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Podcast Transcript - December 4, 2007

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Hello, and welcome to this weeks Annals of Internal Medicine Audio Summary for our December 4, 2007 issue. I’m Michael Berkwits, Deputy Editor at Annals.

We have another exciting issue for you this week, with articles on the use of telbivudine for the treatment of chronic hepatitis B; the three medications most responsible for emergency department visits by older adults; and the risk for fatal pulmonary embolism in patients with venous thromboembolism who discontinue anticoagulants. I’ll tell you about those articles, but in this week’s summary you’ll get a bit of a break from strictly clinical topics in two conversations, the first with the authors of a survey study assessing physicians’ attitudes and behaviors about medical professionalism, and the second with the authors of an American College of Physicians manifesto that makes clear the potentially unethical consequences of pay-for-performance programs, and lays our principles of implementing those programs that are important for preserving patient-rather than incentive-focused care. Plus I’ll review all the other articles in this week’s issue.

Bur first, here’s an in-depth summary of those feature articles.

Medical Professionalism

In 2002 Annals published a physician charter that proposed 3 fundamental principles of medical professionalism - dedication to patient welfare, respect for patient autonomy, and promotion of social justice in the health care system – and a set of specific commitments – such as commitments to maintaining competence and to managing conflicts of interest - that set standards for how physicians could and should meet those principles.

In this week’s issue, lead author Eric Campbell and his colleagues from Masschusetts General Hospital’s Institute for Health Policy in Boston report the results of a national survey assessing physicians’ commitments to those standards.

The authors sent a survey to about 3500 providers in 3 primary care and 3 non-primary care specialties asking if they agreed that the charter commitments were important, and asking, with the use of patient scenarios and direct questions about past actions, if their behaviors tracked those commitments.

Their study had weighted response of 58%, and three main findings.

First, most respondents agreed that the commitments were important, with the exception that about 25% did not agree that periodic board recertification to maintain professional competence was necessary for their practice or for professionalism.

Second, behaviors reflecting the commitments did not always match the commitments themselves. For example, 11% of respondents admitted to inappropriately revealing confidential information about a patient, and only 25% said that they had actively looked for racial or sex disparities in their practices, clinics, or hospitals.

Finally, there were differences in behaviors by specialty, and no one came out looking lily white. If anything, anesthesiologists and pediatrician came out on top, being more likely to report an impaired colleague, accept new uninsured patients, and participate in quality improvement programs in the case of anesthesiologists; and being more likely to undergo competency assessments, report serious medical errors, and see patients who were unable to pay for services in the case of pediatricians. Internists tended to provide responses in the top half of the response distributions, although they were less likely than other providers in other specialties to provide care without reimbursement in settings serving poor and underserved patients. There were also differences by practice setting and reimbursement mechanisms, although to be clear, all of these differences were differences in proportions of providers who said that they engaged in the behaviors; different specialties had different response rates, and the authors didn’t perform formal statistical comparisons or report results as statistically significantly differences. But you could figure that out yourself to a degree by closely examining the confidence intervals around the proportions in the paper’s Table 4 and seeing which overlap, and which do not.

Based on these findings, the authors conclude that the professional aspirations embodied in the Charter on Professionalism are relevant and meaningful to physicians even though professional behaviors appear to vary by norm. They acknowledge that their measures are far from perfect and that the association between self-reported and actual attitudes and behaviors may be limited. They don’t acknowledge that there are health system and other forces that keep even the best-intentioned providers from acting on these professional ideals, and they don’t say what I as an individual provider can or should do with these results.

So I called two of the study’s authors to ask them these and other questions. Dr. Eric Campbell and Dr. David Blumenthal are both at the Institute for Health Policy at Massachusetts General Hospital and Partners Health System in Boston, Dr. Campbell as an Associate Professor of Medicine and Dr. Blumenthal as a Professor of Medicine and Professor of Health Policy as well as Director of the Institute. They were kind enough to take the time to explore with me the concept of professionalism a bit more than we editors could allow them to in their research report.

Q: Dr. Campbell and Dr. Blumenthal, thank you for talking to me.

DB: Thank you for having us.

EC: Thank you.

Q: You imply in the paper’s introduction that promoting professionalism among physicians is one way to improve the quality and efficiency of health care. In what ways would you say professionalism improves health care quality, and in what ways would you say it improves efficiency?

DB: I think that if you look back at the recent history of the US health care system, you’ll see that we have tried very hard to improve the functioning of the health care system through using regulatory means and through promoting competition in markets. We’ve done neither of them perfectly, and neither strategy has significantly improved the cost of care or the quality of care. That leads us to look for alternative ways of making the system function better. One of the reasons why markets don’t function well is that there are asymmetries of knowledge between patients and providers of care -- a fundamental flaw -- and one of the reasons regulation doesn’t function well is that there are just too many decisions made by doctors and patients and health care institutions every day for regulation to effectively control them. It would work much better if those who were most informed about decisions made decisions that were consistent with their patients’ interests and with the interests of the larger society. It would become much more a self-regulating system than it is now, and ultimately. I think, professionalism is about. in a major way, self-regulation in the patient’s and in society’s interest.

Q: One of the primary findings of the paper is that professional behaviors often didn’t match attitudes. So how confident are you about that finding given that all your behaviors were self-reported, and that are selection and desirability and maybe other biases that could have inflated responses to both parts of the survey?

EC: You raise a very important point which you mention in our study is the fact that there is this thing called social desirability bias in that, not just physicians but any- most people answering surveys don’t like to admit to behaving or holding attitudes that may be considered against what are the prevalent norms in one’s field or social reference group.

So clearly we might say for example that the level that we found that physicians support attitudinal norms about professionalism are probably likely to be overestimates. We found that behaviors probably run along the same lines, is that people may overestimate engaging in behaviors that are seen as positive, but at the same time they are likely to underestimate engaging in behaviors that are seen as counter to the norm. Now with that said we’ve used a number of survey techniques to control for these things in that we allowed people to respond anonymously, which research in the survey field has shown that reduces this bias to some extent. Now we can’t totally eliminate it but we certainly believed it’s reduced given the way in which our study was conducted.

Q: And let me ask you another methodologic question, which is that your response rate was something like 58%. What implication does that have for the generalizability of the findings to physicians.

Well 58% in terms of survey physicians is a very good response rate, and it’s getting harder and harder all the time to achieve those response rates. With that said, there’s also no magic number. The issue is not the response rate, the issue is the extent to which the people who respond differ in any systematic way from the folks who don’t. And as long as your responding group is big enough, in theory, you don’t have a problem. We’re very confident in what we’ve achieved, partly because of the high response rate, and because of the fact that we didn’t see differences in response by specialty, for example, which suggests that at least along one variable, our respondents were similar to the population from which they were drawn.And we found that physicians differ significantly on many of the attitudes and behaviors regarding professionalism by their specialty, and clearly that’s something we need to explore in the future that there are really kind of systematic and predictable ways in which for example primary care doctors differ from other specialists such as anesthesiologists and/or cardiologists. And I think the next step in this survey has to kind of begin to address those specialty-specific differences and what impact that might have on, really, the concept of professionalism within a specialty. and between specialties as well.

DB: Cardiologists don’t see the owning of an imaging facility and referring patients to that imaging facility as problematic nearly as often as other physicians do, so that the principle of putting patients’ interests ahead of your financial interests, they’re not as sensitive to that norm as some other specialties might be. Another thing that is interesting though is that cardiologists are more likely to report that they see uninsured patients, for example, than general internists are. And that may be because they see fewer of them in general, or may be because they in general earn more money and feel less pressure and have more time. These are all speculative conclusions. But I think it highlights the fact that physicians are not all alike. Their circumstances, their training, and maybe their self-selection in to professional areas affect their conformance to professional norms.

EC: And specialists were significantly more likely to report that they feel prepared to evaluate new clinical information. They were more likely to report impaired and incompetent colleagues than were primary care doctors.

DB: Especially anesthesiologists.

EC: And I think those reflect the culture of these specialties

Q: And also perhaps the risk for impairment, right, in some specialties?

DB: Yeah.

EC: Absolutely.

Q: The ABIM charter and the questions in the survey reflect our modern preoccupations, for example with improving healthcare quality and reducing disparities, and managing conflicts of interest and errors. But I also wonder about a less modern, and some people might even say a more heroic conception of professionalism that isn’t addressed directly in the Charter, in which doctors place patients’ interests above all others. So that’s embodied by classic images of the doctor sitting at a patient’s bedside through the night waiting to make sure they’ll get better, or stories of physicians canceling important personal commitments to attend to emergencies. And I wonder if you thought you could speak to that, and if there’s a role for that kind of behavior, and if that ideal would be enough to address all the domains in the Charter and in your survey?

DB: I realize that your original reference was to the famous English painting of a physician sitting at the side of a sick child. But I think that within the ABIM norms, there are questions about putting the interests of patients ahead of personal interests of physicians. On the behavioral side, they’re not explicitly stated or as fully developed as one might like. But they definitely are there with respect to, for example, financial conflicts of interest, and a willingness to see patients who are not insured and therefore can’t pay, as well as a willingness to get involved in relationships with industries that might lead to biases in medical decision making. But I would agree that we haven’t explored that traditional notion of altruism and of putting patient interests ahead of professional interests as fully as we might. And we are, by the way, repeating this survey some time next year, at the end of next year, so we have an opportunity to expand on some of these dimensions and I think this would be one that would be worth exploring. There’s a parallel set of questions that have arisen very explicitly in some countries other than ours, actually a very interesting national experiment with that set of questions about professionalism that occurred as part of the SARS epidemic. Institute on Medicine as a Profession is exploring the opportunity to do a similar survey in China, and in the pilot study that the Chinese developed based in part on our survey, they had a whole battery of questions about the willingness to care for SARS patients and what their respondents actually did during the SARS epidemic. So I think that is in some ways a paradigmatic instance of what you’re talking about. The ultimate willingness to sacrifice for your patient is the willingness to put your own life at risk by being in the presence of a potentially fatal and contagious illness. I suppose you could say that we saw some similar kinds of testing of physicians’ altruism, professionalism, during the early stages of the HIV epidemic and we didn’t as a profession always shine in that light. So I think it’s a very interesting area to explore.

Q: So we have the ABIM charter, and we have these results from your survey. So what’s the next step – what does the Institute on Medicine as a Profession or the American Board of Internal Medicine or we as individual providers do with this information?

DB: I think that one locus of activity should be the specialty society. I’d like to see other specialty societies, besides the American College of Physicians and the American Board of Internal Medicine, engage systematically in whatever assessment they think is appropriate for measuring the conformance of their members with professional norms, and then to develop interventions that might improve that rate of conformance. So I think that’s one locus of action and I think our survey suggests that different specialty societies may emphasize different norms because their members will conform differently with different norms. The other thing where I think we collectively need to apply some effort is in public policies that can affect professionalism, and organizational settings that can affect professionalism. Once you focus on professionalism as a kind of Third Force aside from competition and regulation in managing the health care system, it becomes reasonable to ask what mechanisms can be used to reinforce professionalism, and almost to do an impact analysis when you’re making policy or organizing your physician workforce, asking how will this affect professionalism. So it seems to us that large groups and pre-paid group practice have certain advantages in terms of stimulating professionalism; Universities have certain advantages; and similarly some other solo practices seems to have a lot of disadvantages and we think that that’s another reason to look at organizational setting and how you pay doctors may also have some impact. So I think that specialty societies, public policy, physician organization are all potential points of influence.

Q: Is the idea there that pay for performance wouldn’t just be process measures such as HBA1C and clinical outcomes, but that physicians might be reimbursed for adherence to professional norms?

DB: I think we would need to do much better than we have in terms of measuring adherence to those norms, but yes, I could see that as one type of outcome if you can get consensus about which norms payers, employers, and physicians agree are core to appropriate functioning of the health system.

EC: This was really our first try and we are going to be doing this survey again in about a year. We’re going to be doing some additional work on the survey instrument, trying to refine it, make it a little more comprehensive, fix a few of the questions that didn’t work so well. We’re going to be fielding it among some of the same groups that we fielded it this time to get longitudinal data, as well as including some new specialties of psychiatry I believe is one that we’re going to focus on in the next round as well, and we should be in the field, I would guess, in the next year or so. In addition, we also plan to do this study comparing doctors in the UK versus doctors in Scotland, so that we’ll be able to get both a U.S./non-U.S. comparison as well as a comparison looking at the differences in professionalism while taking into account the differences and the changes that have happened in England compared to Scotland and their health care reforms as well.

DB: And as I mentioned we’re talking about other international collaborations. We’re having discussions with some collaborators in the Netherlands and in the EU and in China. I guess one of the questions that one could ask is whether professional norms and behaviors are attributes of Western culture uniformly or whether they vary across nations and cultures within the West and even across cultures West and East. So we’re asking I think some more generic questions about the universality of professionalism as a concept.

Q: Dr. Campbell and Dr. Blumenthal, thank you very much for talking to me.

DB: You’re very welcome

EC: Thank you.

That was Dr. Eric Campbell and Dr. David Blumenthal, both of the Institute for Health Policy at Massachusetts General Hospital and Partners Health System in Boston, and the lead and senior authors respectively on this week’s article, entitled “Professionalism in Medicine: Results of a National Survey of Physicians.”

Listeners interested in thinking more about medical professionalism should consult the Charter itself; the editorial accompanying this week’s report “Medical Professionalism and The Parable of the Craft Guilds”, by none other than Hal Sox, Annals editor-in-chief; and check out the website of the Institute for Medicine as a Profession, a nonprofit foundation and research institute affiliated with Columbia University focused on promoting professionialism in medicine. They’re at www.imapny.org.

Guiding Principles for Ethical Pay-for-Performance Programs

Our other featured article this week is a College position paper on pay-for-performance that’s being called an Ethics Manifesto by the College’s Ethics, Professionalism, and Human Rights Committee.

The paper raises the concern that pay-for-performance systems could create unacceptable conflicts of interest, because rewards from favorable quality ratings could create provider incentives that conflict with what’s important to the patient.

Measuring HbA1c is a good example. Systems that reward good performance on such a highly specific measure could lead providers to give up on or refuse to accept new patients whose HbA1c is difficult to control. Such systems could lead providers to neglect other aspects of their patients’ care, even if they don’t deselect the patient from their practice, and to order tests or even give treatments that patients don’t need to ensure that the measure meets the systems’ definition of quality, so that the provider can maintain their income.

The principles that emerge from these concerns are that pay-for-performance incentives should reward providers who care for older, more complicated, and more vulnerable patients at least as much as they reward the care of less complicated patients. The paper makes the additional claim that measures of quality on which rewards are based need to incorporate domains of care quality that are important to patients and key to improving their health, such as provision of good counseling and good communication; continuity of care; maintaining patient confidentiality; and ensuring access.

The authors make the case that ethical pay-for-performance systems need to develop broad and reproducible measures of these care elements, and to recognize not just isolated care measures, but comprehensive care of the patient. Such systems need mechanisms to notify patients that incentives are in place; and they need to introduce administrative oversight of physicians -- admittedly a potential burden to individual providers – the sole purpose of which is to ensure that patients aren’t fired from provider practices because the patients literally don’t measure up, and to prevent provider unwillingness to accept new patients who might make the providers’ quality measures worse.

So these are great principles, and I’d vote for all of them right now if I were handed a ballot, but they also seemed pretty abstract. So I went to the authors and asked for a little more detail about what they were trying to say and do. Lois Snyder is Director of the Center for Ethics and Professionalism at the American College of Physicians, and Richard Neubauer is a member of the Committee; a regent on the College’s Board of Regents; he’s Chief of Internal Medicine at the Alaska Native Medical Center in Anchorage Alaska; and he’s a Clinical Assistant Professor of Internal Medicine at the University of Washington in Anchorage. Together they cued me in a little more to what they and Committee were thinking.

Q: Ms. Snyder and Dr. Neubauer thanks for talking to me.

RN: You bet.

LS: Thanks for having us.

Q: What does pay-for-performance look like in 2007 and 2008 – are there programs in place now in health systems or large practices or elsewhere that meet the Committee’s definitions of pay-for-performance?

LS: The Committee used a broad definition of pay-for-performance: performance measurements tied to financial incentives to bring about clinician and systems change. Recent surveys suggest that there are now well over a 100 pay-for-performance initiatives nationwide sponsored by a variety of health plans or coalitions, public insurance programs. For example, the Agency for Health Care Research and Quality found that more than half of HMOs use pay-for-performance programs and the Commonwealth fund found that more than half of state Medicaid programs have one or more pay-for-performance programs with nearly 85% expected to have them within the next 5 years.

RN: And I would add that there is also the so called pay-for-reporting program that was recently started by CMS and Medicare over the past year and that may evolve into a pay-for-performance program in the future. And also England has put in place a pay-for-performance program that involves a very large number of performance measures.

Q: So what does the Committee see as the potential downsides to those programs? Let’s say most internists are giving patients their flu shots and their pneumovax shots, for example, or checking HbA1c levels in their patients with diabetes. Why is rewarding them for doing those things consistently, and consistently well, a problem?

RN: Okay, so the potential is that pay-for-performance programs that rely on a limited set of measures may have a number of unanticipated consequences. Most people agree that paying for higher quality can be valuable both economically and ethically. Reaching agreement on the details of how the program should work is a bit harder. The Committee expressed in this paper their concern that medically appropriate care for individual patients should take precedence over other considerations and that incentives should encourage that. Potential pitfalls of pay-for-performance could include deselection of challenging patients; gaming the system to achieve good scores on a limited set of performance measures rather than focusing on the patient; and finally, harm to the patient-physician relationship, as another unintended consequence.

Q: The Committee makes recommendations that sound like they might balance the potential adverse effects of pay-for-performance programs. What are those recommendations?

LS: Overall, the College wants to ensure that pay-for-performance programs help improve the quality of care in a manner that aligns with the goals of medical professionalism and also with the views of patients. Measures need to reflect what’s important to patients. Things like access and continuity of care with trusted physicians, effective communication, adequate time for office visits, coordination of care across settings and providers, the role of the family in care. There also needs to be transparency in these programs so that patients are aware of incentives and there needs to be monitoring of programs to ensure that so-called challenging patients are not deselected or otherwise discriminated against.

Q: So in an ideal world, who do you think should be responsible for those actions, say, notifying patients of incentives that might work against their interests or developing procedures to prevent patient deselection?

RN: That is not addressed specifically in this paper, but the College has said in the ACP Ethics Manual and other College policy that physicians should disclose potential conflicts of interest to patients and that purchasers in health plans should also disclose to patients any arrangements that may influence care. A particular problem in this specific area of pay-for-performance is that many physicians may not personally identify being paid for performance as a potential conflict of interest. A valuable outcome of addressing this issue prospectively could be that the public will better understand the incentives that may influence their care.

Q: So let’s take that a little further. You acknowledge in the paper that notifying patients about incentives that work against their interests could increase the risk that patients won’t trust their physicians. But you say that secrecy and not being transparent has worse consequences. What consequences are you imagining?

LS: Well of course every payment system creates incentive and potential conflicts of interest. Patients should know the basis for health care recommendations they receive and whether contractual or other arrangements might influence clinician judgment to promote or limit treatment. We feel that trust is imperiled when potential conflicts of interest are not disclosed, leaving patients in the dark, or leaving them to wonder if anything influenced their doctor’s recommendation.

Q: The paper mentions developing objective measures of the values that you emphasize as a way of insuring that a full range of values are represented in pay-for-performance programs. Let’s take developing objective measures of continuity as a way of presumably preventing deselection of patients. Wouldn’t that kind of measure penalize providers for non-adherent patients who disappear for long periods in much the same way that pay-for-performance programs might?

RN: Yeah, I think that’s a very good observation. That’s why these sorts of programs are very complicated. Patients often choose to refuse all sorts of recommendations from their physicians and that’s certainly their right. But at the end of the day the sorts of measures that are going to reflect the best care, especially for patients with multiple chronic problems or the elderly, are very important. What we don’t want as we say in the paper is the outcome where “the patient died but the electrolytes were in balance.”

Q: Who does the Committee intend as the audience for the paper - who do you hope’s going to read it and will take notice?

LS: We hope that physicians, patients, policy makers, payers that they all read the paper. Since all of them need to recognize and support the importance of the patient-physician relationship and the ethical obligations of physicians to their patients.

Q: And why is this a Manifesto rather than a Position Paper or a Recommendation Statement?

RN: While this is a Position Paper of the College, we purposely chose the word Manifesto in the title. The definition of the Manifesto is a public declaration of principles, policies, or intentions. And we specifically wanted to focus attention on the fact that pay-for-performance programs need to adhere to basic ethical and professional standards that place the whole patient in the forefront, not just a few aspects of their care.

Q: I wonder if part of the problem lies in the language that we use. That is, pay-for-performance sounds venal, as if it puts financial incentives first, ahead of caring for the patient. I wonder if we talk more consistently about value based purchasing, if that idea would more easily accommodate a range of values, including those that you emphasize in this week’s paper. Do you think there’s a difference between pay-for-performance and-value based purchasing and do you think this paper might look different if the Committee were addressing value-based purchasing of health care instead of pay-for-performance?

RN: I think that the problem with pay-for-performance is that if it’s grafted on to a dysfunctional payment system that doesn’t recognize the care of the whole patient and continuity of care as one aspect of that, that’s where the problem lies. If we look at value-based purchasing in a global fashion, I think what that really means is trying to figure out what we want in our healthcare system, and our current payment system doesn’t really address that.

LS: And I would just add that I think you’re absolutely right about the language “pay-for-performance.” That “pay-for” and “performance” don’t really recognize the importance of what’s going on here: the patient-physician relationship and the delivery of health care. And in fact, patients would be rather surprised probably by the term pay-for-performance when their expectation is that their physician is doing for them the right thing in the first place. Why would they be paid extra to do a test that they should be getting anyway? So I think you’re absolutely right, the language is perhaps part of the problem.

RN: One other additional thought on that. It always seemed to me that the best way to improve physician performance on any specific set of things would be to give point-of-care feedback. In other words, if you knew that you’re only meeting expected goals and how often you’re doing hemoglobin A1c measurements 50% of the time, you would correct that as a caring physician. The problem is that we don’t have the tools to know that in our practices. I’m not sure that paying for performance on that is the best way of changing that behavior.

Q: Are there initiatives that you’re aware of that would allow individual providers of practices to monitor their own performance in that way?

RN: Well I think the patient-centered medical home concept that the ACP is promoting is on the right track to getting to that answer.

LS: Well, and electronic medical records would go a long way to our collecting that information.

RN: And that is part of the patient-centered medical home concept.

Q: Ms. Snyder and Dr. Neubauer thanks so much for talking to me.

LS: Thank you.

RN: Thank you.

That was Lois Snyder, Director of the Center for Ethics and Professionalism at the American College of Physicians, and Richard Neubauer a committee member and a regent on the College’s Board of Regents, talking about the position paper they coauthored this week entitled Pay-For-Performance Principle That Ensure the Promotion of Patient-Centered Care: An Ethics Manifesto.

Readers interested in pay-for-performance should also look at a perspective in this week’s issue making the case that ventilator-associated pneumonia, which is out there as a possible quality measure for critical care patients, is an exceptionally bad pick for a quality measure because diagnosis is so imperfect and subjective. And you may also want to revisit a review of pay-for-performance, entitled “Pay-for-performance and accountability, related themes in improving health care” by John Rowe (that’s r-o-w-e, published just over a year ago, in our November 7, 2006 issue.

Other Articles In This Week’s Issue

Other articles in this week’s issue include an industry-funded randomized trial of telbivudine for the treatment of hepatitis B e-antigen chronic hepatitis, suggesting that telbivudine may provide greater viral suppression than the comparator drugs used in the trial, adefovir and lamivudine. Listeners interested in a more complete summary of this article should go to audio summary on our annals.org website.

We have a national surveillance study suggesting that warfarin, insulin, and digoxin are responsible for 1/3 of visits to the emergency department by the elderly for adverse drug events, an observation that’s important because puts into a different perspective the widely held perception that other drugs, such as benzodiazepines, NSAIDs, and tricyclic antidepressants, are most harmful to the elderly.

We have an observational cohort study of about 2000 patients with venous thromboembolism suggesting that 4 to 9% will die from fatal pulmonary embolism in the an average 4 1/2 years after discontinuing anticoagulation.

We have an Update in Oncology, the 9th of 10 updates appearing this year based on presentations given at the American College of Physicians annual Internal Medicine 2007 session held in April in San Diego.

And finally, this month’s In The Clinic supplement is a good one, on Heart Failure.

Well that’s it for today.

Technical support for this summary was provided by Andrew Langman, Neil Kohl, and Beth Jenkinson.

Special thanks to Kevin Stahl and all our friends at WHYY, public radio and television of Philadelphia, who helped produce these podcasts.

Send feedback, suggestions, comments, and criticisms about this summary and the journal to podcast@annals.org.

Check back in 2 weeks for a complete summary of our regularly scheduled December 18, 2007 issue.

I’m Michael Berkwits, and thanks for listening.

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