A Foundation for the House of Medicine

When you build a house, you begin with the foundation. The same holds true for the U.S. health care system. The President and Congress are scrambling to put up a reform structure that would have a better chance to succeed if the cinderblocks and joists were in place. No health care system in our country can develop adequately unless supported by validated information, policies and procedures based upon accurate data related to its most important features, and updated continuously. While there are agencies and institutions that can answer some of our questions, a comprehensive assessment is lacking. We should learn much more - the sooner, the better. Conflicted entities cannot be relied upon for objectivity, so if the government would like to increase its role in health care, creating a method for objectifying the rationale for change is the correct place to start.

The need to do something about health care is predicated upon the notions that we spend too much, perhaps to achieve inadequate outcomes and leave too many people without access to a reasonable desired amount of care. The rush component is fiscal and therefore political. Predecessors created entitlement programs that have grown for many reasons and are projected to break our bank. So, we have come to the brink where there is little tolerance for growth in health care, and the rhetoric of rationing. Difficult choices lie ahead.

What might we do to establish the foundation? I believe that it will be best achieved by incremental processes that can be managed to significant contributions. I want to learn much more about what health care I should be receiving and why I should want it. While we spin expensive and frustrating cycles on global reform, biting off much more than we can chew, I urge federal and state governments, science agencies, medical societies and organizations, and academic institutions to put forth all necessary effort to accomplish the following, in order to provide a foundation for successful health care reform:

Focus on outcomes.

As a doctor, I can do the best job for my patients if I’m able to form an impression and make decisions based upon facts. A man comes to me with the worst headache of his life and a stiff neck. Does he have a migraine, meningitis, bleeding aneurysm, brain tumor, abscess or something else? My physical examination puts me in the ballpark, but then I need assistance. What tests are available and what are their costs and risks? Is there a decision tree for best practices that I can follow? Is there a neurologist or neurosurgeon available with whom I can consult? If he needs an operation, do I know the skill and success rates of the operators to whom I can refer him? Would he be better off staying in my hospital or being transferred?

We cannot afford to keep practicing medicine by impression when there is a clear need to objectify our behaviors. Whether by creating a national clearinghouse for health care-related data or accomplishing this through individual efforts, we should seek to be evidence-based. There are means to establish, for instance, the immediate and long-term outcomes of a similar, if not identical, brain surgery on a doctor-by-doctor, hospital-by-hospital, and state-by-state basis. The same way that we enjoy consumer reports for automobiles and computers, we should be privy to analyses that guide us to the best doctors, hospitals and practices. For starters, each medical specialty can accomplish systematic reviews. These will guide us to complete the necessary prospective evaluations needed to refine our initial conclusions about clinical, financial and societal implications.

Rationalize drug therapy. Assign the Food and Drug Administration to compare every drug on the U.S. market with branded and generic versions available anywhere, worldwide. If there are not yet reasonable comparative analyses, then design and implement them as soon as possible. Ensure drug quality, then purchase at low cost. Next, compare alternative drug therapies and regimens. Strive to determine the precise incremental differences in outcomes. Create scoring systems if need be, and make them understandable and functionally interoperable.

Define the needs and desires of the American people for health care. I’m tired of listening to middle-aged pundits preach the value of an elder’s life, as if they have insight. Let’s put the issues to the American people and find out what they really want. And whatever “it” is, let’s find out if the respondents are willing to pay for it for others, even if they don’t want it for themselves. Carefully designed interview and polling methods should shed light on the desires, if not necessarily the needs, of persons who pay taxes, care about their families and deserve credit for their life histories and ability to make these sorts of decisions.

Create a mandate for advance directives. This recommendation is directed at a potentially controllable aspect of cost containment, and relies upon on the explicit desires of individuals. As part of each person’s state tax return, he or she should be required to complete an advance directive, which could be changed or amended at any time for any reason. A person should be allowed to decline to complete the directive, but only by officially indicating their declination.

Pay active attention to medical manpower issues. The U.S. population is growing. The ratios of doctors to consumers, and the distribution of primary care physicians and specialists, will perpetually be out of whack unless there is active manipulation of training incentives and financial support for doctors who are necessary to keep this nation healthy. We are not training enough doctors to handle our increasingly elderly and medically complex population. There should be active management to train and recruit doctors, nurses, therapists, technicians and other allied health professionals.

Use computers for decision support. Someone needs to take a strong hand to prevent proliferation of an electronic Tower of Babel. My impression of current electronic medical record offerings is that they are designed for billing purposes, not to facilitate real-time clinical decision support. The promise of cost containment because of computer technology will not be fulfilled unless their use guides practitioners to be more effective, eliminate unnecessary hospitalizations and procedures, and diminish errors. Furthermore, electronic medical records are not yet easy to use. Do we really have our best and brightest software engineers working on these tools?

Create health coaches. Uncoordinated care is the most expensive kind, because it leads to delay in diagnosis, redundancies, excess testing and procedures and failure to put episodes into context. Every person, particularly elders, should have access to a qualified health coach, whose responsibility is to allow the patient to be aware of history and options.

Support medical science to the maximum degree possible. Consider this list: cancer, dementia, diabetes, stroke, arthritis, immunodeficiency, infectious diseases. All of these are unsolved mysteries unless we allow scientists to create new knowledge. Discovery advances all aspects of medicine. Arbitrarily restricting research budgets is a foolish approach to cost containment.

And while we’re at it…

Stop demonizing doctors. With the exception of a small percentage, physicians are not driven by the desire to make enormous sums of money. Physicians struggle with themselves constantly about providing expensive life-prolonging care to neonates, elders and terminally ill persons, the cost of drugs, and our current global financial dilemma. Our debates are also about decency, compassion, wanting to do our duty, and accepting enormous responsibilities each day of our careers. Physicians who succumb to perverse incentives to magnify their incomes should be controlled, but they do not define U.S. health care, any more than greedy lawyers define the legal profession, child molesters define the clergy or corrupt politicians define government.

Understand what rationing really means. We are nowhere near the need to ration healthcare in this country. What we are near is an unwillingness to devote the amount of financial resources necessary to support the projected rate of growth in health care spending. To understand which programs need to be curtailed, or never initiated, we have to get our priorities straight. Let’s deal with two situations that will never change. First, we are governed by elected officials who have varying degrees of health care knowledge and interest. They have never shown a willingness to allow doctors to take the lead on reforming the system, arguing that if the health care profession wanted change, it would have created it. The problem with that logic is that no industry in this country makes the laws, and changes in the system cannot come any other way. What our government should do is put the best and brightest doctors in charge of setting the standards and working within the system to make incremental changes that address the foundation issues I discussed above. The second situation is that you cannot teach people health care economics when they don’t feel well. It is human nature to seek relief from suffering and improvement in one’s personal situation. The enlightened individual at the end of his or her days may go quietly (and inexpensively) into the night, but that is not the basis upon which we should expect to build our health care system.

Analyze health care systems of other countries. How many opinions are there about whether or not U.S. citizens would be better off with the Canadian system, British system, Swedish system or some other system? Let’s decide what’s important to us – mortality, morbidity, life span, wait time for hip replacement, drug rehabilitation – and do the comparative analyses. If there is a system that performs better than ours on issues that really matter to us, then we ought to be able to understand why and determine whether and how we can make the situation better here.

Quit considering a visit to the emergency department to be a failure. The maturation of emergency medicine as a specialty, and the way our EDs have responded to the failure of the health care system is a success story. Unless a patient has immediate access to the right specialist, the ED is the fastest, most accurate, and often only reliable direct route to the doctor who knows how to treat the problem. Think about it. You need a CT scan, neurologist and perhaps interventional radiologist when you have a stroke. Will you find that in your general practitioner’s office? Never. You need hydration, antibiotics, metabolic testing and a chest x-ray when you have pneumonia. Call your family doctor? Not likely. Rather than trying to drive patients out of the ER to an understaffed and overbooked community clinic that will immediately bounce anyone who is truly ill, why not refine and expand the ER concept to provide cost effective urgent care to people? Which leads me to…

Don’t count on healthy lifestyles to solve our problems. I am not a pessimist by nature, but it is difficult to believe that non-mandated suggestions to correct our diets, lower our weight, stop drinking and using drugs, and show caution on the freeways will thrive in our culture of consumption, fast food and cars, diminishing exercise, and disregard for the environment. If our laws allow the use of tobacco, firearms and fast foods, then we will continue to have lung cancer, gunshot wounds and fat people. We actually have a “sick care system,” not a health care system, and to suggest that it could be otherwise any time soon is to put way too much faith in human nature. What is reality? I think we should plan to live longer while being less able to care for ourselves, continue to blow ourselves up during wars with weapons, birth too many babies, and celebrate the right to be sugar and grease eaters, not wear helmets and lay out without using sunscreen. We won’t live forever, and our health care system should be designed for how we actually live, not the way we have been instructed to live. If and when we wise up, we can make the adjustments.

So, if we wish to build a house of medicine upon a foundation of data, communication, collaboration, value and accountability, then let’s be real about where we are, what we want, and how quickly we can alter health habits. Let our best medical minds work together to control our destiny by gathering and facing the facts, with every measure at our disposal.

By Dr. Paul Auerbach

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The Weight Debate: Obama’s Pick for Surgeon General

Right around the time the Senate finished grilling Obama’s Supreme Court nominee, Sonia Sotomayor, Obama’s pick for surgeon general—Dr. Regina Benjamin—began her own version of a confirmation hearing in the arena of public opinion.

On one side of the scale is the above-average weight of Dr. Benjamin’s extraordinary resume; on the other side, her above-average personal weight. The question that is hanging in the balance and one that has sparked a lively (and hopefully healthy) debate in the blogosphere and beyond is this: Despite her credentials, does Regina Benjamin’s perceived weight issue disqualify her from being the country’s leading spokesperson on matters of public health?

Dr. Benjamin’s resume speaks for itself. She is a highly decorated family physician from rural Alabama and a champion of the medically underserved—having made headlines for her tireless work after Hurricane Katrina. She has had heaps of honors bestowed upon her, including a McArthur genius award and a Nelson Mandela Award. She was the first African-American woman elected to the American Medical Association’s board of trustees. This list goes on and on.

However, the full-figured Benjamin has been called out by many in online comment forums who think the surgeon general should, at the very least, look healthy at first glance, with the goal of leading by example. Some question the choice for a country plagued by obesity. Some question her stint as the president of Alabama Medical Association—in one of the unhealthiest states in the nation.

Talk to political experts, and most will agree that the surgeon general is a largely symbolic post with some inherent influence but without much administrative authority. Interestingly enough, that makes this debate even more relevant. But it seems symbolism is in the eye of the beholder. Do you see an award-winning African-American family doctor who works selflessly to help those who struggle to help themselves. Or do you see an overweight physician from one of the unhealthiest states in America. It’s a debate that has sparked conversations about health all across the country, which we all can agree is a good thing.

We want your thoughts: Which matters most—Dr. Benjamin’s credentials or her weight?

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Go for a Run, and Help Kids in Need

The Fresh Air Fund is looking for runners to join its NYC Half-Marathon team. Through sponsorships, each runner on the team raises money that will fund free programs for kids from low-income communities. More runners means more money going to kids in need.

The Fresh Air Fund has been around since 1877 and has provided free summer vacations for nearly 2 million children in that time. Last summer, nearly 5,000 kids escaped the hot, crowded streets of New York City to stay with host families in cities and towns across 13 U.S. states and Canada. The organization also hosts Fresh Air camps and other enrichment programs for thousands of kids throughout the year.

Last year, the Fresh Air Fund Racers raised more than $125,000 through the NYC Half-Marathon. That money directly funded their programs, and they are hoping to raise even more this year. It’s a great race and a great cause. Click here to register with the Fresh Air Fund Racers. The organization is also looking for families to host kids for a summer vacation. Find out how.

By Ryan Wallace

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Your Questions Answered

Our regular updates on the H1N1 virus have sparked a lot of questions among our readers, so we've provided a list of your most frequently asked questions and their answers in order to keep you informed, allay your fears, and help keep you safe and healthy.

Q: At what point should I seek medical attention if I believe I've been exposed to the swine flu?
A: You should seek medical attention if you've been suffering from any flu-like symptoms (such as fever, headache, body aches and cough) for more than 24 hours. Let your healthcare professional know if you suspect you've been exposed to the H1N1 virus (widely known as the "swine flu") because of recent travel to Mexico or contact with someone diagnosed with the disease.

Q: If I received a swine flu vaccine during the swine flu outbreak of 1976, am I safe from infection by the current swine flu virus?
A: No. The vaccine you were given to guard against the H1N1 virus is unlikely to provide protection against the current strain of the virus. But a new vaccine is being developed and could be available as soon as June, 2009.

Q: Can I get swine flu from eating pork products?
A: No. The flu is not spread through food, so there is no danger of getting swine flu from consuming pork products.

Q: Can I be infected with swine flu if I handle a pig fetus during a classroom dissection?
A: No, it's highly unlikely for you to be infected in this way. The preservatives used to prepare a pig fetus for dissection should kill any virus the fetus may have been exposed to.

Q: Can my pets become infected with swine flu?
A: Not likely. According to veterinarian Michael Watts, "There is no evidence that dogs, cats, or 'pocket pet' species can be infected with the new H1N1. Although the virus contains some genetic material from an avian influenza virus, there is no evidence this strain can infect birds." Even so," the doctor says, "You should contact your veterinarian any time your pet develops symptoms of a respiratory infection."

Q: How effective is the use of facemasks in preventing swine flu infection?
A: Masks can be effective when used properly. The mask should fit snugly over your mouth and nose, and it should be changed every couple of hours, because prolonged exposure to your own moist breath can turn the mask into a sponge that soaks up outside germs, making you even more susceptible to infection.

Q: I'm pregnant. Should I take greater precautions than others when it comes to the swine flu?
A: Yes. There's evidence that pregnant women could be at higher risk for complications when it comes to infection with H1N1, so pregnant women should be tested for H1N1 and get treatment immediately if they test positive.

Q: How can frequent travelers avoid becoming infected with the swine flu?
A: Frequent travelers should take the precautions everyone else does to prevent infection, including washing hands frequently and avoiding contact with sick people. Make sure to use disposable paper towels in public restrooms for drying hands, turning off faucets and opening doors.

Q: Why has there been such a high death rate for those infected with swine flu in Mexico?
A: The World Health Organization is still investigating the spread of H1N1 in Mexico and why mortality from the virus has been so high in that country. Some experts point to the poverty of the victims, the large concentration of people in such a small area, and the hesitation of those inflicted to seek swift medical attention as possible answers.

Q: What are my chances of a full recovery should I be infected with the swine flu?
A: Excellent. The anti-viral drug treatments Tamiflu and Relenza have proven extremely effective in combating the H1N1 virus. Just make sure you keep a close eye on your health and get treatment if you come down with symptoms that point to the swine flu.

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Swine Flu: What You Need To Know

Swine Flu Update - Tuesday, May 5, 5:00pm:

A 33-year-old Texas woman, already suffering from other health problems, died today from the H1N1 virus. Though not yet reflected in today’s report from the Centers for Disease Control and Prevention, this makes the second H1N1 death in the United States. Last week, a toddler from Mexico died from the flu in a hospital in Texas.

According to many experts, most of the confirmed cases in the U.S. have been much less severe than expected. "We have started to see encouraging signs that this virus may be mild, and its spread may be limited," said Homeland Security Secretary Janet Napolitano in a press conference.

Also today, President Felipe Calderón lessened the national alert level in Mexico, where the flu has apparently begun to taper off. The government did cancel Cinco de Mayo festivities, though, as a precaution.

Swine Flu Update - Tuesday, May 5, 8:00am:

With 403 confirmed cases in nearly 40 states, U.S. health officials are backing off severe public alerts. Most of the cases have been milder than expected, and school closings do not seem to help stop the spread.

“So far, the severity of illness in this country is similar to that of [seasonal] flu, and that's very encouraging, said Richard Besser, acting director of the Centers for Disease Control and Prevention.

On a global scale, H1N1 has sickened at least 1,124 people in 21 countries. The virus appears to be easing off in Mexico, where it hit the hardest.

Swine Flu Update - Monday, May 4, 3:00pm:

After four days with most of the country’s operations shut down, Mexican officials announced today that many businesses will reopen on Wednesday. The Mexican Health Ministry said Saturday that the worst of the virus is over.

Meanwhile, China has quarantined dozens of Mexican travelers, leading Mexican government officials to say their citizens are being unfairly targeted.

Here in the United States, the Centers of Disease Control reports confirmed cases 36 states, up six states since Sunday. However, most of the 279 cases have been relatively mild. "While we're not out of the woods, we're seeing a lot of encouraging signs," said CDC Acting Director Richard E. Besser in a press briefing today.

Swine Flu Update - Monday, May 4, 8:00am:

The World Health Organization’s official tally lists 985 confirmed cases in 20 countries. Colombia and El Salvador are the latest countries joining the list.

Responses in different parts of the world are causing political tensions, not to mention travel problems. Roughly 70 Mexican travelers have been quarantined in Chinese hospitals and hotels, leading Mexico authorities to claim discrimination. On Saturday the Chinese government cancelled all flights from Mexico, leaving many Chinese travelers stranded.

Adding to the overall controversy is the statement by Mexican health officials that the H1N1 flu is easing off. Some health experts claim WHO may have overreacted with warnings that a pandemic is imminent.

“I’m not predicting the pandemic will blow up, but if I miss it and we don’t prepare, I fail,” WHO General Director Margaret Chan said in a recent interview. “I’d rather over-prepare than not prepare.”

Swine Flu Update - Sunday, May 3, 6:00pm:

Latest totals have reached 898 confirmed cases in 18 countries, with Colombia reporting the first confirmed case in South America. Here in the United States, 226 confirmed cases have been reported across 30 states, the most recent being in Pennsylvania.

In Mexico, Health Secretary Jose Angel Cordova said evidence suggests that the H1N1 flu is on the decline in that country, with 506 confirmed cases and 19 deaths. The epidemic has slowed, Cordova said, because of the government’s lockdown on schools and businesses and ban on public events.

Meanwhile, the World Health Organization urges that any farm animals possibly infected with H1N1 must be contained and monitored. The concern follows an outbreak among pigs in Alberta, Canada, where the virus was apparently spread when a farm worker, after becoming ill in Mexico, unknowingly infected the animals. Health officials are working to understand how the virus was passed from person to pig.

Swine Flu Update - Sunday, May 3, 10:00am:

The number of confirmed cases continues to rise, but the World Health Organization says there are still no signs of a pandemic.

According to the latest tally from the Centers for Disease Control and Prevention, 21 states have reported 160 confirmed cases in the U.S., with one death. WHO announced 787 confirmed cases in 17 countries. Officials stress that a pandemic indicates the geographic spread of a disease, not the severity. To become a full-fledged pandemic, H1N1 would need to spread across communities in at least one other country in a new region of the world.

On Saturday, Canadian health officials reported that a herd of pigs in Alberta had become infected, apparently by a farm worker who became ill on a recent trip to Mexico. This is the first reported case of H1N1 showing up in pigs, and the first case where the virus has apparently crossed from human to animals. Both the farm worker and the 2,200 pigs have recovered.

In a joint statement released Saturday, the United Nation’s Food and Agriculture Organization, WHO, and other international health groups said the H1N1 virus cannot be spread by eating pork and pork products. "To date there is no evidence that the virus is transmitted by food," the statement said.

Swine Flu Update - Saturday, May 2, 10:00am:

The first confirmed case of H1N1 in Hong Kong has led to the quarantine of close to 300 people after health officials determined that a hotel guest had contracted the virus.

After a 25-year-old Mexican man stayed in the hotel and later became sick, officials ordered some 200 guests and 100 staff to remain in the hotel for seven days to stop the spread of the virus.

On Saturday morning, the World Health Organization said that although it is still preparing for a pandemic, the sharp rise in the number of confirmed cases of swine flu to 658 was due to the confirmation of suspected cases in Mexico as opposed to newly reported instances. While the majority of cases have been in Mexico, a total of 16 countries now have confirmed of H1N1.

"What the increase reflects is that we are moving forward in confirming many of the cases that have been left untested for some time, so in an way that's reassuring," said WHO spokesman Paul Garwood. "So we haven't seen, say, a spike in new cases or new influenza cases appearing in Mexico City, for example," Garwood continued. "It's just the fact that this reporting backlog is bearing fruit and we're seeing the results of that."

Read Dr. Paul Auerbach's blog about who should get tested for the virus.

Swine Flu Update - Friday, May 1, 9:00am:

The warning level remains at Phase 5 on a six-step scale, indicating that a pandemic is imminent. So far 11 states have had confirmed cases of the H1N1 virus, commonly called swine flu. Today the number of confirmed cases worldwide rose to 331, up from 257 on Thursday, according to the World Health Organization.

During a pandemic, a new virus affects people in several parts of the world at the same time, with mild to severe consequences. “Influenza pandemics must be taken seriously precisely because of their capacity to spread rapidly to every country in the world,” said WHO General Director Margaret Chan in a statement on the organization’s web site. “On the positive side, the world is better prepared for an influenza pandemic than at any time in history.” U.S. officials and drug manufacturers are working on a vaccine.

Swine Flu Update - Wednesday, April 29, 9:30am:

The CDC has confirmed the first fatality in the US from swine flu, a 22-month-old child who traveled from Mexico to Houston, Texas for treatment.

"I can confirm very sad news coming out of Texas that a child has died from the H1N1 virus," Richard Besser, MD, acting director of the CDC, said in an interview with CNN. "As a parent and a pediatrician, my heart goes out to the family."

This is the first death attributed to the outbreak in the US, where the reported cases have to date been relatively mild compared to those in Mexico. Health officials have been warning the public for several days that that could change.

Swine Flu Update - Monday, April 27, 4:30pm:

The World Health Organization’s Emergency Committee met today and recommended that the level of influenza pandemic alert be raised from a phase 3 to a phase 4. This indicates that the likelihood of a pandemic has increased, not that one is certain. Epidemiological data about the human-to-human transmission and the ability of this specific virus to cause community-level outbreaks led to the decision. The WHO is not recommending the closing of borders or the limiting of international travel at this time.

Visit the World Health Organization’s website for more information on a phase 4 pandemic alert.

Here’s what you need to know about swine flu:

Why is Swine Flu in The News?
The number of fatalities in Mexico coupled with reported cases in the US, Canada and New Zealand brought the outbreak to the attention of health officials and the media. Also of concern is the fact that the strain in Mexico is attacking healthy young people, a trait usually associated with pandemic flu bugs.

What is Swine Flu?
Swine flu is just what it sounds like…a strain of flu that effects pigs and usually remains just that. Sometimes a strain of swine flu will mutate and is contracted by humans. This strain appears to be a mixture of swine, avian and human viruses and mutated viruses concern health officials due to their resistance to existing vaccines. A high fever, consistent cough, sore throat and possibly vomiting and diarrhea are the most common symptoms of swine flu, but those symptoms can be caused by countless other conditions as well. If you or someone you’ve been in close contact with has recently returned from Mexico and your flu-like symptoms persist, contact your doctor. Only a lab test can identify swine flu.

No vaccine for swine flu exists currently, but the Center for Disease Control has begun the steps needed to create one, in case that becomes necessary. This season’s flu shot does not offer protection to this virus.

What is the Government Doing?
Since this is a quickly developing outbreak and there are still many unknowns, the White House has likened their efforts to preparing for a hurricane. "Really that's what we're doing right now. We're preparing in an environment where we really don't know ultimately what the size or seriousness of this outbreak is going to be," Homeland Security Secretary Janet Napolitano told reporters. The act of declaring this a public health emergency clears the way for shipping roughly 12 million doses of flu-fighting medications from a federal stockpile to states that may need them. The Center for Disease Control says that isn’t currently needed, as the cases in the US are less severe than those in Mexico.

While the government is taking the right precautions, it’s important to point out that this is not a global pandemic — at least not yet. The true number of cases, why the Mexican cases are more severe and how easily the virus spreads are sill unanswered.

Can Swine Flu be Treated?
Yes. This specific strain can be treated with Tamiflu and Relenza.

How to Protect Yourself
The most common question on everyone’s mind is “how can I protect myself?” The good news is that common health tips that help stop the spread of seasonal flu can be effective with preventing swine flu as well. The following are recommended steps from the CDC:

• Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
• Avoid touching your eyes, nose or mouth. Germs spread this way.
• Try to avoid close contact with sick people.
• If you get sick with influenza, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them. What is the best way to keep from spreading the virus through coughing or sneezing?

At this point, the best advice is to take the right precautions and to not panic. The CDC will be issuing statements and advice as more information is known. Follow the developments on Healthline.com and other major news outlets.

Healthline’s Chief Medical Officer, Dr. Paul Auerbach will be posting ongoing updates about this outbreak in his blog.

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