot continue to be placed economically between a rock and a hard place and simply offered a pillow of pity as compensation.

I agree that reform is contentious and painful, but so is making a choice between food and prescriptions. When a senior citizen skips a meal in order to fill a prescription or pay an insurance premium, it is once again illustrated that something is wrong with this picture. And when yet another uninsured child misses her annual physical and vaccinations, this flies in the face of the Surgeon General's message of the crucial importance of preventive medicine to the over all health of the nation and its citizens.

I don't have the answer to fixing this enormous challenge that our nation faces, but I can hear in my mother's voice over the phone that this simply has to change. The United States ranks behind many other industrialized nations when it comes to important markers of public health (like infant mortality, for example), and the fact that so many Americans continue to languish without health insurance would be laughable if it wasn't so tragically sad.

Every generation strives to leave a hopeful economic and social legacy for its offspring, and my mother's generation, who lived through the Great Depression, is no slacker in this regard. But when we see octogenarians eschewing good nutrition in order to pay for their basic health needs, we must realize that we are forgetting the sacrifices that our elders made for us in decades past. Change will come, but what cost we pay in the interim certainly remains to be seen.

Swine Flu and the Working Poor

Several times today, the issue came up regarding what a conundrum the working poor face when forced to keep a child with flu-like symptoms out of school for a week.

With the CDC recommending seven days of home isolation for any child exhibiting a flu-like illness, we discussed in staff meeting what a difficult scenario this must be for parents who work in low-wage occupations that offer no sick time or personal time to care for their sick children.

As Barbara Ehrenreich so deftly illustrated in her seminal book, "Nickel and Dimed: On (Not) Getting By in America", the working poor are employed in occupations where not being able to come to work is almost ubiquitously grounds for instant termination.

So, when a single mother of three who cleans offices for a non-unionized cleaning company, she lives in fear of a child falling ill and missing school. Since her other family members also work in jobs they must protect by never missing a day of work, this "nickeled and dimed" wage earner is between a rock and a hard place when the school sends her feverish child home and demands that he or she not return for seven calendar days.

I am in no way stating that the CDC is erroneous in its recommendations for protecting the public from sick individuals potentially infected with the H1N1 virus, but we must not overlook the plight of the poor and the working poor when mandating sick days for children whose parents are at such risk of losing the little employment they have.

Now, government cannot solve every problem for every citizen at all times, but when we are mandating such a strict policy of isolation from school during a time when every person with a job desperately needs to retain that job in order to survive, there is a missing piece to the economic puzzle that must be examined, if not addressed.

Many workers are woefully unprotected from being laid off or fired when they miss a day of work for reasons well beyond their control, and the H1N1 virus may very well prove to be a problem for many workers on the edge of the wayward economy.

Reaching Out To the Margins

Yesterday, I received a call from a young college student with an interest in Public Health who wants to volunteer at our health department. After a telephone conversation and a string of emails, I gleaned that she is from Cape Verde, speaks Cape Verdean Creole (Portuguese married with African dialects) as her first language, and also speaks and understands some Spanish. Thinking quickly, I realized that this is a golden opportunity to utilize this individual's language and cultural knowledge to reach out to the Cape Verdean community in our town. While not as sizeable as our Chinese, Tibetan, Cambodian, and Latino communities, I know for a fact that a pocket of Cape Verdeans are scattered amongst the population, and this young woman may be the key to doing some important outreach to a marginalized segment of our municipality.

The director of our health department is dedicated to issues of racial justice and social equality, and a significant multi-year social justice grant has given our department just the push it needed to bring to life her much appreciated vision. With a part-time worker devoted to fulfilling the social justice grant and a Cambodian outreach worker dedicated to the Khmer community in our area, we are well aware that there are ethnic and racial groups that also deserve our attention.

While public health does indeed involve immunizations and infectious disease surveillance, the 21st century has brought the very enlightened awareness that the control of chronic disease is where we should be focusing in the wake of the 20th century's successes vis-a-vis the virtual eradication of vaccine-preventable diseases such as polio and measles. However, to control chronic diseases and improve quality of life and lifespan, we must also ascertain why and how health disparities occur amongst various ethnic, racial and socioeconomic groups, subsequently taking concerted action to assuage those disparities. From infant mortality to rates of diabetes, people of color are more burdened than their caucasian counterparts. While some genetic differences may account for a small portion of these differences, it has been demonstrated time and again that socioeconomics and the very stress of living in a racist society can indeed have a significant impact on health outcomes. Of this we are now certain, although some are still not convinced.

So, enter my new, young and earnest Cape Verdean volunteer, who is excited that I even know anything at all about her language and culture. When health care professionals and agencies take pains to make contact with marginalized and vulnerable segments of the population, everyone benefits. Gathering data on sub-populations and ethnic groups is a useful and intelligent undertaking which, as a bridge-building exercise, encourages dialogue, communication, and the building of trust. Vulnerable citizens with poor English-language skills and discomfort with American culture are more likely to reach out for assistance and utilize existing services if they feel seen and understood. While a well-meaning white outreach worker without appropriate language skills can make some inroads, a worker who is a native of the target population's country and who speaks the language fluently can make significantly more progress within a community that may feel collectively invisible.

My town may still be white by a vast majority, but our segments of Latino, Caribbean, and Asian citizens is apparently growing by the month. Cambodians, Tibetans, Cape Verdeans, Central Americans---these communities are all growing, and even as their children learn English and quickly become Americanized translators of culture and language for their elders, reaching out to those elders who are less comfortable with the transition to American life is key. I will use this new volunteer energy to my benefit, and to the benefit of our town, our department, and the people who we serve.

Reaching out to the margins is crucial, and as bridges are built, those living on the edges become significantly less marginalized. The margins make us see that we are all more similar than we are disparate, and taking culturally sensitive action in order to serve those who are most vulnerable improves the quality of life for all concerned. The reach of the human heart and its compassion is without measure, and I have seen for myself how magic can happen when our arms are opened wide enough to embrace those who lack our cultural, economic, and social privilege. Our community's diversity is an enormous strength, and our ability to welcome all into the heart of the community speaks volumes about our singular and collective humanity.

(c) 2009 NurseKeith

Temporarily Joining the Ranks

So, dear Readers, as of 12:01 am today, my wife and I are officially uninsured. Caught in that painfully ubiquitous American conundrum, we are both gainfully employed, both starting new jobs (that, admittedly, don't pay exceedingly well), and our new insurance will not kick in until January 1st. With several chronic illnesses between us and a number of medications we take on a regular basis, this could be cause for concern.

Counting our blessings, we indeed realize that, unlike the majority of the other 38 million uninsured Americans waking up this morning, our uninsured status is, in fact, temporary. A month from now, as we ring in the New Year, we will also ring in the renewed security that paying monthly health insurance premiums can bring. Our privilege is not lost on us, but having just been to the emergency room on Thanksgiving Day, I am given pause to remember that life and illness do indeed sometimes happen on their own schedule. But like I've said before, middle class privilege is something we do not take for granted, and our very survival is in no way threatened by this unfortunate but temporary turn of events.

Meanwhile, my incredulous friends in Canada and Europe wonder how such a "powerful" country can leave so many of its citizens in the lurch, many actually going bankrupt when they cannot pay their medical bills. My response is that the United States' free market system coupled with an ingrained Puritan work ethic and "pick-yourself-up-by-your-boot-straps" cowboy mystique leads many mainstream Americans to think of themselves rather than of others, assuming that those who "have not" probably don't deserve it anyway. Ronald Reagan's evisceration of Public Assistance---further decimated by Bill Clinton in the 90's---painted "Welfare Moms" as deadbeats who purportedly birthed children just to get on the dole. We were all expected to make it on our own, and those who didn't were expected to eat our crumbs.

If I sound cynical, it's because there has been a great deal to be cynical about in the last decade of American life. With the economy in shambles, healthcare on the rocks, two never-ending wars, and poverty and hunger on the rise, some healthy cynicism is indeed in order.

So, as the Obama administration revs its engines, I wait patiently along with my fellow citizens, hoping for some change, but admittedly less starry-eyed than many of my brethren. I honestly expect little to change in the next year in terms of the machinations of American healthcare economics, although I do hold out hope that the ranks of the uninsured will somehow be decreased as rapidly as possible. Changing such an entrenched system will not be easy, and some say it is truly impossible with so many economic and political toes to be stepped on. Well, the poor, uninsured and hungry in this country have been repeatedly stepped on throughout the decades, so if the insurance industry cries "foul" as it suffocates, let's simply call it just desserts.

This next month of "insurancelessness" does certainly give me a lot of food for thought. I am grateful that this chapter will be short-lived, but I am all too well aware that, for many others, it is a chapter that seems to never end.

Google Health Advisory Council Misses the Boat

Google, in its cultural ubiquitousness and apparent desire to touch on every aspect of society, has created a Google Health Advisory Council with a mission, as reported on the Google Blog, to "help us better understand the problems consumers and providers face every day and offer feedback on product ideas and development." The announcement continues: "We have formed an advisory council, made up of healthcare experts from provider organizations, consumer and disease-based groups, physician organizations, research institutions, policy foundations, and other fields."

In its infinite wisdom, Google has overlooked many key communities within the broad field of healthcare experts, including nurses. As expected, the Advisory Council is overwhelmingly made up of doctors and executives. With 22 members in all, the Council boasts only five women, and although I cannot say for sure, I am relatively certain that people of color are grossly underrepresented as well. As for "experts" in medical care, where are the patients/consumers, the lay people who struggle with the healthcare system daily? Where are the people on Medicaid, senior citizens, the disabled, the homeless, the uninsured, the underinsured? They are often the real experts, and they are woefully missing as well.

Beth Anderson, RN, editorializes about Google's shortsightedness on NursingLink, and points out that medical librarians are another group of experts who have been neglected by Google in its population of a very limited and narrow Advisory Council. Kim at Emergiblog appears to have been one of the first medical bloggers to speak out about these gross oversights, and I am sure that many more will communicate their disappointment and disapproval to Google in the coming weeks and months. Kevin, MD has also chimed in, adding his voice to the outrage. Here are just a few reactions linked on Kevin's blog. Adding insult to injury, someone from the diabetes community is missing from this "expert" council,which also completely lacks anyone representing the specialty area of mental health, psychology or behavioral science. On the lighter side, Dr. Wes chimes in with an Arthurian twist, while medical librarians voice their disappointment and outrage.

Google may be very talented at gobbling up major slices of the world without swallowing, but in attempting to create an Advisory Council on healthcare, the good folks at Google seem to have choked on their own hubris. Perhaps the feedback will cause some buyers remorse and compel Google to rethink their strategy. Or perhaps they will steamroll ahead with their Ivory Tower council and continue to spurn those from whom we have the most to learn about healthcare, access to healthcare, and the vicissitudes therein.

Are you listening, O Mighty Google?

Communities of Color and Medical Research

Yet another aspect of racial disparity within the medical field has recently come to the fore. The U.S. Department of Health and Human Services Office of Minority Health has launched several initiatives, in partnership with the Baylor College of Medicine, to address the relative lack of access to medical research and clinical trials experienced by communities of color and ethnic minorities. For more information on the EDICT (Eliminating Disparities in Clinical Trials) Study, please visit this site, which is a partnership between Baylor College of Medicine and The Intercultural Cancer Council.

The preponderance of participants in clinical trials for new medications and treatments are white, and this uneven racial distribution of participants in clinical trials can skew research data by failing to reflect the specific effects of new treatments on people of color. One would imagine, for instance, that differences in kidney filtration rates (GFR) and metabolism would certainly offer insights into the relative effects of certain substances on people of different races, and recruiting more members of non-white communities is crucial for this process. As several articles point out, many communities and individuals lose access to potentially valuable treatment, and researchers lose by having precious little data from which larger generalizations and assessments can be extrapolated based upon their racially skewed and biased data. In the end, future generations suffer as important racial and ethnic differences vis-a-vis responses to treatment and disease are lost to the fog of ignorance. It is a lose-lose situation for all involved.

NPR's recent story on the initiative and its potential benefits also touched on the fact that, based on historical experience, African-Americans have learned to be mistrustful of scientific research. It is well known that slaves in the South during the Antebellum period were experimented upon, with gynecological procedures, surgeries and sterilizations performed on female slaves without their informed consent. This would be reason enough for widespread distrust.

Most infamously, the Tuskegee Syphilis Study, conducted between 1932 and 1972 in Alabama, denied treatment to poor, mostly illiterate African-American sharecroppers for their syphilitic condition. Horribly, the men were never informed that they were infected with syphilis, and were duped into thinking that they were receiving free treatment while the government researchers simply tracked how the disease ravaged their bodies. Even after penicillin was discovered to be the cure for the disease in 1947, the scientists withheld that information from the "participants" in the interest of watching how the disease would progress untreated until death. The study was stopped in 1972, and the fallout from this most heinous event in American medical and scientific history led to the establishment of Institutional Review Boards (IRBs) for the oversight and design of human biomedical research.

With African-Americans more likely to die of cancer than any other racial or ethnic group (according to a study by the American Cancer Society), establishing trust between people of color and the world of biomedical research is in the African-American community's interest. However, based upon historical racial experience, it is immediately understood why African-Americans might have a (perhaps healthy) distrust of the scientific and medical research communities. Even though open access to experimental treatments for cancers with poor prognoses is often a desperate patient's last hope for cure or palliation, fear of exploitation by researchers is an understandable reservation shared by many medically marginalized communities.

In my view, the studies undertaken by the Department of Health and Human Services and Baylor College Of Medicine are long overdue and sorely needed. One would hope that, with skill, cultural sensitivity, and a careful examination of past errors, misdeeds, and lapses of judgment, this "research divide" can be bridged for the benefit of all.

Dental Care and Medicaid's Blind Spots

If a poor African-American child dies from the complications of an untreated dental abscess, will anyone care? Apparently many people do, and a hearing on Capitol Hill may only be the beginning. From NPR to cable news, the story has traveled the wires.

Deamonte Driver, a 12-year-old from Maryland, died recently from complications of a dental infection for which his mother could not find treatment. The boy's family is insured by Medicaid, and I do not believe the firestorm surrounding his death will be extinguished any time soon. While managed-care bureaucrats argue that plenty of dentists could have treated Deamonte, the health department of Prince George's County lists only 50 dentists willing to treat the approximately 50,000 children with Medicaid in that county alone.

Speaking of the seven-month battle to secure dental care for Deamonte's brother, Laurie Norris, a lawyer from the Baltimore-area Public Justice Center was quoted as saying, "It took the combined efforts of one mother, one lawyer, one help-line supervisor and three health-care case management professionals for a single Medicaid-insured child."

It was pointed out during the Capitol Hill hearings that Maryland has the lowest reimbursement rates in the nation for dental restoration procedures. We all acknowledge that dentists and other providers must be able to meet their overhead, pay staff, have adequate salaries, and be able to repay significant business- and education-related debt. However, what do we tell these children whose teeth rot in their mouths? And what do we tell mothers like Alyce Driver, who has lost her son before his thirteenth birthday because she could not find timely dental care in one of the wealthiest nations on Earth?

Political will is not easy to muster in this country, especially when it involves increasing benefits for poor communities of color. As the presidential campaign escalates in rhetoric and promises, much lip-service is paid to abstract concepts like "the sanctity of life" and no child being left behind. Deamonte Driver was left behind, and his life was certainly sacred to his mother and family, as it also must be to us all.

So, back to my original question. If an African-American child dies from an untreated dental abscess, does anyone care? Apparently so. Now, what will be done to honor Deamonte's short life and prevent others from suffering a similar fate? This society has some choices to make. Let's pray that the will to make those choices exists, or such stories will only be repeated for years to come.

Vulnerable

Vulnerable. They are a "vulnerable population" and that is why we serve them. Why are they vulnerable, you ask? They are poor. They are mostly people of color. Many of them do not speak English, or speak very little. They suffer inordinately from chronic illness. What illnesses? HIV/AIDS, addiction, Hepatitis B and C, tuberculosis, asthma, diabetes, hypertension, gastrointestinal illnesses, autoimmune disorders, chronic pain, mental illness.

The vulnerable often live on the fringes of society. They live in public housing projects plagued by poor sanitation, roach infestation, vermin, poor maintenance, shoddy and outdated construction. High-rise apartment buildings with only one elevator which consistently breaks down are the norm. Poor security is de rigeur. Litter and trash are ubiquitous. Drugs and guns flow in the streets. Violence is accepted as a part of life. Apathy can be contagious.

When one feels disenfranchised by the society, one learns to value one's environment and surroundings less. One also may begin to value even one's self less, as well. Elders are abandoned to poverty. Children are left behind by a school system in shambles. Agencies serving the poor become corrupt at the core, bleeding the funds away from their intended recipients, filling instead the bellies of the prosperous. Young men are carted off to jail by the score, while their pregnant young girlfriends quit school and lose their drive to succeed and escape the cycle.

We see it every day. We wrestle with it. We cajole our patients into action, into self-determination and responsibility, health and self-care. Well-being. Being well. We want them to be well. To be more than well.

They are vulnerable, and we seek to empower and protect them. To heal them. To help them heal themselves. The healing is done not only on a personal level. Healing takes community, partnership, a certain level of "buy-in" by a critical mass of the population. Many hands make light work, and we consistently reach out for hands wherever they are proffered. We join hands across this troubled city and seek any path which may lead towards elevation and growth, upward movement, empowerment, healing.

Vulnerable. Yes, they are vulnerable. And we reach out our hands. Again. And again.

"To Sleep, Perchance to Dream......"

We send an inordinate number of our patients for clinical sleep studies, and many of them return with diagnoses of Obstructive Sleep Apnea, Restless Legs Syndrome, and occasionally more esoteric scientific labels of "disordered sleep". It is widely understood that individuals with morbid obesity often suffer from apnea---periods during sleep wherein respiration will temporarily cease---and a considerable cohort of our patients spend their nights tethered to machines which enable them to breathe normally during those hours set aside for nocturnal rest which most of us take for granted.

It came to my attention today that some cutting-edge and forward thinking diagnostic sleep centers are beginning to offer sleep studies in hotel rooms rather than the relatively sterile sleep labs generally located in hospitals and medical centers across the country.

Many of us have difficulty sleeping in strange places and foreign beds. If we knew we had a sleep disorder and were sent to a sleep center for diagnosis, why would we necessarily be comfortable enough in a laboratory to fall into a sleep pattern which mimics that which the technician would like to monitor and assess? Thus, a new marketing niche for sleep centers and hotels is born.

In Chicago and Cleveland, these hotel-hospital alliances seem to be thriving, and patients apparently appreciate the more cozy and private environments which can create sleep experiences more closely aligned with a patient's natural sleeping state.

So, is this type of "boutique" healthcare only for a select segment of the population? Who would be offered such a service? Who would be denied? Who would never be told it existed?

For those readers who already are acquainted with this writer's sociopolitical stance vis-a-vis the provision of equal healthcare for low-income populations, you will not be surprised that this trend of medical care does indeed raise a few red flags for me in a certain contextual framework.

Working with low-income Latinos on Medicaid in the inner city, I immediately wonder how many of our patients---if, of course, they met clinical criteria---would even be offered such a service. Our patients---most of whom have never been able to afford a single night in the most moderate of hotels---live in public housing, have little access to transportation, and certainly live as some of the poorest in the country, most well below the official level of poverty.

Consider for a moment the following scenario: Medicaid and, say, Blue Cross/Blue Shield will both agree to pay for a diagnostic stay in either the traditional hospital sleep lab or the hotel version. A provider in a sleep disorder clinic has a university professor with narcolepsy in exam room #1, and a disabled Latino woman with obstructive sleep apnea in exam room #2. Given that each patient meets clinical criteria for a stay in the new Marriott-based sleep center, and each insurance will reimburse at the same rate, which patient will be offered the opportunity for a night at the hotel-based clinic, and which will be relegated to the cinder-block sleep room at the hospital? It's a no-brainer, really, and my trusty "Healthcare Inequality Detector" (patent pending) reaches the red zone of the meter in no time.

Call me cynical, folks, but I have seen enough in the last ten years to know that our patients will often----but not always---be sent to the back of the healthcare bus, so to speak. I don't always mean to be a burster of bubbles (or do I?), but when I see a new specialty being offered that potentially smacks of elitism or classism, I somehow feel the need to point out the potentially inherent disparities which may be encountered therein. As I explore the new offerings of such services in our region (which are now beginning to manifest), this will be one aspect of such care that will certainly fall under my scrutiny (and that of my aforementioned Healthcare Inequality Meter).

So, in your wanderings and peregrinations, dear Reader, keep an eye out for such disparities, empower patients to receive the care they need, and champion the notion that even the poor deserve a good night's sleep at the Raddison (especially if Medicaid is paying the bill).

Healthcare Disparities and Providers Who Care

It was incredibly refreshing and inspiring to attend an open house this evening for a new Infectious Disease (ID) practice in our city of employment. In the last 25 years, the role of the ID provider has greatly expanded, taking center stage in the fight against AIDS. This particular physician, having emigrated from Puerto Rico to attend medical and public health graduate school here in the US, was struck by the disparities being experienced by her own ethnic community. This realization led her to pursue a specialization in infectious diseases, taking up the gauntlet of HIV/AIDS treatment and the stemming of the waters engulfing the Latino community.

In her presentation, the director of this organization drove home the point that disparities in healthcare vis-a-vis the care of ethnic minorities is an area requiring the utmost attention and sensitivity.The centerpiece of the presentation, other than introducing her staff, revolved around the notion that the target population---mostly HIV- and Hepatitis C-infected low-income Latinos---need culturally competent and flexible healthcare which caters to their special needs and challenges, not only medically, but also within the psychosocial and socioeconomic realms.

Low-income patients face many challenges in terms of childcare, transportation, financial constraints, social stigma, as well as disempowerment and disenfrachisement from the society at large. Complex multi-generational family structures, chronic illness, and other challenges complicate the pursuit of care for diseases as complex as Hepatitis and AIDS, and this particular provider clearly stated that her practice strives to be flexible to the patients' life circumstances which may inhibit or challenge care. Flexible visit times, allowances for late arrivals, and asistance with transportation, childcare and other psychosocial issues all pay dividends in terms of the potential for successful treatment.

As we have learned in our practice, flexibility and understanding go a long way towards fostering positive relationships between provider and patient, and it is upon that foundation that successful treatment is achieved. If a patient does not feel seen, understood, and welcomed as they are, the ability to provide holistic and comprehensive treatment is immediately handicapped and may eventually backfire. It is clear that other practices are pursuing the same laudable goals to which we also aspire, and when I feel that another provider is singing my song and walking the same path, that is indeed a heartening experience which I do not take for granted.