Dr John M

cardiac electrophysiologist, cyclist, learner

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Stopping COVID19 in Nursing Homes is No Easy Task

May 27, 2020 By Dr John

My city, Louisville KY, recently had a spike in COVID19 infections. It came from a handful of nursing homes.

That nursing home and long-term care facilities account for large percentages of COVID19 cases has been well documented. In some cities, the majority of cases come from these facilities.

These facts have sprouted platitudes about “protecting our elderly.” What makes this a platitude is that it belies the challenges faced by nursing facilities.

Two recent papers shed light on these challenges.

First is an article by Chris Pope in the City Journal. Second is an academic-like defense of Stockholm City’s elderly care. The latter paper came in response to the former chief epidemiologist of the Public Health Agency of Sweden Johan Giesecke who bluntly said that Sweden has failed in protecting those in elderly care.

My wife spent a handful of years practicing palliative care and hospice in nursing homes. Her stories confirm the challenges brought out in both these papers.

I don’t think many people get the reality of life in nursing facilities.

Taken from these two articles, here are 7 challenges for protecting people from COVID19 who live in nursing facilities:

  • Residents spend most of their day in close contact with others, indoors, eating meals together, often sharing rooms, and needing high-touch care from caregivers who move room to room.
  • How can you social distance when residents need on average of four hours daily of personal care? Why so much? Almost half of residents have dementia, 2/3rds have bladder incontinence, 1/3rd require rehab, 2/3rds are chair-bound and 15% require respiratory therapy.
  • Healthy people do not get admitted to nursing homes. The vast majority of residents have not one but multiple chronic conditions, such as high-blood pressure, heart disease, diabetes and lung disease. (All risk factors for COVID19 mortality).
  • People in nursing homes are already near death. [I]n 2016, while nursing-home residents made up just 0.4 percent of the U.S. population, they accounted for 19 percent of deaths.”
  • Because of the last two points, residents of nursing facilities travel back and forth from hospitals–further increasing the risk of being infected with serious pathogens.
  • Work in nursing home is neither glamorous nor well-paid. “Nursing-home staff often work in multiple facilities, share housing with those who work at other care homes, and rely on public transportation.”
  • While many nursing residents have advanced dementia, many do not. The isolation of people from other people, including their loved ones, is hardly an easy intervention.

While these words lay out problems not solutions, I do so in hopes to provide some reality to the difficulties in protecting the most vulnerable.

Often heard on our hospital wards is something like this: “Mrs Jones is going to the nursing home to get stronger.”

While this is true for a select few elders who’ve had a recent surgery or brief illness, for many elders, the truth is they are going to the nursing home because they are too frail to be home. And that frailty is a result of their long life.

I’ve said before that I hate this virus. I wish it never came.

But its presence does seem to be teaching us a lot.

One lesson has been the dangers of accepting shoddy medical evidence (hydroxychloroquine); another is the limits of epidemiological models, and a third may be the stark realities of protecting older vulnerable patients who are close to the end-of-life.

We can hope that advances, say, better testing, more protective gear for nursing home workers, a vaccine, or even smarter policy changes will help reduce the effect of COVID19 on nursing home residents.

But it won’t be easy. We will have to be careful with what we consider success and failure.

JMM

P.S. I wonder if mandatory 2-month rotations in nursing facilities for medical trainees might help doctors better understand the realities faced by older patients.

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Filed Under: Doctoring, General Medicine, Hospice/Palliative Care, Knowledge Tagged With: COVID19

Thoughts on Justice Scalia’s Death

February 20, 2016 By Dr John

When I heard Justice Antonin Scalia had died suddenly, presumably of cardiac causes, I spent time reading and thinking about the famous judge. Three themes seemed worth putting down in writing.

Read more here: Justice Scalia’s Death: Three Lessons for the Healthcare Community

JMM

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Filed Under: Doctoring, Health Care, Healthy Living, Hospice/Palliative Care Tagged With: Justice Scalia

Hospice and Palliative Care and Cardiology TweetChat Recap

February 18, 2016 By Dr John

Thanks to Dr Bernadette Keefe (@nxtstop1) last night’s Hospice and Palliative Medicine (#HPM) Tweet Chat has been “storified.”

Here you go>

JMM

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Filed Under: Hospice/Palliative Care

Join us tonight for #HPM Palliative Care Tweet Chat

February 17, 2016 By Dr John

Screen Shot 2016-02-17 at 5.50.32 AMTonight, February 17, at 2100 EST, Staci and I will host a Tweet Chat about cardiology and palliative care. It’s a great way for the general audience to learn from Staci. As a cardiologist married to a palliative care doctor, I get to know things that most cardiologists don’t know.

The one-hour session revolves around three questions that are outlined over at Pallimed.

****

Here are some of the details:

What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 2/17/2015 – 9p ET/ 6p PT
Host: Dr. Staci Mandrola and John Mandrola

Twitter Feeds to Follow:

Staci Mandrola @drstacim

John Mandrola @drjohnm

HPMChat @hpmchat

Go to www.hpmchat.org for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along.

Try using the search function on Twitter. If you do have a Twitter account, we recommend using tchat.io for ease of following. You can also check out the new site dedicated to #hpm chat – www.hpmchat.org

Two other notes:

Paula Span of the New York Times has a great piece on the benefits of getting palliative care involved early.

If you are not on Twitter, you should be. It’s beautiful way to learn from and connect with people across the globe. Don’t listen to the preconceived notions about Twitter. In the healthcare realm, Twitter buzzes with smart thoughtful people. The other reason I like Twitter is that it hones short-writing skills.

If you continue to resist Twitter, my Tweets come across my Facebook DrJohnM page.

See you tonight.

JMM

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Filed Under: Hospice/Palliative Care

We must inject more care into healthcare

October 25, 2015 By Dr John

A frail elderly women has a leaky heart valve. It caused her legs to swell and increased her work of breathing when she pushed her walker around the house.

One doctor wanted to relieve her suffering. She suggested palliative care; she wanted to make her disease less severe but without removing the cause. Other doctors said no, the answer was to cut the bad valve out and fix the disease.

It’s America; you know what happened.

After heart surgery, which was successful in relieving the leaky valve, her health deteriorated. (My wife Staci talks often of the elderly and the house-of-cards analogy.)

A prolonged post-op course led to a nursing home stay, then more hospital admissions, for infection, falls, fractures, then more infections, a blood clot, chronic pain, and, after eight trips back to the hospital in her last 18 months, this women died an American death: hospital lights blaring, tubes attached, monitors beeping. Delirium added to her family’s suffering. During all this, while her humanity leaked away, the repaired heart valve remained perfectly competent.

You could tell the same story with a different surgery, or chemotherapy for cancer, or many other scenarios of death denial. But it does not have to go like this.

BJ Miller is a doctor. He is also a patient.

The title of his talk is: What really matters at the end of life.

It’s worth 20 minutes of your time.

JMM

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Filed Under: General Cardiology, Health Care, Health Care Reform, Hospice/Palliative Care

Avoiding a bad death requires preparation

July 31, 2015 By Dr John

If there was a hashtag for sub-specialty healthcare and ICU medicine in the United States it would be:

#WeCanButShouldWe

A recent study led by Dr. Harlan Krumholz (Yale University) showed that we have become more efficient at keeping elders alive. This is not surprising. And it’s good news in the sense that technology–if used wisely–can enhance both quality and quantity of life.

The key phrase above is…if used wisely.

The obvious fact remains: Human beings don’t live forever. The same medical technology that can extend life can also prolong death. Most cases we review each month in our peer-review meeting begin with an elderly or chronically ill person who suffered excessive care at the end of life. This happens because the default in hospitals is to do everything.

Life-prolonging care in 2015 is aggressive, often painful, and doctor-centric. Life-prolonging care steals autonomy and shuns dignity. Life-prolonging care is immense.

The key to avoiding a bad death is preparation. To prepare is to make something ready for consideration; create in advance; have a plan. Dr. Dan Matlock (University of Colorado) and I wrote that doctors, electrophysiologists particularly, should help their ICD patients make plans for turning off shocks when death is near. Dr. Jeffrey Burns (University of Pennsylvania) urged kidney doctors to help dialysis patients plan for the future–and avoid futile CPR. Dr. Atul Gawande educates the entire world with his best-selling book, Being Mortal.

Then there is ZDoggMD, who spreads common sense in his unique way:

To make ready. This is the key.

JMM

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Filed Under: Doctoring, General Cardiology, Hospice/Palliative Care, ICD/Pacemaker

Update: Social justice of AF care, NOAC monitoring, population health and two new podcasts

April 20, 2015 By Dr John

Hi All,

Here is a short update of the past week.

The first thing to say is the Atrial Fibrillation Care: Put the Catheter (and Rx Pad) Down post has gotten a lot of attention. It stayed on the most popular list all week. It has over a 130 comments, and I have received many emails on it. It is a big moment in AF care.

Screen Shot 2015-04-16 at 2.29.45 PMI would also point you to an interview I did with Dr. Prash Sanders from Adelaide. Prash is the senior researcher on the LEGACY trial. His team’s work has been most responsible for the change in thinking of AF care. The title of the post: LEGACY PI Throws Down the Gauntlet to US Physicians

Is AF care fair?

One aspect of AF care that I discussed recently with one of my partners was the notion of social justice. An AF ablation costs $100,000; a redo ablation costs $100,000. That is a lot of money. And now we know that in most cases, lifestyle changes either eliminate the need for procedures or render them more likely to succeed.

So…how fair is to spend $200,000-plus to treat a patient with AF? Think of what could be accomplished if that much money was used to care for the needy in our community? Is it right or just to allocate that many resources to a disease that is most often due to life’s excesses?

Population Health?

This leads me to population health–a hot topic in the hospital these days. The thinking goes that hospitals will be charged with delivering health to the population it serves. That is funny. As if health comes from hospitals. My mantra on the matter of health in populations: #BuildParksNotCathLabs.

Monitoring of NOAC drugs:

My column last week delved into the issue of monitoring patients who take the new anticoagulant drugs dabigatran, rivaroxaban and apixaban. Conventional wisdom–powered by marketing–has it that these drugs are more convenient than warfarin because less monitoring is required. A new study suggests otherwise. Researchers from Stanford looked at 67 VA medical centers and found great variation in patient’s adherence to the drug (dabigatran). They also discovered a yet unappreciated benefit from pharmacists.

The title and the link of the post is here: Should NOACs Be Monitored Like Warfarin . . . and by Pharmacists?

Two new podcasts:

In This Week in Cardiology for April 17th, I discussed NOAC monitoring, news from the FDA, including a warning on two new diabetes drugs, the future of cardiac devices and physicians’ view of electronic health records.

In This Week in Cardiology for April 10th, I discussed cooling after cardiac arrest, sports-related cardiac arrest, young adults and statins (ouch), antidotes for Factor Xa anticoagulant drugs and Staci’s letter to cardiologists on palliative care.

Great read of the week:

The best medical writing of the week came from my colleague and fellow writer Dr. Melissa Walton-Shirley. Trust me. Read her stirring essay A Death Well Lived. 

JMM

P.S. I rode 80 miles Saturday. It felt great.

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Filed Under: AF ablation, Athletic heart, Atrial fibrillation, Doctoring, General Medicine, Health Care Reform, Hospice/Palliative Care, ICD/Pacemaker, Reflection

I will host Hospice and Palliative Care Tweet Chat — #HPM

February 10, 2015 By Dr John

#hpm chat 2015 02 11This Wednesday Feb 11th, at 9 PM EST, one day after PBS Frontline features Dr. Atul Gawande and his new book Being Mortal, I will guest host the Hospice and Palliative Care (#HPM) Tweet Chat.

Dr. Christian Sinclair is a physician leader in HPM and a co-editor of Pallimed. He recently commented on my stewardship piece on theHeart.org. Christian then emailed me to ask whether I wold host #HPM chat on Twitter.

I agreed because I know cardiologists could benefit from talking with hospice and palliative care pros.

The good news about medical technology is that people are living longer. That is also the challenge. Cardiologists are increasingly called on to treat the elderly and frail. We are innovators and doers, but human beings are not immortal.

Yet, I am sure of this: When life-prolonging measures are no longer effective or desired by the patient, the opportunity to deliver care, beautiful care, remains. It is just that most doctors have little (to no) training in helping patients transition to care with different goals. Too often, we fail to see that there is always something else to do.

Here are the three proposed topics:

T1: Frailty is an important predictor of outcomes, but how do we get specialists to see it, talk about it, and use it in decision making? (re: the coming revolution in percutaneous valve surgery.)

T2: ICD generator-change surgery in the elderly: How do we best present the different paths? It seems a simple question but it is not because it means discussing competing causes of death. (We can use the Drs Drye case report in Circulation Outcomes.)

T3: What is the role of palliative care in advanced heart failure? Could early palliative care be as useful in advanced heart disease as it is in advanced lung cancer?

I hope you tune in–or even Tweet in.

JMM

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Filed Under: Doctoring, Hospice/Palliative Care, Social Media/Writing/Blogging Tagged With: Tweetchat

The power of the specialist physician — and stewardship

January 30, 2015 By Dr John

Screen Shot 2015-01-30 at 6.13.12 AM

My latest column over at theHeart.org discusses the disordered balance of power in the doctor-patient relationship.

As most of you know, I harbor strong biases about the quality of medical decisions, especially in the elderly. Attached. Yes, I am attached to the issue of decision quality. Nearly all of electrophysiology, and much of cardiology, involves preference-sensitive decisions. This means doctors are called to align treatments with the goals of the patient. We hold great power; we must use it justly and wisely.

My latest essay arose from an unusual source. The prominent medical journal Circulation Outcomes publishes a section they call Caregiver Viewpoint. The editors aim to understand patients’ experience of cardiovascular disease. Patients, families or caregivers write articles that explore the effects of treatment–on them. (Remember Dr. Montori’s discussion on the burden of care.)

You can imagine that this exercise–of looking at how patients experience communication, decision making, care coordination, access, cost, timeliness and safety–could get thorny for doctors.

In the latest Caregiver Viewpoint, two physician daughters wrote about their Dad’s experience with an ICD at the end of his life. Their father, a retired psychiatrist, survived a cardiac arrest at age 79. He had an ICD and stent placed at that time. He then did pretty well. The ICD never had to act. He aged. So did his ICD, which developed a lead problem that forced a medical decision at age 86. He faced two choices: deactivate the device (because a malfunctioning lead can cause inappropriate shocks) or undergo a risky lead revision surgery.

The bulk of the story centers on the daughters’ view of their Dad’s experience with his specialists. They felt he experienced less than ideal decision quality.

Here is the title and link of my essay: The Specialist: With Great Power Comes Great Responsibility

If you read it, take time to look at the comments. My good friend Dr. Jay Schloss took issue with both mine and the daughters’ one-sided viewpoint. His words made me think.

JMM

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Filed Under: Doctoring, Hospice/Palliative Care, ICD/Pacemaker

Because there is nothing else to do

November 8, 2014 By Dr John

If you ever hear your doctor say we are going to do something because there is nothing else to do, be afraid. Be very afraid.

First of all, it should be self-evident that if caring and empathy and relief of suffering count as doing something, there is always something to do for patients.

A growing problem in medicine, especially in death-denying specialities like cardiology and oncology, is that having nothing else to do translates to not having a cure, or a promise of immortality. In times past, such misthink wasn’t so hazardous. Now, however, the inability to see failing organs as the natural order has never been more scary.

Caregivers in 2014 choose from a vast array of tools to prolong death, and, in the process, destroy one’s humanity. It has become quite easy to make human beings worse. We have ventilators, dialysis machines, restraints, shocking devices (and vests), mind-altering drugs and nursing homes–where, contrary to popular speech, elderly patients rarely go to get stronger.

Caregivers in 2014 are also burdened with distorted expectations. When a 90-year-old person dies, he does not die of heart failure, kidney failure or stroke; he dies of old age. I’m not sure when this notion got lost but it is long gone.

Here is a case:

An elderly man presented with symptoms of a stroke. The good news was he recovered quickly. The bad news was what he went through. The really bad news was the endemic misthink underlying this case.

The frail but functional gentleman endured a lengthy hospital stay, which I mention because the danger of immobilizing the elderly is under-appreciated. During this long stay he underwent numerous expensive and invasive tests, all of which confirmed what was obvious from the original brain scan: he had a small stroke from age-related blood vessel disease (atherosclerosis).

Now to what almost happened. More than one of his doctors noted that the anti-clotting drug he was taking to prevent strokes had failed. Drugs should not fail. And when they do, they must be changed.

That’s when I got the call. “Is it okay to change this patient to drug X?”

“No. It is not.”

There were numerous reasons I said no. The first was that he was doing well on the “failing” medication. It was doing other important things for him. The second reason was that no drug reduces the risk of stroke or heart attack to zero. The third and main reason for not switching was a complete lack of evidence to support using the new drug for this scenario. Maybe it would be better, but we don’t know because it’s not been studied for this problem. What’s more, the proposed drug requires good kidney function to maintain balance (steady state levels). This patient, like many elderly patients, had impaired kidney function.

Perhaps you can see the issue.

Treatment was being switched solely because there was nothing else to do.

How did I deal with this situation?

I leveled with the patient. Literally. I sat down in a chair next to his bed. (I was tired after a long day, so it felt good to sit.) I began with the good news: he was okay, and he was going to be okay tomorrow, too. It was a small stroke. He was going home soon. This truthful news brought a smile, which was nice to see.

He asked about the new medication.

I explained my reasoning.

“Good, he said. I looked that drug up. It’s expensive. I could not have afforded it.”

I explained further that I could not predict the future but he was on the best therapy we had to offer.

***

This was a mild case. Nothing terrible happened. It’s not hard to imagine the trauma that could occur when nothing else to do think drives caregivers to operate or deliver chemotherapy.

There remains many challenges for healthcare. One is surely how to see the natural order of life and death. Another is to count caring and empathy and relief of suffering as doing something.

JMM

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Filed Under: Doctoring, General Cardiology, General Medicine, Health Care, Hospice/Palliative Care

To deprescribe…Adding a new verb to the language of doctoring

October 14, 2014 By Dr John

What follows is my most recent editorial in the Journal of the Kentucky Medical Association. It is reposted with permission.

****

Screen Shot 2014-10-14 at 5.54.25 AMOne day every month, my wife Staci, a hospice and palliative care physician, goes to see an elderly woman in the nursing home. The routine has gone on for years, which is surprising because the woman was admitted to the home with terminal diagnoses. But this patient didn’t die; she keeps living, month after month. “How is she?” I often ask. “She is fine. She eats, drinks, moves around in her chair and doesn’t have the frowny face of pain.”

How did a hospice doctor achieve such longevity and well being for her patient?

“I took her off almost all her medication, except a small dose of a pain reliever. Old people (like her) need food, and drink, and pain relief, not pills.” Staci says.

This case introduces an important new action verb in doctoring–to deprescribe. As modern medical technology advances, and people live longer but with more chronic diseases, the act of deprescribing has never been more relevant.

Let’s start with the act of prescribing, which lies at the core of what doctors do to help patients. Sadly, these days, most of what we advocate for are chemical modulators of body systems—pills. It doesn’t have to be this way; we could authorize smarter eating habits, more exercise, sleep hygiene and stress management strategies. But these are hard, and pills are easy. So it is then; in the name of health, patients, especially the elderly and infirmed, end up taking lots of pills.

If you work in a hospital you live the bleak statistics of over- and mis-prescribing. The FDA reports that adverse events from drugs have tripled in the last decade, with more than 117, 000 deaths in 2013. Hospital and emergency room visits due to adverse drug reactions number in the millions and up to one in six hospital admissions of older adults occur because of an adverse drug reaction. Older adults are especially vulnerable to poly-pharmacy and pill burden. As patients age they accumulate chronic diseases, organ function wanes, and drug clearance declines—a perfect storm for adverse drug reactions.

The list of medication harm is a long one. In the last month alone, I’ve seen patients with…a fractured hip due to low blood pressure from vasodilators, bleeding due to over-anticoagulation, confusion from diuretic-induced hyponatremia, cardiac arrest from QT-prolonging antibiotics, and 1:1 atrial flutter from an antiarrhythmic drug used to treat (previously) asymptomatic atrial arrhythmia.

So here is my proposal: Rather than just prescribe, I would propose that we, the healthcare community, collectively embrace and promote the action verb, deprescribe.

I know what you may be thinking: rarely is it a good idea to substitute a big word, deprescribe, when a small one, like stop, would do.

But deprescribing is more than just stopping a therapy. It’s more than just an action; it’s a way of thinking, a mindset. It brings to the fore another important verb (and noun)…need. What do patients need? And who determines this need? How do needs change over time?

For instance, does an 80-year-old with multiple problems and a prognosis measured in months to years need a cholesterol-lowering medication? Does a 74-year-old with Parkinson’s disease need a “perfect” blood pressure of 120/80? In my field of electrophysiology, a common opportunity to reassess need occurs when a patient with an ICD (internal cardiac defibrillator) comes for generator change. In the intervening years since implant, many things might have changed—the patient’s goals for care, accumulation of competing causes of death, improvement in cardiac function–such that deprescribing ICD therapy is our duty.

I know it’s not easy to embrace deprescribing. It goes against the culture of what we were taught: diseases need treatment. The problem, though, is that we aren’t treating diseases, we are treating people. So it’s complicated; it’s all connected. And things change over time. What was once a useful drug, one that relieved an important symptom or moved a relevant surrogate, can become harmful.

There will be barriers and pitfalls to the mindset of deprescribing. Chronologic age is not physiologic age—so there isn’t an age threshold. Some medications require weaning rather than abrupt stopping. Also, patients (and doctors) can grow attached to the association of living and taking medicines. But association is not causation.

Perhaps the biggest barrier to deprescribing is that it requires caregivers to face the certainty of end-of-life. This is where the going gets tough, for generalists and specialists alike. It’s not easy to think and talk about death and dying with our patients. But if we, as health professionals, won’t do it, who will?

The act of deprescribing offers an opportunity to inject care back into healthcare. Let’s embrace the idea together. Please help me add the new verb to our language.

JMM

Reference:

From Medscape: People’s Attitudes, Beliefs, and Experiences Regarding Polypharmacy and Willingness to Deprescribe

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Filed Under: Doctoring, General Cardiology, General Medicine, Health Care, Hospice/Palliative Care, ICD/Pacemaker Tagged With: Deprescribe

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John Mandrola, MD

Welcome, Enjoy, Interact. john-mandrola I am a cardiac electrophysiologist practicing in Louisville KY. I am also a husband to a palliative care doctor, a father, a bike racer, and a regular columnist at theHeart.org | Medscape

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Find me on theheart.org | Medscape Cardiology

  • Electrophysiology commentary on Medscape/Cardiology

Mandrola on Medscape

  • My Medscape column on general medical matters

For patients...Educational posts

  • 13 things to know about Atrial Fibrillation — 2014
  • A new cure of AF
  • Adding a new verb to doctoring: To deprescribe is to do a lot
  • AF ablation — 2015 A Cautionary Note
  • AF Ablation in 2012–An easier journey?
  • Atrial Flutter — 15 facts you may want to know.
  • Benign PVCs: A heart rhythm doctor’s approach.
  • Caution with early Cardioversion
  • Decisions of 2 low-risk cases of PAF
  • Defining success in AF ablation in 2014
  • Four commonly asked questions on AF ablation
  • Inflammation and AF — Get off the gas
  • Ten things to expect after AF ablation
  • The medical decsion as a gamble
  • The most important verb in our health crisis
  • Wellness Requires Ownership

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