2014 Stanford Medicine X: Online Patient Communities

"Communicating The Experience Of Illness In The Digital Age" is the title of a panel from the 2014 Stanford Medicine X conference. This panel was moderated by Pam Ressler with panelists Susannah Fox, Meredith Gould, and Colleen Young. The video is above from the MedX YouTube page. The text summary is from this storify account. Also check out the groups pre-conference notes.

Do online communities matter? Of course, they do. But, what IS an online community? How do you define it? That's a more difficult question. Does just telling your story get you into an online community? Does self-disclosure get you into an online community? This panel was one of the ones that I was really looking forward to, especially with my pre-conference chat with our pal Meredith Gould in the video below.

Here are some of my reactions to some things that happened in the panel discussion and beyond:

• Communicating Illness In The Digital Age: I read the pre-conference notes from this group. The idea of this panel started with a very public attack on someone who disclosed their illness online.  As I read more about this controversy, I saw that the online community rose up to respond to this bullying tactic. People should be able to disclose this type of information out there online. In a recent post of mine, there was a nasty comment left by a reader. Revealing and discussing your illness online should be allowed, and I'm glad this group had that discussion.
• My Self-Disclosure Story: I started my online life as an anonymous blogger. But, as I started to connect with the people who were leaving comments on by blog posts (this was before twitter & facebook), I felt compelled to reveal myself, little by little. I started with really grainy out-of focus black-and-white pictures to see what the reaction was. Then, I began the slow process of revealing my true name and photo, etc. At first, I received some private and public attacks. But with time, I was able to accept that with self-disclosure comes good and bad, and you have to be able to handle both. I totally understand people who are hesitant to get out there and tell their story on social media. The panelists in this discussion did a good job in outlining both the positive and negatives of self-disclosure.
• The Role of Self-Disclosure in Online Communities: Just because you have a group of people together, they don't necessarily make an online community. Self-disclosure is certainly one of the first steps. But, you need a community manager and community members to be ready to receive self-disclosures from members. It is definitely a big leap for a person to self-disclose something that may have them harshly judged by others. This should be celebrated and hopefully foster further self-disclosure. "The value of online communities lie with the community managers who drive them."
• "How might we, make this look less like witchcraft, because that's what people outside the community, sometimes think of us?" - Susannah Fox. This is a great question and something similar that I get asked a lot. It is very difficult to explain the connection that people have to one another, whether it's an in-person community, or an online community. For those on the outside, it can definitely look "cult-like" and weird. People have a need to belong and people have a need NOT to feel alone. Communities, whether online or in-person, satisfy this need. 

In my closing thought, even though this is entitled "Online Patient Communities," all these ideas and concepts can apply to any online community. I think about my own peer group of Family Physician social media activists called the #FMRevolution (meaning Family Medicine Revolution). Our numbers could be stronger and our activity on twitter centers around our own Family Medicine conferences. But, definitely something missing is the role of digital self-disclosure. When we get together in person, I treasure those times with my FM peers as we catch up. But, could our online community strengthen if I could decrease the discomfort of digital self-disclosure? I will certainly try to answer that question...

2014 Stanford Medicine X: Depression & Chronic Illness

On Day Two at the 2014 Stanford Medicine X Conference, the best panel ever done in the history of meeting happened. And, no one saw it. Why? Well, it was the very last session at the end of the day, and many people were getting ready for the cocktail reception outside and enjoying a beautiful night in Palo Alto. I don't blame them. However, through the wisdom of the conference organizers, this panel was placed on the main stage, which meant that it would be broadcast and recorded for all of you. That video is above.

"This is going to be a conversation that is going to be a little bit of a challenging one for each of us individually, and possible for the for community at large, because of the heavy issues that we're dealing with," moderator Sarah Kucharski said opening up the panel entitled "Depression in Chronic Illness and Coping Through Online Communities." The panelists were Hugo Campos, Ann Becker-Schutte, Gonzalo Bacigalupe, Erin Moore, and Scott Strange.

It was clear to me that some of these panelists have not discussed this topic in public before, and it was clear that they did not fully realize this until they began speaking on stage. This is why, I believe, that this was the best panel ever done at MedX.

This panel could not have been done in year one or year two of this conference. This is a sign of the maturing of the meeting and the maturing of the rich conversation. This conference and these brave people on stage are not afraid to push the limits of discomfort and awkwardness (in a good way) to talk about the topics that need talked about. Well done!

What follows below are my observations from this 45 minute session. I encourage you to watch the entire session, because I know that you will be able to pull more out of this fascinating conversation.

• Self-care is so important and needs to be talked about more
  • It doesn't matter if you're a patient, a caregiver, a physician/provider, or a mix of all three. Care of oneself is something that is desperately needed to make sure that you can care for others. I'm a Family Physician, and I know that this is something that is not talked about publicly in medical education as far as taking care of yourself as a medical student, resident, and attending physician. I know that I need to take care of my own health so that I can take better care of my patients, but sometimes it feels selfish to do the things that I need to do for me. I know I'm not the only one who thinks like this.
• The thinking that there is always someone worse than me
  • Denial of your own feelings and your own care is common, especially if you tell yourself that "well that person or that patient is worse" so I'm ok. The fact is that you may not be ok, and you need the courage to face those feelings
• When facing these anxiety and depression feelings, initially it is common to go outside of your familiar community and seek out an outsider
  • It was fascinating hearing that even though you have a friend or friends in an online community, their initial thoughts was to not ask their own illness/disease communities first, because they thought it may be seen as weakness
  • "We shouldn't be afraid to say I am suffering today. This hurts today. I don't know which way to go today. That's not weakness. That's honesty," Ann Becker-Schutte said later at about 36 minutes in the vid.
• "Physicians need to accept that the mental health stuff is part of what's going on, but not a reason to stop looking for answers," Ann Becker-Schutte says about 26 minutes into the video above
  • I agree that this is happening out there, and I don't make excuses for it. Earlier in the day, there was a session that mentioned the frustrations of the 10 minute office visit. As a Family Physician, I feel those time restraints and to focus the interview on one problem. But, it is true that just because someone has a mental health diagnosis, that is not a reason to stop looking for answers for other symptoms. This comment really resonated with me.
• How do you find the right mental health professional?
  • One of the panelists found a counselor/therapist on twitter
  • Another panelists said that "I didn't know how to tell them what was wrong with me when I was asked. Very uncomfortable"
  • The tip was to call 2-3 people and interview them over the phone before you take that big step to go to their office
  • This part of the discussion really made me think, because I was thinking about an earlier session in the day called "How To Find The Right Doctor" in which they were looking at numbers, and I hear all the time about physician rating sites. Makes me think that recommendations to mental health professionals are probably a lot different than recommendations to non-mental health professionals
• The panel beautifully got to the point about talking about the online community. Yes, there are strengths of your own online community. Being a part of the community, finding the strength to talk about your feelings to your empowerment community can be tough, but needs to be done. For the community, they have to be ready to hear from individuals and offer support and not give them the impression of weakness. Meeting halfway and supporting each other is the strength of the community.

Sorry for the rambling, but this panel really made me think. And, on this last day of 2014 #MedX, there will be another panel on mental health/wellness issues that I will be looking forward to.

This will be my last post that I write while I'm out here at Stanford, as I will be going home tonight, and back to work tomorrow. I will undoubtedly have more to say as I further process this #MedX experience. Thanks to Dr. Larry Chu, the meeting organizers, the meeting sponsors, and all of the participants (both in person and online) for making this a fabulous experience for me, and what I really needed both professionally and personally as I continue sharing my story....

Most Compelling Stories of 2014 Stanford Medicine X Day One

As I write this, it is after 1am in my home time zone. Yet, I feel inspired to write about my experience at Day One of the 2014 Stanford Medicine X Meeting. What you see above is the famous badge that this meeting is known for. In addition to the enormous size of the badge itself, it is also a book which holds the meeting schedule inside and other information like the wifi password, etc. There are QR codes all over the place here, so on the badge as well. One day, all meetings will have a cool badge like this.

The three most compelling stories (in my humble opinion) follow below. They also include a video piece which I stole from the conference video feed at this link. Now before you ask me, the link is only for the last couple of hours of Day One, not the entire day. Hopefully, the conference organizers will make the entire day available sometime soon.

"These prosthetics turn kids into superheroes," is a quote from Jon Schull from E-Nabling The Future. This is a passionate group of people in the Maker Faire tradition of creating cool stuff. This group is passionate about using 3D Printers to create prostheses (artificial limbs like artificial arms) for people who need them.

Jon told a fascinating story about how they use technology to make an artificial arm a reality for a child. In the video above, you see the end of the presentation in which a child is brought up to show off her new arm and share how she feels about it. Cool story on how technology can make things better for a little girl.

THE most powerful three minutes of Day One was by someone who wasn't even at #MedX in person....

"The underserved are not separate or different from us. The underserved could be any of the people in this room. I'm appalled at times to see how separated people are from those they are ostensibly helping. We need it to be not 'Us versus Them.' Some of us have been or will become them. I AM THEM." This is part of the powerful ignite talk entitled "The Underserved Patient" by Erin Gilmer (on twitter @GilmerHealthLaw). 

The video you can see above. She could not attend in person, but she did pre-record her talk. The power of her voice and her storytelling is something I'm still thinking about and processing. This talk was a smaller piece of a full letter that she wrote to conference organizers. The full letter can be found at this link via Heart Sisters.

Finally, the panel that had twitter abuzz, was focused on a guy who is not even on twitter, not even in the program schedule, and proudly proclaims that he avoids smartphones....

"Most technology solutions are great for everyone except the end user," Devon Low proudly said while sitting on a panel entitied "The No SmartPhone Patient" moderated by our pal Dana Lewis. San Francisco General Hospital connected with Mr. Low and asked him to be on this panel.

I encourage you to watch the edited video above which I focused on Mr Low. There are so many pearls of wisdom in this 20 minute video. He starts out by sharing his story about being diagnosed with chronic lung disease. He doesn't use a smartphone for any kind of tracking, but he does carry paper chart/records with him when he sees his primary care physician and his specialists.

How did he learn about his disease? Through public library computer access. He challenges physicians, providers, and anyone who will listen - to share as much relevant information with patients. "If you want me to be an active participant in my care, then physicians/providers should make my health information interesting and compelling so I want to look at those statistics."

Our pal Chris Snider tweeted, "Devon Low is grounding this entire conference in a much needed dose of reality. Living in the cloud can create tunnel vision." Now, later in the panel, Mr. Low said that he is not on twitter and hesitant to be on social media, at this point. I totally understand that. But, I hope that he continues to tell his story and to consider include digital communication (like social media) to share his story...

Selected for TedXYoungstown 2015

I've always dreamed of being on stage to deliver a TED-like talk. I've watched TED and TEDMED talks for a long time and dreamed of an opportunity to take the stage at one of those venues. TEDX is marketed as the "minor league" for events like TED and TEDMED. I'm happy to announce that I have been selected to speak at a TEDX event in our local community of Youngstown, Ohio.

TEDxYoungstown will take place on Friday, January 23, 2015 on the campus of Youngstown State University. Take a look at the fabulous speakers list at this link. I'm honored to be included on this list of excellent speakers! The first meeting of the TedXYoungstown speakers will be next week, and I'm looking forward to meeting them and the organizing team!

According to the TedxYo site, my topic will be "Medical Professionals and Social Media." For about 2 years now, I have been giving talks talking about Medicine & Social Media, Family Medicine & Social Media, and similarly titled talks.

To be honest, I'm totally intimidated with the process of putting together a TEDX talk. I've seen the videos. I've talked with people who have seen them in person. I mean, these are really good talks. Can I do that? How do I have to prepare to give a great TedX talk?

One of the things that I'm doing to prepare is attending to this weekend's Stanford Medicine X conference in which there are great speakers and great topics. As I have written in a previous post, I'm looking for inspiration in general, but I'm also looking for inspiration for the construction of my January TedXYoungstown talk.

I'm a self-admitted perfectionist, and there is no one that puts more pressure on me - than me. But, I enjoy setting a high bar for myself to deliver an oration that will be unique, that will be inspirational, that will have people talking for a long time.

The reality is that I really haven't figured out anything yet for this speech. I have a million ideas, but I need a way to focus this nervous energy and just get to work to assemble my message. I'm telling you right now, this will be the most difficult, yet (I hope) the most gratifying speech that I have ever written. Have I raised the bar too much? I hope so. If you don't expect the best out of yourself, then no one will...

Looking For Inspiration From #MedX 2014

This will be my first in-person experience at the Stanford Medicine X conference (the twitter hashtag for the conference is #MedX). In the past couple of years, I have seen and experienced the meeting through the internet via their fabulous live video stream of the meeting.

As I was watching the meeting from thousands of miles away, I could not help but feel the energy and passion of the speakers as they were telling their stories and sharing how they believe the patient experience could be better in this broken health care system of ours. The meeting has shown a lot of growth and progression in the past couple of years.

Then comes 2014, this year. I made it a point on my calendar to block out those dates, and make sure that I was not working (the past couple of years, I found myself "on call" can could not attend the meeting).  I even felt inspired to even try to be a speaker at the meeting, but I do not feel that I have a compelling story to tell.

With the conference in just a few days, I find myself at another cross roads in my social media career. I was a year ago, when I quit the internet and social media, only to return about a month later.

My work life has become very busy, and possibly overwhelming. I just read an article from the New York Times entitled, "Why Doctors Are Sick Of Their Profession." A lot of that article applies to me. Now, I don't say that to try to garner sympathy. It is that article, coupled with my recent rant called, "The Medical Chart Is Coming To An End. Here's Why," gives you a snapshot into my mindset going into #MedX. 

I'm not going to lie. I have high personal expectations going into this Stanford Medicine X conference. I'm looking to recharge my social media passion, and my passion as a physician. The Health Care bureaucracy is frustrating, and as I said in my essay, "This is not what I signed up for when I went to medical school." 

So, even though Stanford Medicine X markets itself as being a conference for patients and for the patient perspective, there are many other people out there (namely me) that are looking to express an opinion, to tell a story, and to inspire others in the work that I do. I'm looking forward to catching up with long time friends and to make new ones as my #MedX story begins...

Ebola Vaccine: Why It Doesn't Matter

"Dr. Sevilla, what do you think about the Ebola virus," a patient recently asked me. My patient and I talked about the recent news reports stating that over 1,500 people have died because of the virus. "There's a vaccine that's being developed," I told my patient. "Well, that's great. I'm definitely going to get it, IF...."

"IF...," I asked my patient. "Well, Doc you know how these things go. IF it's covered on my insurance, IF there are no side effects, and IF there are no bad preservatives in the shot, then sign me up."

According to this article, human trials for a proposed Ebola vaccine will start this week. However,  I really don't think the future Ebola Vaccine will matter. Let's change the word "Ebola" to "Influenza" or "The Flu" for a second. Yes, Ebola has killed around 1,500 people, none within the United States. Influenza kills from 300 to 49,000 people EACH YEAR in the United States according to numbers from the Centers for Disease Control and Prevention. How successful are we (and I'm including me in this) at giving our patients influenza vaccine? We can do better. I can do better.

Here are the factors determining whether patients in the United States will consider taking a proposed Ebola vaccine:

Law of Vaccine Supply and Demand: Remember the Flu H1N1 epidemic from 2009? The country was obsessed with the Bird Flu, like they are now with Ebola. My patients were scared to get the Bird Flu, and they refused the regular Flu vaccine because H1N1 was initially not included. Then, a few months later, H1N1 was included. What happened? Suddenly, demand dropped. In the vaccine world, in my experience, when there is no supply (like the current Ebola non-vaccine) or few supply, the demand goes way up. However, when there is an abundance of flu vaccine (like this year), many patients gladly refuse the vaccine.

Insurance Coverage: A common question I get whether it's prescription drugs, testing, or vaccines is this one: Is it covered by my insurance company? Now, don't get me wrong. I'm very sensitive to this. My guess is that an initial wave of potential Ebola vaccine will not be covered, or will have spotty coverage, and this will drive down demand. In general, the annual influenza vaccine is covered by insurance. Do my patients take the flu vaccine? Some do, and some don't.

Side Effects: "Dr. Sevilla, I don't want the vaccine because I'm allergic to it." How many doctors have heard this before? With a potential Ebola vaccine, people are scared of Ebola, but some are more scared of potential side effects of a vaccine. Of course, there are some legitimate allergic reactions. But, I believe some patients use mild reactions as a cop out to receive any vaccine, especially the yearly Influenza vaccine.

Preservatives: As soon as a potential Ebola vaccine is announced, I predict the anti-vaccine extremists will be out there on social media and traditional media - trying to scare the public that the Ebola vaccine is worse than Ebola itself. They have previously used the excuse that preservatives and additives to vaccines in the past to try to scare people. Will this decrease demand? We'll see.

The truth of the matter is that we probably won't see an Ebola vaccine any time soon in the United States. Trials are set to begin in the United States, but the first vaccines will likely be deployed to the epidemic areas of West Africa. Don't get me wrong, it is a tragic situation in that part of the world. But, the hype that is being generated by people and by the press in this country, is overblown, in my opinion, at this point in time.

My patients ask me about a potential Ebola vaccine and Ebola treatments every day. When these vaccine and treatments actually become a reality in this country, will patients take the vaccine? Will you take the vaccine? Think about it...

Image Credit: Shutterstock.com

Countdown to Stanford Medicine X 2014

I'm very excited to be attending my first Stanford Medicine X meeting in just a few days. For the past couple of years, I was unable to attend in person, but was able to watch the live video stream of this fabulous event.

Later this week, I'll post some of my personal goals and expectations of the meeting. Before that, I wanted to share with you four pre-conference conversations that I had leading up to this years meeting.

What you will see below are Google Hangout interviews with Bryan Vartabedian, Meredith Gould, Sarah Kucharski, and Christopher Snider. These interviews were done in the past three weeks. My intention was to write a separate blog post about each interview. Unfortunately, I have run out of time, so I present these interviews all in one post. Hope you enjoy our conversations!

Finally, if you cannot attend in person, you can still sign up for the FREE video stream from the meeting through the Stanford Medicine X Global Access Program. Yes, that's right, it's free. However, you have to sign up at their website here and then you will have Global Access to the meeting :)

My guest will be Dr Bryan Vartabedian (@Doctor_V) from 33Charts.com and Assistant Professor of Pediatrics at Baylor College of Medicine. We will be discussing our current opinions about Physicians & Digital Technology, the upcoming 2014 #MedX Conference, and much more.

Digital Strategist & Author Meredith Gould will be joining me to talk about the upcoming #MedX Conference, her current & future writing projects, and whatever else comes up!

Sarah Kucharski, aka The Afternoon Napper on social media, is a 2014 #MedX E-patient Advisor. In our conversation, we'll be discussing the upcoming +Stanford MedicineX conference, her E-Patient story, and whatever else comes up!

Christopher Snider, ePatient Advisor at Stanford Medicine X 2014, will be joining me to talk about the upcoming #MedX conference. He is also the host of The Just Talking Podcast which celebrates its 5 year anniversary this fall

Direct Primary Care by Dr. Ryan Neuhofel

Dr Ryan Neuhofel (@NeuCare), Family Physician, will be joining me to talk about Direct Primary Care, his experience at the AAFP 2014 National Conference of Family Medicine Residents & Medical Students, and more!

Thanks to Ryan Neuhofel, MD, MPH, for the opportunity to talk about Direct Primary Care in the Google Hangout video above. I have interviewed him about six months ago while at the NeuCare Family Medicine office in Lawrence, Kansas. That video follows at the end of this blog post.

He is known as Dr. Neu on twitter and the internet, and he has been telling his story since the opening of his practice in December 2011. Earlier this month, he was on a panel telling the Direct Primary Care story at the National Conference of Family Medicine Residents and Medical Students of the American Academy of Family Physicians.

In the video above, our conversation begins with how he describes Direct Primary Care to prospective new patients. Just like trying to define Family Medicine, it can be difficult to exactly define Direct Primary Care, because each practice is different. He also describes how he differentiates between Direct Primary Care and "concierge" medicine.

We also cover some of the common misconceptions about Direct Primary Care, like DPC patients are usually young people without any insurance. He states that there are many patients who come to NeuCare Family Medicine, do have insurance, usually high deductible private insurance, who pay out-of-pocket expenses anyway.

Dr. Neu states that there are many medical students and residents who visit his practice with the goal of opening their own Direct Primary Care practice when they complete their formal medical training. In fact, right at the end of this video, he introduces us to a medical student who is shadowing him today.

As I have said on this website in the past, I am glad that medical organizations, like the American Academy of Family Physicians, are recognizing Direct Primary Care as a legitimate alternative to our current broken health care system. It's always great talking with Dr. Neu, except for the fact that I continue to mispronounce his name when I interview him. Sheesh...

Mike Sevilla, MD talks with Ryan Neuhofel, MD, MPH two years following the start of his Direct Medicine practice called NeuCare Family Medicine in Lawrence, Kansas. Also check out the following links - http://NeuCare.net - http://DrMikeSevilla.com

The Bryan Vartabedian Interview

Dr. Bryan Vartabedian, one of today's most well-known Physician Social Media leaders, unofficially announced his new book on last night's Google Hangout interview (video above). The details will be outlined next week on his website 33Charts.com, but I received an exclusive preview of its contents.

"This is a practical guide to life as a doctor in the connected age," Dr. Vartabedian discusses at around eight minutes into the video above. He goes on to state that this book will be an extension of the current content that is on his 33 Charts website. @Doctor_V would not give up the title of the manuscript, only stating that more details will be revealed next week.

Not using the traditional publishing route, we discussed why he chose the E-publishing route. At around 45 minutes into the video, he states that he chose the platform called TinyPass to initially publish and to initially receive feedback from readers. "Publishing is traditionally an endpoint. I see this hopefully as a start. This type of book must evolve as technology evolves." 

We began the video interview above talking about next week's Stanford Medicine X conference in which he will be co-presenting a Master Class on Physician Online Identity with Dr. Wendy Sue Swanson. We agree that there is no other type of conference like this out there in which patients and the patient's point of view are placed front and center. There is certainly value to this, and I am looking forward to my first #MedX conference next week. 

On a personal note, I've been very happy using the Google Hangout format for video interviews. In the past, I have used audio podcasts, particularly the Mike Sevilla Radio Show, of which I have over 300 episodes, to create conversations and have interviews.

In addition to the #MedX interview with @Doctor_V above, I also invite you to check out recent Google Hangout video interviews I've done with #MedX E-patient delegate Meredith Gould and #MedX E-patient advisor Christopher Snider. Hopefully, I will be able to squeeze another interview or two before next week's #MedX conference...

The End of the Medical Chart

"Dr Sevilla, I have a question for you," a patient asked me this week. "I'm going to tell you something, but I DO NOT want it put in the chart." Hmmm, I asked myself, can I really do that? It's the patient's wish, right?

The patient went on to tell me that she heard about this week's story about a hospital network being hacked and 4.5 million records being stolen. "What if that was my information?," the patient asked. "Does that mean that information in an electronic medical record could be out there for anyone to see?"

"How do I know your server won't be hacked?" the patient went on to say. "Doctor, what if I asked you to not put this in the electronic record, and to put this in my old manila folder paper chart?" Can you imagine the disruption of trying to maintain a digital chart, and also going back to maintaining a paper chart as well?

Much has been written about the inadequacies of the digital medical record, but as more and more digital medical records breaches occur (and I'm not even going to touch on the security flaws of Healthcare.Gov), how comfortable will patients be in giving medical and non-medical (ie-financial) information?

Just a few observations on why I think we're coming to the end of the utility of the medical chart:

• Loss on the Story and Narrative: Back when I was a first year medical student 20 years ago, the most important thing was recording the patient's story in the medical record. For example, to be as specific as possible in who, what, were, when and why the patient was having their symptoms. In today's digital world, when I read a medical student or resident note, it's like reading twitter. Very brief, vague, and not really that useful. I think we, as medical professionals, have lost the art of telling the story of our patients because of the digital record.
• The Medical Record as a source of billing and false accountability: Now, I'm not the first person to say this, but the medical record has become a place, literally, to check the box and less a place to really come up with the solution for patients. Many believe that the electronic medical record is a way for "big brother" (whomever that is) to keep an eye on clinicians, and eventually find a way to compensate less. My cynical mind is slowly (and reluctantly) agreeing with this point of view
• Security Breaches will become MORE and not less frequent: I predict that there will be a coming wave of concern to the point where patients will insist that certain medical data NOT be recorded in the electronic health record. What will the clinician do at that point? Do we follow the "patient centered" model because that is what is being emphasized now? Or, do we follow the medico legal fears and record it anyway for fear of being sued for an incomplete medical record?

Of course, I'll have comments and tweets telling me I'm overreacting. And, still other tweets telling me that they have been saying things like this all along. Is this the future of medicine? Is this the future of medical care in America? This is not what I signed up for, and I'm mad, and sad, at the same time. All I wanted to do is take care of patients, and hopefully have an impact in their lives. It seems more and more that is becoming more difficult...