Denial Ain’t Just a River in Egypt: 5 Stages of Reactions to Quality Report Cards

We received the our monthly physician quality report cards recently.  Software mines our EHR and generates these reports to tells us if we are meeting our quality goals.  These goals are defined by recognized guidelines or insurance companies pay for performance programs.  As usual, a great hue and cry arose from the audience.

I prefer creating and using our own data instead of relying on incomplete and inaccurate claims data from insurance companies.  While I firmly believe that we must measure our performance then use the data to improve our clinic operations,  I have been through this often enough to find our reactions humorously consistent.  Dr. Kubler-Ross could use us as a case study.

1. Denial – “These patients aren’t mine.  The attribution algorithm is wrong.”
2. Anger – “I referred him 5 times to get a colonoscopy”
3. Bargaining – “If they could just correctly identify my patients, then I would know where to start.”
4. Depression – “This is impossible.  How can I get my patients to exercise?  I’ve told them a thousand times.”
5. Acceptance – “OK, fine.  Schedule those diabetics to see me with our dietitian so we can talk about healthy eating.”

After a few meeting we work through Stage 5 and get back to work.

Engage With Grace

From Paul Levy’s Not Running a Hospital blog

@engagewithgrace #blogrally12 Once again, a group of us (including Matthew Holt, Alexandra Drane and our friends) are launching the Engage With Grace blog rally to coincide with Thanksgiving weekend. As in previous years, we’re suggesting that people who want to join the rally simply post the attached “ready made” blog content starting tonight, November 21, and leave it up through the entire weekend (consider it a much-deserved break from blogging for a couple days).

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you’ll most certainly be right.’

We love it for three reasons:

1)      It reminds all of us that living with intention is one of the most important things we can do.

2)      It reminds all of us that one day will be our last.

3)      It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.

Most of us do pretty well with the living with intention part – but the dying thing? Not so much.

And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….

Then one day it does – happen to someone else.  But it’s someone that we love.  And everything about our perspective on end of life changes.

If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has.  Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values.  And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf.

Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught?

Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter.  Here’s the crazy thing – in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important.

Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony.  So let’s take that off the table right now, this weekend.  Know what you want at the end of your life; know the preferences of your loved ones.    Print out this one slidewith just these five questions on it.

Have the conversation with your family.  Now.  Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW.  Have it this Thanksgiving when you are gathered together as a family, with your loved ones.  Why? Because now is when it matters. This is the conversation to have when you don’t need to have it.  And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating.  We find sharing almost everything else about ourselves fascinating – why not this, too?   And then, one day, when the real stuff happens?  You’ll be ready.

Doing end of life better is important for all of us.  And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die.

One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama.  Others had before. Why was this day different?  Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.

Each of us has a story – it has a beginning, a middle, and an end. We work so hard to design a beautiful life – spend the time to design a beautiful end, too.  Know the answers to just these five questions for yourself, and for your loved ones.  Commit to advocating for each other.  Then pass it on.  Let’s start a revolution.

Engage with Grace.

A Teaspoon of Honey, Not a Teaspoon of Sugar, Makes Your Child’s Cough Better

Now that the FDA tells us to avoid most over the counter (OTC) cough and cold medicines in children under age 4,  what are we to do?

While I did not agree with these recommendations at first, I now like encouraging supportive care and milder treatments like nasal suction and nasal saline drops.  Since most OTC cough and cold medicines had little  evidence to support their benefit in young children, I am now happy to use them less often.

These Israeli investigators studied several types of honey in the treatment for nocturnal cough in children ages 1-5 years.  Whether the benefit is due to real reduction in the cough drive, or to simply giving the parents something to do, I will consider this for the next child I see.

Maybe we have always used OTC cough and cold medicines in young children because they gave us and the parents something to do, not because they actually worked.

http://www.essentialevidenceplus.com/infopoems/dailyInfoPOEM.cfm?view=160364

But Doc, I’ll just gain weight if I quit smoking

I saw this in the British Medical Journal.  My patients know they shouldn’t smoke, but fear of weight gain holds many back.  These are some useful statistics to share with them.

The meta analysis by Aubin et al ( http://www.bmj.com/content/345/bmj.e4439 ) showed:

•    Average weight gain was 8-11 pounds 1 year after quitting
•    13% of people gained more than 22 pounds  
•    16% lost some weight
•    Method of quitting didn’t affect weight.

Commentators noted 

• Study participants may have enrolled because they have less willpower than average; so people who can quit smoking on their own may be less likely to overeat and gain weight.
• Cohort studies have shown short-term weight gain among quitters but long-term trends similar to those of non-smokers
• Being a bit overweight doesn’t kill you, but smoking may.

An accompanying editorial can be found here: Quitting smoking and gaining weight: the odd couple | BMJ.

How Healthy Is Houston? Health of Houston Survey 2011

Some of the results are not surprising, but others contradict our assumptions:

• Houston’s rate of mental illness is twice the national average (twice that of Los Angeles County)
• Almost half of Houstonians reported difficulty purchasing enough food or paying their mortgages
• 34% of adults under 65 are uninsured
• 56% of Hispanic residents are uninsured compared to 14% of whites
• When undocumented residents are excluded, 46% of Hispanics are uninsured
• Half of adults have no dental insurance (explains why family doctors see so many dental complaints)
• 32% of adults are obese
• 3% were frightened for their safety

A Q&A with Dr. Stephen Linder

Written by: Anissa Anderson Orr  |  Updated: August 28, 2012

As a professor of public health, Dr. Stephen Linder helps inform Houstonians about ways to prevent disease and stay healthy. But diagnosing each community’s health care needs poses a challenge. Studies on the health of Houston-area residents—a diverse population of nearly 6 million people—don’t always show the whole picture.

“Doing a population-based survey was the missing piece in the mosaic of data that Houston needs,” explains Linder, associate director of the Institute for Health Policy at The University of Texas School of Public Health. “We needed a better sense of what the total need for health services is on a community-wide basis, rather than keeping a tally of those who actually get services.”

To fill in the blanks, Linder and his colleagues developed the 2010 Health of Houston Survey, released to the public, and on their website, in November of 2011. With information from more than 5,000 households, and covering 28 areas within Harris County, the population study is the first of its kind to report the health of Houstonians by neighborhood (click here to see where your neighborhood stands).

So how healthy is Houston really? We definitely have some room to improve, Linder says. An estimated 20 percent of Houstonians reported they are in poor or fair health—twice the national average. Lack of health insurance, health care access and increased risk for psychological distress were big problems in some neighborhoods. HealthLeader recently sat down with Linder and asked him what the study results say about Houston.
HealthLeader: Houston has always had a reputation, fair or not, for being unhealthy. But did you expect so many of your study respondents to say they were in fair or poor health?

Dr. Stephen Linder: It was a surprise. Our sense was that the interesting feature of the study would be the geographic disparities—some neighborhoods having more problems than others—and not the deviation from national averages. We thought our local rates would be close to the national average, or at least within 10 percent. Not twice the national rate for certain adverse health conditions.

HL:What else was surprising?

SL: We found that Houston had twice the national rate for risk of psychiatric illness. Not only that, the rate for women was twice as high as for men. We compared it to Los Angeles County, which has similar demographics as Houston. L.A. County had lower than the national rate for the risk of psychiatric illness, and thus less than half of the average in Houston, and it reversed the gender disparity. Men were doing a little better than women were in L.A. County, but we have no idea why. When we repeat the survey in 2013, we are going to ask a more extensive battery of questions about mental health to see if we can sort out the source of that gender disparity.

A Look at the Numbers

• Almost half of the survey’s residents (48 percent) were experiencing difficulty buying food or paying their mortgage in the 12 months prior to the survey (2010).
• Thirty-four percent of adults younger than 65 are without insurance. Compared to other groups, more Hispanic and African-American residents are without insurance.
• Half of adults had no dental insurance.
• Thirty-two percent of Houston adults surveyed were obese.
• One in 10 adults took a prescription drug for at least 14 days for mental or emotional health problems.
• Three percent of Houston area residents were frightened for their safety or were not in a safe place to talk about violence.

Source: Health of Houston Survey 2010

HL:Were you surprised by the disparities you found in insurance coverage among Houstonians?

SL: We knew the percentage of people who were uninsured was high in Houston, so we expected a high uninsured rate. But, we found that the overall rate of people who were uninsured was 34 percent in Harris County. That’s not only dramatically higher than the national rate; it is also higher than the L.A. County rate, which is 10 points lower than ours. The real surprise, however, was the disparities across population groups. The largest difference in insurance coverage was between whites and Hispanics. About 14 percent of whites were uninsured, but 56 percent of Hispanics were uninsured. If we exclude those who were undocumented, the number dropped to 46 percent. Asians, African-Americans and whites all had better than the area average in insurance coverage.

HL:What did survey respondents think was the biggest problem facing their neighborhood?

SL: Crime wasn’t at the top of the list. Instead, they named stray dogs and cats as their biggest concern. That wasn’t what we expected. It was worst on the east side of Houston. Strays can be a big problem for neighborhoods, because they increase the risk of animal bites and rabies if you have a lot of animals that have not been inoculated. Usually children are at the highest risk for being bitten.

HL:Does Houston rank the best in anything?

SL: We have done well in reducing smoking rates. Our current smoking rate is lower than the national average. Unfortunately, it is not as low as L.A. County. About 17 percent of the Houston population smokes. Nationally, the average is a little over 21 percent, and L.A. County was 13 percent. So they are doing something right in L.A., but it is worth noting that we are doing better than most places. Another area we did well in was breastfeeding. We have already exceeded the U.S. Department of Health and Human Services’ Healthy People 2020 targets for initiation of breastfeeding. For sustaining breastfeeding up to six months, which is what the Centers for Disease Control recommends, we are below the 2020 targets, but we are doing better than the state is, and better than the national average.

HL:What will the 2013 study look like?

SL: We want to include more questions on mental and dental health and investigate some of the anomalies in the results, such as why the rate of uninsured is so high among Hispanics, and why women are at such higher risk for mental illness. We will start collecting data in 2013, and plan to release the study in the fall of 2014.

HL:What should Houston focus on to improve our citizens’ health?

SL: We need to attend to geographic disparities in health, and to do so in more of an integrated fashion. We should concentrate on those hot spots of need in a way that responds to the full spectrum of needs, as opposed to singling out a disease or condition, like heart disease or diabetes.

There also are inequalities in the burden of illness and access that make some populations more vulnerable to disease. Now we have a way to measure these disparities with the indicators in our survey. Given the scale of the survey and the variety of indicators we have we can understand the problem of health disparities more fully and work toward solutions.
For more information on the Health of Houston survey, visit the UTHealth newsroom.

Should Lack Of Exercise Be Considered A Medical Condition?

I recently returned from a trip to Portland and Seattle.  The legions of cyclists, runners, and walkers I saw in these two cities inspired me.  Bike lanes and beautiful waterfront walking paths abounded.  A Portland city bus even stopped to let me cross the street.  That would never happen in Houston.

The idea that activity is good is not news to any of us.  But if the solution is so obvious, why aren’t we all moving?

This National Public Radio story from last week attempts to answer this question.

Doctors need to prescribe exercise to patients who don’t get enough exercise, a Mayo Clinic expert says.

“You’ve got a bad case of deconditioning,” the doctor says.

Actually, it would be the rare doctor who would say that to anyone. And though it might sound like something to do with hair, in fact, deconditioning is a familiar and more profound problem: the decidedly unnatural state of being physically inactive.

At some point in the last few decades, the human race went from being a species that is active most of the time to one that is increasingly sedentary. The Lancet recently called it an “inactivity pandemic,” responsible for 1 in 10 deaths worldwide. That’s a major shift, and a major public health problem, many researchers have pointed out. Inactivity is linked to heart disease, diabetes and some types of cancer.

Now Michael Joyner, a physiologist at the Mayo Clinic, argues in a commentary out this month in the Journal of Physiologythat one way to deal with the problem is to make physical inactivity a mainstream medical diagnosis. It’s one of the most common preventable causes of illness and death, and Joyner writes, there is “one universally effective treatment for it — exercise training.”

Shots called up Joyner to get him to elaborate a little more on just why doctors need to get more involved with this problem.

“The entire medical research industrial complex is oriented towards inactivity,” he tells us. Insurance companies will reimburse patients for pills for diseases related to inactivity, but rarely for gym memberships. “Physicians really need to start defining the physically active state as normal,” he says.

Joyner says that he thinks about 30 percent of the responsibility to fight inactivity should fall on the medical community. “Physicians need to interact with patients about being active, and they need to write prescriptions for exercise,” he says.

He points to two of the greatest public health triumphs of the 20th century — improvements in traffic safety and the decline in smoking rates — as models for how we should tackle the inactivity epidemic. About one-third of the behavior change came from individuals who started using seat belts and car seats, and those who quit smoking, and doctors directly influenced that, he says. The rest was up to the public health community — to enact indoor smoking bans and harsh drunken driving laws — that helped support the right behavior.

For inactivity, doctors can push patients to get exercise, and cities and towns can make it easier for them to do it, he says, with more bike lanes and parks that can be an alternative to the gym.

Joyner says he increasingly sees two types of patients in his clinic: the ones who follow health guidelines and keep active; and those whose don’t and see no connection between their behavior and their health outcomes.

“We have to be more innovative and creative to figure out how to help the people who aren’t empowered to exercise for their health,” he says.

http://www.npr.org/blogs/health/2012/08/15/158831652/should-lack-of-exercise-be-considered-a-medical-condition?ft=3&f=111787346&sc=nl&cc=es-20120819

West Nile Virus Hits Texas

This year Texas has seen more human cases of West Nile Virus than in recent years.  The Department of State Health Services reports 455 human cases.  The Dallas area has seen more cases than other Texas counties.  Twenty Texans have died of West Nile Virus in 2012.

What is West Nile virus?
West Nile virus can infect humans, birds, horses and mosquitoes. Infection from this virus is most commonly found in Africa, West Asia and the Middle East.

What are the symptoms of West Nile virus infection?
Most people have no symptoms. Others may have only mild symptoms (West Nile fever).  Symptoms usually occur 3 to 14 days after a mosquito bites you and last for 3 to 6 days.

Look for:

• Skin rash
• Fever
• Headache
• Nausea
• Vomiting
• Diarrhea
• Loss of appetite
• Swollen lymph nodes (lymph glands)
• An achy feeling in the back and muscles

Symptoms of more severe illness include:

• A sudden high fever (above 102°F)
• Severe headache
• Stiff neck
• Feeling disoriented or confused
• Tremors or muscle jerks
• Seizures
• Coma
• Weakness or partial paralysis

Contact your doctor if you have any of these symptoms and have recently been bitten by a mosquito.

How is West Nile virus spread?
West Nile virus is most often spread by mosquitoes that become infected by biting birds that carry the virus. This happens most often in the warm-weather months of spring, summer and early fall. You cannot get West Nile virus from another person or from your pet.

Who is at risk for infection with West Nile virus?
People who live where West Nile virus has been found in humans, birds, horses or mosquitoes are at risk for infection. However, even in these areas, it’s very unlikely that you will get sick from a mosquito bite.  You are at a greater risk if you spend lots of time outdoors during the warmer months or if you don’t protect your skin with an insect repellent with DEET.

Who is most likely to get sick?

People 50 years of age and older and people who have weakened immune systems are at greatest risk of becoming severely ill from West Nile virus. Less than 1% of the people who do get infected with West Nile become severely ill.  Most people who either do not develop symptoms or only get mild symptoms. Less than 1% of those people infected will get a severe infection.   Almost all fully recover.

Is there a treatment for West Nile virus infection?
There is no specific treatment. People with mild symptoms usually get better after a few days without medicine.  People who have severe illness may be hospitalized and given intravenous (IV) fluids.

Can West Nile virus cause any other problems?
In rare cases, West Nile virus causes a disease such as a swelling of the brain called encephalitis or swelling of the membrane around the brain and spinal cord called meningitis.

Is there a vaccine for West Nile virus?
There is no vaccine to prevent West Nile virus in humans.

How can West Nile virus infection be prevented?
The best way to avoid infection with West Nile virus is to reduce the number of mosquitoes around your home and neighborhood.

Your best defense is to practice the “Four Ds”:

1. Use insect repellent containing DEET (20-30%), picaridin or oil of lemon eucalyptus. Talk to your doctor before you use insect repellent on your child.
2. Dress in long sleeves and long pants when you are outside.
3. Stay indoors at dusk and dawn, when mosquitoes are most active.
4. Drain standing water where mosquitoes breed. Common breeding sites include old tires, flowerpots and clogged rain gutters.

Questions to Ask Your Doctor

• Is West Nile virus common in this area?
• Am I at risk of contracting West Nile virus?
• What can I do to protect myself from West Nile virus?
• What treatment is best for me?
• Will cold or flu medicines help?
• Can my child get West Nile virus from me?
• What kind of insect repellent should I use?
• If I start feeling worse, when should I call my doctor?

Sources:

http://www.dshs.state.tx.us/idcu/disease/arboviral/westnile/

http://familydoctor.org/familydoctor/en/diseases-conditions/west-nile-virus.printerview.all.html  (Full  handout from FamilyDoctor.org)

My urine culture is negative, can I still have a bladder infection? « Dr. Jen Gunter

Dr. Gunter nicely summarizes symptoms of urinary tract infections in women.

My urine culture is negative, can I still have a bladder infection? « Dr. Jen Gunter.

They Won’t Live Past 21

These words still echo twenty years after I heard them in a first year medical school lecture on congenital genetic disorders.

At the time, patients with Down’s Syndrome (Trisomy 21) were not expected to live far into adulthood. While we needed to learn how to treat them as children and teens, we paid no attention to their possible lives as adults.

Experience has taught me otherwise. I have cared for teenagers and young adults with Down’s Syndrome, completed many medical clearance forms for Special Olympics, and discussed how elderly parents should plan for their children’s continued care after they die.  I have delivered children with Down’s when the prenatal testing said the risk was normal.  I remember the chill we felt when my wife’s 16 week ultrasound showed cysts in our daughter’s brain that suggested Trisomy 18, a lethal genetic defect. As we drove to the amniocentesis appointment, we wondered what we would do if the answer was  yes.  She turned eleven recently.  Thankfully, the answer was no.

As the youngest of eight, the odds were not in my aunt’s favor.  The prenatal testing we have today did not exist in the 1960’s.

She turned fifty last week.

I’m glad you proved them wrong.

Happy Birthday

Time To Swing For The Fences – 2012 Texas Academy of Family Physicians Presidential Address

“OMG, this is wicked cool, I can’t believe I’m president.”

Oh, sorry.  That was my daughter’s version of my speech.  Here’s mine.

Good afternoon, and welcome.

Whether we practice in Houston or Henderson, Wichita Falls or Weimar, El Paso or Del Rio, Alpine or Austin; we are all Texas family physicians.  We bring different perspectives to the Academy based on where we live and where we’re from.  I know what it’s like to work in a large integrated healthcare system, run a community health center, and teach our future family physicians, but I don’t know how to run your practice.  I want to hear from each of you about how we can strengthen family medicine and take care of our patients.

Our health care system is in the midst of a painful rebirth.  The insurers, the government, and the hospitals are pulling us in different directions.  We stand with our patients at the middle of this storm of abbreviations and acronyms:  ACA, ACO, PCMH, EHR, and Medicaid 1115 waiver.

Now, we can ride off into the sunset like the cowboy in the old Western, resigned to obsolescence as the specialists, large hospital systems, and insurers take over healthcare.  Or we can choose to pull up our britches and get to work.  “If you don’t like change, you’re going to like irrelevance even less.”  President Lyndon B. Johnson said there are two kinds of people in the world:  “can-do people” and “can’t-do people.”  I think family doctors are can-do people.

When Bobby Youens and Jorge Duchicella of Weimar grew frustrated at the lack of family physicians in rural Texas, they got together with Tricia Elliott of UTMB to organize a rural residency track.  Instead of resigning himself to complaining about changes in health care, Lloyd Van Winkle of Castroville organized primary care docs into an IPA – and ran for the board of the American Academy of Family Physicians.  When Melissa Gerdes and Mike McCready grew concerned about how family docs would fit into large healthcare systems, they became physician leaders who could advocate for their patients from the inside.  Instead of getting mad, Roland Goertz got even – and headed off to Washington, DC as our academy president to bend the ear of every congressperson and Senator he could find about the value of family physicians.  While other specialties complain about “the government doing this” or “insurers doing that,” family doctors come up with a plan and get to work.

It is easy to get frustrated by the changes hitting us daily, but I urge you to channel your anger into action.  We understand better than most the reality on the ground – and what our patients need.  When patients ask me if I think all the frustrations are worth it, I think of a 1991 CNN interview with an old redneck from Boots and Coots.  Now Boots and Coots is who they send in when the world is going to hell – and someone needs to put the fire out.  Behind him, the burning Kuwaiti oil wells spewed smoke and flames into the sky.  When the reporter asked him why someone would do something so dangerous, he answered in his best Texas drawl:  “Hell, there’s nothin’ I’d rather be doin’ than fightin’ oil fires.”  I don’t push each day to get my patients the healthcare they deserve to quit now.  They deserve my best.  And there’s “nothin’ I’d rather be doin’.”

Let’s be honest, though.  We took some lumps in the 2011 legislative session:  the primary care preceptorship was eliminated, state GME funding for residencies like mine was cut to within an inch of its life, and the loan repayment program which placed family docs in needy communities was slashed so badly it’s on life support.  Medicaid rates weren’t cut, but in typical legislative fashion, Medicaid will run out of money on December 31^st.  Your physician leaders and academy staff have drafted a policy manifesto for the 2013 legislative session:  the Primary Care Rescue Act.  This plan shows our legislators how they can improve the health of their constituents – our patients – by investing in training new family doctors and getting those doctors to where our patients need them.

To improve health care in Texas, we need to:

1. Train more primary care doctors by restoring funding to our residency programs
2. Push our tax payer funded medical schools to train more residents  and make sure the medical students they educate  go where the taxpayers need them
3. Encourage medical students to pursue primary care by funding the primary care preceptorship program
4. Consolidate Texas’ two loan repayment programs and restore their funding
5. Encourage doctors to adopt health information technology by offering loan programs and business tax credits
6. Reward quality improvement by requiring health plans which receive state general funds to increase the fees paid to physicians who achieve national quality certifications from the NCQA and others.

These areas will be the focus of our legislative efforts for the next session.

Now we could trot off to Austin in January with this list in hand to ask for more money – just like the school teachers, the universities, and everyone else whose programs were cut last time around.  Too often, doctors approach politics like a disease to be cured. We come up with a sound policy, then we wait for our leaders to respond to the rightness of our cause.  But being right doesn’t get us votes.

Politicians follow a different logic.  Our most important issue may not be theirs.  We must get to know them, learn what motivates them, and understand what issues matter to their constituents.  Next year, the legislature will make decisions that will have a major impact on healthcare in this state.  Now is the time to lay the groundwork for 2013.

Everyone in this room can contribute.  You each have a state representative and a senator.  Call them.  Remind them you are a constituent – and so are your patients.  “My patients have trouble getting the healthcare they need, they live in your district, and they vote.”

I am honored and humbled to be chosen as your president.  It is time to swing for the fences.  As I look forward to the next 12 months, I think of a slogan from college:  “Lead, follow, or get out of the way.” I am proud to be president of an academy which chooses to lead.

Thank you.