United Kingdom Ends $17 Billion Electronic Medical Records Initiative

The Wall Street Journal on Sept 23, 2011 reported that the United Kingdom will scrap the entire electronic medical records (EMR) initiative that has been 9 years in the making with nearly 6.4 billion pounds already spent.

That action was hinted at back in August 2011 after a scathing parliamentary report stating the initiative to be wasteful and incapable of delivery.

I'm not surprised...

It's hard enough to get a group of doctors in one hospital to agree with a treatment plan let alone agree to a medical records system. The problem is exponentially more difficult when applying it to an entire country.

Physicians practice medicine differently... just like teachers have their own unique way of teaching kids. A method that may work for one doctor or teacher will not work for another. Even the method may change depending on how "busy" things are (teacher with a class of 5 kids versus 30 kids) so a doctor in a busy inner-city emergency room will have different flows and needs from an electronic medical records than a rural family practice with a sedate pace. Furthermore, the needs of a dermatologist is very different from a pediatrician. One can't expect a single EMR system to meet the needs of both perfectly just like one cannot expect a math teacher to use the same teaching methods as a singing teacher.

Forcing physicians to use a single standard electronic medical records without adapting to these realities is bound to fail no matter how much time, training, software, and hardware you throw at it.

A better alternative (my opinion), is to treat electronic medical records like the computers they reside on. There should be many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components... USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the "internet" that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems... but no... they don't communicate at all... which is why paper reports still exist... which are than scanned into the EMR.

Rather than the government (whether the United Kingdom or the United States) dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

The other more insidious side of EMR is the over-reaching health goal mandates which means well, but runs into the same problem of applying standards to all physicians. Take "meaningful use" set by the Centers of Medicare and Medicaid Services (CMS). One of the core measures of meaningful use is adult weight-screening and follow-up.

Now as an ENT specialist, I see patients specifically for earwax. Why in the world would I want to perform a weight-screening when all I want to do (and what the patient only wants me to do) is get earwax out???

Makes no sense.

Does it to you???

Reference:
U.K. Scrapping National Health IT Network. InformationWeek Healthcare. Aug 4, 2011
U.K. Ends Health-Service IT Upgrade. Wall Street Journal. Sept 23, 2011

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Smoker's Kids Have More Ear Infections

Although not entirely new news... a new review paper which collated the results of 61 past studies has reaffirmed that smoking around kids increases their risk of ear infections dramatically.

Just how much?

Kids living with a smoker had a:

• 37 percent higher risk of ear infections and hearing problems
• 62 percent higher risk of ear problems if the household smoker was their mom
• 86 percent more likely to undergo ear surgery than kids without secondhand smoke exposure

Read a MSNBC story on this here.

So don't smoke for your own health as well as your kids' health!!!

Reference:
Parental Smoking and the Risk of Middle Ear Disease in Children. Arch Pediatr Adolesc Med. Published online September 5, 2011. doi:10.1001/archpediatrics.2011.158

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Fauquier ENT Now Participates with Optima Health Insurance

For those patients who have not yet heard...

Fauquier ENT now participates with Optima Health insurance with one caveat... We only participate with the PPO plan only.

For the full list of health insurance policies we participate with, click here.

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Do Cell Phones Pose a Health Hazard? Do Cell Phone Companies Know About Them?

With all the recent news about increased glucose metabolism in the area of the brain in proximity to cell phone antennas (study abstract here), I thought it worth re-printing this blog article I wrote back in November 2010 regarding the possibility that cell phone makers may know more about health risks associated with cell phone use than they may be letting on. There's another blog article I wrote regarding what studies ARE already out there regarding risk of developing brain tumors that I felt worth re-printing below as well.

It is true that some people may find this recent research good news for some young people as it may be the only stimulation their brain gets (joking!), but it does bring some additional concerns that may merit limiting cell phone use as well as how it is used.

I quote (myself)...

Recently, there has been much speculation on whether cell phones pose a health risk.

What I find interesting is that the cell phone makers may actually know more about these risks than they are letting on or even have evidence for them.

If you look in the small print booklet that comes with your cell phone, cell phone makers state that phones should not be in contact with your body or skin and should be kept a certain distance away when in use or when carrying around. The picture of how the Verizon ad guy is using the cell phone is exactly how you are NOT supposed to use the cell phone (cell phone pressed against the face).

For example, in the iPhone 4 small print booklet that comes in the box with the phone, go to page 5 under the section "Exposure to Radio Frequency Energy." I quote:

"When using iPhone near your body for voice calls or for wireless data transmission over a cellular network, keep iPhone at least 15 mm (5/8 inch) away from the body, and only use carrying cases, belt clips, or holders that do not have metal parts and that maintain at least 15 mm (5/8 inch) separation between iPhone and the body."

Now, when I use a phone and answer a call, I have the phone right up against my ear just like the Verizon ad guy. I do not keep it 5/8 inch away from my ear/head.

Now why would a cell phone maker care whether the phone is right up against the ear (so you can hear better) or not unless there is some concern that there may be a danger due to proximity/contact?

Perhaps they are protecting themselves from any possible lawsuit that may occur in the future due to health problems that will occur with phone use over time?

Kind of reminds me of the tobacco industry who for years denied that smoking posed any health risk. Now we know better.

It would be ironic if Paul Marcarelli, the actor of the "Verizon Guy" character, develops a brain tumor due to cell phone use and sues the wireless industry just like the family of David McLean, the actor of the "Malboro Man," sued the tobacco industry for wrongful death when he developed and died from lung cancer caused by smoking.

Something to think about...

So are there studies out there suggesting that cell phones and wireless phones can lead to brain tumors like astrocytoma, malignant gliomas, and benign acoustic neuromas? Several studies published since 2009 containing long-term (10+ years) follow-up have lent support that it does.

The group at greatest risk for development of brain tumors have the following characteristics:

1) Use of cell/wireless phone younger than age 20 (the younger the age with first use, the worse the risk)
2) Use of cell/wireless phone for more than 10 years
3) The more hours of cellular phone use over time, the higher the risk of developing brain tumors
4) Risk higher with analog cell/wireless phones (instead of digital)
5) Risk higher with increased overall total exposure

By some estimates, subjects who used cell phones for at least 10 years had a 2.4-fold greater risk of developing a brain tumor.

Though unclear how exposure to a phone's microwave radiation leads to brain tumors, it is known that the cell signal is absorbed up to 2 inches into the adult skull. Even more worrisome is that the depth of penetration is even deeper in children.

The risk is not just to the brain, but even the parotid gland which sits just in front of the ear. In one study published in 2008 revealed an increased risk of parotid gland tumors with cell phone use. Also, contact allergy is another not uncommon risk with cell phone use.

Symptoms that a patient may exhibit that may suggest a brain tumor are subtle and include hearing loss or ringing of the ear on the same side the phone is used on.

It should be noted that all currently published results are based on retrospective studies and ideally, prospective studies will be required to provide more definitive results. However, that will take a long time and perseverance on both the researchers as well as the subjects since ideally, many of the study subjects should be children who are currently using cell phones (which it seems to be nearly all kids nowadays).

In any case, to be on the safe side, it is recommended to talk on speakerphone or use a wired headset (not wireless), or avoid altogether if at all possible, especially in children.

References:
Effects of cell phone radiofrequency signal exposure on brain glucose metabolism. JAMA. 2011 Feb 23;305(8):808-13.

Risk of Brain Tumors From Wireless Phone Use. Journal of Computer Assisted Tomography, 2010; 34 (6): 799 DOI: 10.1097/RCT.0b013e3181ed9b54

Cell phones and brain tumors: a review including the long-term epidemiologic data. Surg Neurol. 2009 Sep;72(3):205-14; discussion 214-5. Epub 2009 Mar 27.

Mobile phones, cordless phones and the risk for brain tumours. Int J Oncol. 2009 Jul;35(1):5-17.

Cell phone use and acoustic neuroma: the need for standardized questionnaires and access to industry data. Surg Neurol. 2009 Sep;72(3):216-22; discussion 222. Epub 2009 Mar 27.

Cellular phone use and risk of benign and malignant parotid gland tumors--a nationwide case-control study. Am J Epidemiol. 2008 Feb 15;167(4):457-67. Epub 2007 Dec 6.

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Wireless and Cell Phones Increase Risk of Brain Tumors

In an ongoing controversy regarding whether cell phones and wireless phones can lead to brain tumors like astrocytoma, malignant gliomas, and benign acoustic neuromas, several recent studies published since 2009 containing long-term (10+ years) follow-up have lent support that it does.

The group at greatest risk for development of brain tumors have the following characteristics:

1) Use of cell/wireless phone younger than age 20 (the younger the age with first use, the worse the risk)
2) Use of cell/wireless phone for more than 10 years
3) The more hours of cellular phone use over time, the higher the risk of developing brain tumors
4) Risk higher with analog cell/wireless phones (instead of digital)
5) Risk higher with increased overall total exposure

By some estimates, subjects who used cell phones for at least 10 years had a 2.4-fold greater risk of developing a brain tumor.

Though unclear how exposure to a phone's microwave radiation leads to brain tumors, it is known that the cell signal is absorbed up to 2 inches into the adult skull. Even more worrisome is that the depth of penetration is even deeper in children.

The risk is not just to the brain, but even the parotid gland which sits just in front of the ear. In one study published in 2008 revealed an increased risk of parotid gland tumors with cell phone use. Also, contact allergy is another not uncommon risk with cell phone use.

Symptoms that a patient may exhibit that may suggest a brain tumor are subtle and include hearing loss or ringing of the ear on the same side the phone is used on.

It is interesting to note that it is just possible that the cell phone industry is aware of these risks even as it denies any risk of health problems with phone use. If you look in the small print booklet that comes with your cell phone, cell phone makers state that phones should not be in contact with your body or skin and should be kept a certain distance away when in use or when carrying around. Read more about this here.

However, all currently published results are based on retrospective studies and ideally, prospective studies will be required to provide more definitive results. However, that will take a long-time and perseverance on both the researchers as well as the subjects, since ideally, many of the study subjects should be children who are currently using cell phones.

In any case, to be on the safe side, it is recommended to talk on speakerphone or use a wired headset (not wireless), or avoid altogether if at all possible.

References:
Risk of Brain Tumors From Wireless Phone Use. Journal of Computer Assisted Tomography, 2010; 34 (6): 799 DOI: 10.1097/RCT.0b013e3181ed9b54

Cell phones and brain tumors: a review including the long-term epidemiologic data. Surg Neurol. 2009 Sep;72(3):205-14; discussion 214-5. Epub 2009 Mar 27.

Mobile phones, cordless phones and the risk for brain tumours. Int J Oncol. 2009 Jul;35(1):5-17.

Cell phone use and acoustic neuroma: the need for standardized questionnaires and access to industry data. Surg Neurol. 2009 Sep;72(3):216-22; discussion 222. Epub 2009 Mar 27.

Cellular phone use and risk of benign and malignant parotid gland tumors--a nationwide case-control study. Am J Epidemiol. 2008 Feb 15;167(4):457-67. Epub 2007 Dec 6.

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Santa Claus, A Sick Patient Needing Medical Care

ENT Journal published in December 2003, a humorous paper on Santa Claus as a patient with numerous medical problems. Given it is Christmas Eve, it is probably worth revisiting the article which lists among his many medical problems:

• Allergies to woodwork (sawdust and varnish) and materials used in preparing teddy bears, dolls, and other gilts.
• Asthma exacerbated by reindeer exposure as well as the hay and straw in the stable which makes his nose run
• His symptoms get worse when he leaves the North Pole where there is no pollen to regions of the Earth where vegetation and pollen are plentiful, especially in the Southern Hemisphere where it is summer.
• Going down chimney's irritates the eyes and his nose resulting in sneezing fits. Probably carcinogenic as well.
• Santa is considerably overweight, and his cheeks appear quite ruddy suggesting high blood pressure.
• Probably has type 2 diabetes exacerbated by milk and cookies left for him in millions of homes.
• He smokes a pipe putting him at increased risk of oral, throat, and lung cancer

Merry Christmas!

Suggest you leave for Santa a glass of water and a low-calorie, low-salt granola bar instead of milk and cookies tonight!

Read the full article here.

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Patient Experience Just As Important As Clinical Expertise

I read with great interest an article in the New York Times "How Does Your Hospital Room Make You Feel?" regarding how a patient room... how a hospital appears... private rooms... may play just as important a role in where a patient goes for treatment as the clinical expertise of its doctors.

Indeed, amenities are a critical part of the patient experience and possibly even a more valuable component of patient-centered care as reported in the New England Journal of Medicine. A patient’s nonclinical experience inspires clinical productivity, drives improved clinical outcomes, and improves overall patient satisfaction.

Not that such reports are a big surprise. It's something I think all major non-healthcare corporations have already realized for decades. Just walk into any Abercrombie & Fitch or Toyota car showroom. Such businesses hit all of our senses to the 10th degree... There's the visual stimulation of models (human or otherwise). Popular music playing in the background to stimulate the ears. Lovely perfume smells in a clothing store or fresh leather in a car showroom to stimulate the nose. And oh yes... freshly baked cookies or candies to bring some zing to the taste buds.

How can you NOT like what you see/hear/taste/smell??? And, buy some things along the way given you have been stimulated into such a good mood?

Indeed, it's surprising why hospitals weren't the FIRST institutions to maximize the senses to bring peace to mind/body/soul and... to also provide medical treatment.

SO... it is with great satisfaction that our practice is affiliated with a hospital that subscribes to the importance of these non-clinical factors. Fauquier Hospital has:

• Private patient hospital rooms
• Family and friends can drop by any time, day or middle of the night
• Food that's actually good
• Patient friendly architectural features including:

• built-in sleeping accommodations for family members
• carpeted corridors and additional windows
• lamps have replaced overhead lighting
• halls have been carpeted to keep down noise or are finished in faux wood for a warmer feel
• community artwork hangs on the walls
• barriers between patients and staff, such as those sliding-glass windows that close nurses off from patients and the public, have been removed
• elevators for patients and the public are separate
• no constant paging over the intercom system, either; instead, unobtrusive music plays all the time.

• Also, a culture fostering patient care is presented.

Come check out Fauquier Hospital here!

Read the NYT article here.

Read the New England Journal of Medicine Article here.

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Do Cell Phone Makers Secretly Know Cell Phones May Cause Health Problems?

Recently, there has been much speculation on whether cell phones pose a health risk. Wikipedia has a nice summary of those concerns.

What I find interesting is that the cell phone makers may actually know more about these risks than they are letting on or even have evidence for them.

If you look in the small print booklet that comes with your cell phone, cell phone makers state that phones should not be in contact with your body or skin and should be kept a certain distance away when in use or when carrying around. The picture here is exactly how you are NOT supposed to use the cell phone.

For example, in the iPhone 4 small print booklet that comes in the box with the phone, go to page 5 under the section "Exposure to Radio Frequency Energy." I quote:

"When using iPhone near your body for voice calls or for wireless data transmission over a cellular network, keep iPhone at least 15 mm (5/8 inch) away from the body, and only use carrying cases, belt clips, or holders that do not have metal parts and that maintain at least 15 mm (5/8 inch) separation between iPhone and the body."

Now, when I use a phone and answer a call, I have the phone right up against my ear as shown in the picture here. I do not keep it 5/8 inch away from my ear/head.

Now why would a cell phone maker care whether the phone is right up against the ear (so you can hear better) or not unless there is some concern that there may be a danger due to proximity/contact?

Perhaps they are protecting themselves from any possible lawsuit that may occur in the future due to health problems that will occur with phone use over time?

Kind of reminds me of the tobacco industry who for years denied that smoking posed any health risk. Now we know better.

Something to think about...

I should add that most studies to date do not show any definitive long-term harm from using cell phones, though studies following patients for more than 10 years do show an association with brain tumors. The greatest consistent risk is more from contact allergy.

BUT, to be on the safe side, it is recommended to talk on speakerphone or use a wired headset.

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New Video Produced on Using MediTech EMR on the iPad!

Our office has been instrumental in bringing the Apple iPad to Fauquier Hospital allowing physicians to access MediTech.

In order for physicians to see how MediTech can be accessed and used on the iPad, our office has created a YouTube video tutorial. Not only is MediTech shown, but also PACS. This video has been added to our YouTube channel.

Please note that this video is in REAL-TIME. It has not been speeded up. The system we are using is Citrix Version XanApp 5 and MediTech Client/Server v5.6.4 PP13.

Watch the video on YouTube here or below.

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records

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UPDATE #2: iPad and MediTech Electronic Medical / Health Records

This blog article is a continuation of prior blogs (6/12/10 and 9/20/10) I wrote on the use of the iPad with Meditech.

Since June 12, 2010 when I first wrote about my experiences of using the iPad with my hospital's Meditech EMR system, a LOT has happened...

First, the hospital has upgraded its Citrix infrastructure to allow iPad (as well as Mac) connectivity to the hospital's MediTech EMR using the Citrix Receiver app (free in iTunes). I reported this back in 9/20/10.

Since than, the hospital has done a remarkable job optimizing and speeding up the connectivity to the point where using MediTech on the iPad is JUST AS FAST as using it on a hospital networked desktop. Of course, the iPad needs WiFi access to achieve these speeds.

Furthermore, I can now access PACS directly via Citrix Receiver app on my iPad rather than going through MediTech which is just great!

My only complaint now (which may not be possible to address with current Citrix software) is the initial prolonged time it takes to get to the MediTech logon screen. After that, speed is quite zippy.

From my conversations with individuals in the know, the next step would be to create a "MediTech" app on the iPad, rather than going thru Citrix Receiver app.

Obviously, one way of doing this is if MediTech creates a native application for the iPad which does not appear to be likely anytime in the near future.

A more likely solution that may be achievable in the next few months is to create a "virtual" MediTech iPad app using Citrix as the engine "under-the-hood". This is an active area of development and I am optimistic that such a virtual MediTech iPad app will soon be available.

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

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UPDATE: iPad and MediTech Electronic Medical / Health Records

Ever since I wrote my initial impressions of using the iPad with Meditech EMR on June 12, 2010, that blog article has received almost a thousand hits since that time, averaging about 20 hits per day. I've even been featured in Meditech news.

Also in the interval period, I have received numerous inquiries from health systems all over North America using MediTech regarding more specifics on how the iPad is used/incorporated into MediTech EMR.  Due to this interest, I've decided to write an update regarding what is going on since that initial blog article...

SO... I no longer need to use LogMeIn in order to access MediTech. Since then, Fauquier Hospital has upgraded their Citrix infrastructure so I now use a Citrix Receiver app (free in iTunes) to access MediTech.

Things are of course much faster, but still not quite as fast as I would like it to be. Currently, the hospital and I are working to resolve some of the speed issues seen. McKesson PACS (radiology imaging software) also is on the drawing board for direct Citrix access rather than going through MediTech which would also be welcome.

I recently heard from a confidential and utterly reliable source that MediTech has been asked to create a native app for the iPad (thus avoiding Citrix altogether), but the company at this time has politely declined to develop such an app that would hugely improve the user experience and most likely speed.

I would encourage all MediTech users to contact MediTech directly and demand/request that such a native iPad app be developed which would be immensely beneficial and strongly desired. Otherwise, alternative 3rd party software like Citrix will have to be used along with its inherent handicaps.

Click here to view MediTech's contact information.

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

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Positive Patient Feedback

Dr. Chang received a bonsai tree from Fauquier Hospital for having received positive patient feedback for the past 4 consecutive quarters. How nice!

Read other patient testimonies here.

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Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR

On Sept 8, 2010, a story was published in MediTech Magazine regarding how Dr. Chang has piloted the use of the Apple iPad with MediTech electronic medical records used in Fauquier Hospital.

Click here to read the story (pdf document).

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

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Fauquier Hospital VIPeds Medical Camp Program on Channel 9 News

It was quite cool to see Fauquier Hospital's innovative VIPeds Medical Camp program featured on Channel 9 news. This unique hands-on program is for teenagers to learn more about the health profession and opportunities found inside a hospital.

Local teens learn to apply a cast, to harvest a cornea (I personally have no idea how to do that!), to suturing a wound closed. No ENT related procedures however...

Check out the video segment here.

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Dr. Chang Invited to Be a Judge for the 2010 Web Health Awards

Dr. Chang has been invited to be a judge for the Summer 2010 Web Health Awards. Now in its 12th year, the goal of the Web Health Awards is to recognize high-quality electronic health information. The awards program is organized by the Health Information Resource Center (HIRC), a national clearinghouse for professionals who work in consumer health fields.

Read more about the Web Health Awards here.

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RANDOM: Benford's Law Applied to Health?

Today, I listened to an amazing NPR RadioLab episode titled "Numbers."

In one of the stories in this episode, Jad and Robert Krulwich educated me on an interesting mathematical phenomenon called Benford's Law. Simply stated, Benford's Law states that in lists of numbers from many (but not all) real-life sources of data, the leading digit is distributed in a specific, non-uniform way. According to this law, the first digit of a number is "1" almost one third of the time, and larger digits occur as the leading digit with lower and lower frequencies, to the point where 9 as a first digit occurs less than one time in twenty. This is completely contrary to the expectation that the number 9 or 8 should occur equally as frequently as 1 or 2.


(From "The First-Digit Phenomenon" by T. P. Hill, American Scientist, July-August 1998)

But get this... This law holds true whether talking about random samples from a day's stock quotations, a tournament's tennis scores, the numbers on the front page of The New York Times, the populations of towns, electricity bills in the Solomon Islands, the molecular weights of compounds, the half-lives of radioactive atoms, and much more.

It seems to me that if the universal natural state of order follows Benford's Law... I wonder whether it also holds true for the human body...

I did a pubmed search and it seems that there have been a few researchers who had the same idea, most applied only to basic biological processes:

- Biologic kinetic rate parameters follow Benford's Law (abstract)
- mRNA transcription data from a wide range of organisms and measured with a range of experimental platforms show close agreement with Benford's law (abstract)
- Different states of anesthesia can be detected by Benford's Law (link)

Just for giggles and kicks, I looked up normal bloodwork values for a human being. This website nicely listed the most common normal values. I than jotted down the frequencies of the first integer of all the lab values listed and here's what I came up with:

#1 (30.5%)
#2 (17.1%)
#3 (10.2%)
#4 (10.2%)
#5 (7.3%)
#6 (7.3%)
#7 (6.5%)
#8 (5.8%)
#9 (5.1%)

Amazingly... though the frequencies don't match up perfectly, they do come eerily close to Benford's Law.

With larger lists of numbers, the approximations may come even closer. Potential neat project for a student, eh?

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