Turn! Turn! Turn! (Musings on how the TM community now puts cost above all)

Updated: 27 July 2014 

Dearly beloved,

We are gathered here today because a change is happening, one that we in the transfusion medicine (TM) community should all be aware of, the death of the precautionary principle in transfusion medicine (TM). But life goes on, and now we see the birth of risk-based decision making (RBDM), which is probably at the toddler stage.

Lean and Sigma Six was the flavour of the decade in blood centres and transfusion services. I can only imagine how much money consultants made and still make off this cash cow. Now the new cash motherload for consultants is RBDM.

The blog's title derives from a Pete Seeger classic of the 1950s.

I decided to blog about RBDM because it was featured in the June issue of AABB News in the form of a report on the 2014 National Blood Foundation (NBF) Leadership Forum in Washington, DC on 28 April.

Although AABB News is 'news lite' compared to the full strength journal,Transfusion, I wonder how many working professionals (technologists, nurses, physicians) read the NBF forum report. I suspect few.

But here's the thing. It's worth reading on several levels, including the ability to pass top executives in the hallways of power and quip,

• 'Hey, Graham. How's our transformational innovation going? And do we have any adjacent initiatives on the burner? 

Read on to discover more. The NBF leadership forum highlighted

• Appropriate Use of Medical Resources, Risk-Based Decision Making and Strategies for Innovation

Leach Bennett's presentation (I searched for it on the web and found it and took the liberty of lifting a few diagrams from it. If inappropriate, let me know):

• Risk-Based Decision Making for Blood Safety

RBDM - A PARADIGM SHIFT?
RBDM is a major initiative of the The Alliance of Blood Operators (ABO). ABO is international, at least for developed countries. ABO would not make sense for poor countries, which have little or no money to prevent kids dying from diarrhea, let alone effectively prevent risks to the blood supply.

From what I can tell, RBDM is a process for high level leadership dudes to decide things like whether to implement new blood safety measures or not. Its ascendancy signals that the precautionary principle is truly dead. As Thomas Kuhn may have said, there's been a paradigm shift, folks.

Sorry, I know using 'paradigm shift' to describe abandoning the precautionary principle for RBDM is an abuse of what Kuhn meant, but the phrase is one of the most abused ever.

By paradigm, Kuhn meant a 'set of assumptions, definitions, laws and techniques that are shared by the members of a scientific community.' That has since been expanded to relate to members of any community, including the transfusion medicine community and is used in the 2014 paper by Menitove, et al., cited below.

BTW, if you've never read The Structure of Scientific Revolutions, give it a try. It's accessible and fascinating:

• Thomas Kuhn: the man who changed the way the world looked at science

By examining history, Kuhn explained why incorrect scientific ideas persist and how they're finally rejected. Because people believe what they know, science is inherently conservative. A current scientific theory ('paradigm') is hard to dislodge and takes much evidence or a powerful single piece of evidence to overturn. When this occurs, Kuhn called it a 'paradigm shift'.

So let's look at RBDM to see if it's a TM paradigm shift.

RBDM takes off
RBDM has been around for a few years but is now gaining steam in NA and all developed nations. For example, in Oct. 2010 a consensus conference was held in Toronto, Canada:

• Leach Bennett J, Blajchman MA, Delage G, Fearon M, Devine D. Proceedings of a consensus conference: Risk-Based Decision Making for Blood Safety. Transfus Med Rev. 2011 Oct;25(4):267-92. 

And now this 2014 paper

• Menitove JE, Leach Bennett J, Tomasulo P, Katz LM. How safe is safe enough, who decides and how? From a zero-risk paradigm to risk-based decision making. Transfusion. 2014 Mar;54(3 Pt 2):753-7.

As Judie Leach Bennett, LLB, LLM, director of CBS's Centre for Innovation explains,

The goal is to optimize the safety of the blood supply by enabling the proportional allocation of finite resources to mitigate the most serious risks, recognizing that the elimination of all risk is not possible.

Leach Bennett is a lawyer whose earlier jobs at CBS included Executive Director, Legal and Risk Management, and Legal Counsel. (LLB is a Bachelor of Laws, LLM a Master of Laws.) The well respected Leach Bennett is also the Chair of The Alliance of Blood Operators (ABO) RBDM Steering Committee.

SMOKE AND MIRRORS?
How did the supposed 'zero-risk paradigm' in transfusion medicine evolve to a paradigm of risk-based decision making (RBDM)? First, there never was a zero-risk paradigm in TM. The public may have wanted zero-risk but TM professionals knew it was impossible. If anything, what ruled after the HIV/HCV transfusion-related tragedies was a precautionary principle paradigm.

Discussing the nuances of the precautionary principle and the pros and cons of applying it (whatever 'it' means) is beyond the scope of this blog and my competence. To me it always meant

• If there was considerable evidence that a serious risk existed, we should try to prevent it, even if it wasn't proven beyond a shadow of a doubt. 

And providing we can afford to do so, given that health resources are finite and priorities are necessary. And forgetting that the cost of wars fought since 9/ll have been huge for many countries, most of all the USA:

• Cost of USA wars through 2013: $3.1 trillion and counting

That said, 2 papers on the precautionary principle:

• Alter HJ. Pathogen reduction: a precautionary principle paradigm. Transfus Med Rev 2008 Apr;22(2):97-102.
• Wilson K. A framework for applying the precautionary principle to transfusion safety. Transfus Med Rev. 2011 Jul; 25(3):177-83.

But back to the Menitove paper. Let's assume zero-risk was a TM paradigm. Was it a paradigm shift in the Kuhn sense, meaning zero-risk was dislodged over time by a preponderance of evidence or a single powerful piece of evidence? Not really.

Papers on RBDM suggest the paradigm has changed because the COST of preventing some risks is too expensive. For example the opening sentence of

• Menitove JE, Leach Bennett J, Tomasulo P, Katz LM. How safe is safe enough, who decides and how? From a zero-risk paradigm to risk-based decision making. Transfusion. 2014 Mar;54(3 Pt 2):753-7.

Health care costs have risen to 17.4% of US gross domestic product, and health care economists urge a reversal of this unsustainable trend.

Leach Bennett in her presentation to the NBF's 2014 leadership conference, under 'Impetus for Change', references the precautionary principle as the TM response to the 1980s blood tragedies but then states:

• [It's] Clear that pursuit of 'precaution at all costs' is unsustainable
• Blood safety decision-making is increasingly complex: science,ethics, social values, economics, public expectations, context

Note how science is placed first, with economics in the middle. This graphic on 'health economics and outcomes' from her presentation is enlightening:

Instead of cost and effectiveness, many risk assessment models put safety first, i.e., consider the severity of a risk and its probability of happening:

Leach Bennett's NBF presentation is well worth reading because it explains where we are going. The science part ('Risk Intelligence'):

Comprehensive patient outcome and quality data, including hemovigilance, will guide decision-making and help define acceptable risk.

The 'Effectiveness and Cost' part:

Reliable information and tools will be readily available to balance risks, costs and benefits in a manner which optimizes donor safety and patient outcomes.

The entire RBDM Change Agenda: Source: Judie Leach Bennet's 2014 NFB presentation, Risk-Based Decision Making for Blood Safety

And note what's third on the Change Agenda: Blood operators will take an expanded leadership role in vein-to-vein blood safety. In Canada, that would be our national blood suppliers, CBS and Héma-Québec.

Sounds a wee bit like a unilateral power grab, no? And there's that word innovation again.

GESTALT SWITCH
TM's abandoning the precautionary principle to protect blood safety, and now championing RBDM, is not a true paradigm shift, but could be called a 'gestalt switch'.

OMG, you say, not more jargon! Bear with me. I'm just 'tarting up' the RBDM movement to assess cost vs benefit in blood safety with bafflegab that's an alternative to 'paradigm shift'.

Gestalt is a German concept meaning the whole is greater than the sum of its parts. Gestalt means shape (or form) in English. Gestalt is used in psychology to describe an approach which aims to see something as a whole rather than its individual parts.

A gestalt switch requires an emotional and intellectual switch to think differently. For example, what do you see? A white vase? Or 2 black profiles facing each other? To see one or the other requires us to make a gestalt switch.

That's what our TM 'thought leaders' are doing with RBDM. Because of cost constraints, they've designed a completely different way of conceptualizing risks to blood safety and how to prevent them.

• Zero risk is impossible (something we've long known).
• Safety isn't paramount because it's too expensive. Safety is shades of grey.
• Let's promote the change to RBDM as safety first, because that's what the (somewhat deluded) public wants.
• Moreover, let's associate the cost-saving movement with a sexy name like innovation to make it more palatable. For example:

Judie Leach Bennett, once Director of CBS's 'Legal and Risk Management', now heads the CBS 'Centre for Innovation'.

Title of the AABB News report: Appropriate Use of Medical Resources, Risk-Based Decision Making and Strategies for Innovation. 

INNOVATION BAFFLEGAB
Another speaker at the NBF leadership conference was Brian Quinn, employed by a company owned by Deloitte Consulting, Chicago.

Quinn highlighted innovation in his closing talk, describing three types:

• Core: existing products
• Adjacent: new business areas adjacent to existing core strengths
• Transformational: inventing products and creating new markets

I love the last, transformational. It's one of the words banned by the UK's Local Government Association in 2009. Yet it's a favorite of CBS leaders and usually features prominently in CBS's annual reports to Canadians.

 To read more about this new consulting bafflegab on innovation, see

• Managing your innovation portfolio (Harvard Business Review, May 2012) 

Looks like Monitor Deloitte has moved from consulting for Libya's Muammar Gaddafi to the world's TM community, among others.

BOTTOM LINE
The RBDM movement means we've truly jettisoned the precautionary principle (whose application to TM has been flawed at times) for cost uber alles. It's reality and well foreshadowed.

If RBDM prevailed earlier, it's possible that much of what the TM community did since 1981* to protect the blood supply would never have been done. [*When the CDC's MMWR published a report describing cases of a rare lung infection, Pneumocystis carinii pneumonia, in 5 young, previously healthy, gay men in LA.]

Perhaps a good thing in some cases, but a quasi-cost-effectiveness approach was used decades ago and caused harm, e.g., Canada's decision not to implement surrogate tests for non-A, non-B hepatitis (hepatitis C) because they were too 'unscientific'/ineffective (poor sensitivity and specificity) and too expensive. This decision led to many thousands of Canadians being infected with HCV.

Or the blood supplier (then Canadian Red Cross), clinicians, and government deciding that most hemophiliacs were probably already infected with what became known as HIV, so should continue to receive non-heat treated factor VIII concentrate derived from tens of 1000s of blood donors. Gotta use up that expensive, paid-for stock on the shelves? Seems likely but we'll never know because minutes of crucial meetings were mysteriously shredded.

All of which identifies the flies in the RBDM ointment:

1. TM professionals don't always know what measures are more or less effective to enhance blood safety. Sometimes measures that seem costly at the time and are deemed flawed (ineffective) can save the health care system mega-bucks in the long run, to say nothing of human suffering, as in Canada's hepatitis C debacle.
2. Just like the public in general, health professionals sometimes get caught up in mob psychology. If thought leaders religiously proselytise a particular policy, it's hard for acolytes to dissent and be designated heretics. Definitely not a good career move. 

To everything there is a season. The old blood safety season (new season):

• 'Above all, do no harm' (Only do no harm if it's cheap and effective.) Note: Doing harm can result from acts of omission.
• 'If harm is suggested, but not proven beyond a shadow of a doubt, we should try to prevent it.' (If harm is possible, don't prevent it unless the measure is cheap and effective.)

Because the health care money pot is finite, it's now all about risk vs benefit, similar to return on investment (ROI) in the financial world.

• Soon we will spend money only on cheap, effective blood safety measures. All else is no or maybe.

Of course, the RBDM model was developed by smart, well meaning transfusion professionals and is more complex than I've focused on here. Among other aspects, RBDM includes assessing science, ethics, social values, economics, public expectations, and context.

But it's human nature to go for the simplest tool and, because  economics fits the bill and is a driver for RBDM, it will likely carry more weight.

Updated 16 July 2014
In reply to Roger (see comment below): Invariably those making decisions promote safety above all but, when you examine what they say, often a different picture emerges. 

Note the words used to soothe the public that all is well, you can trust us. For example:

1) The goal is to optimize the safety of the blood supply by enabling the proportional allocation of finite resources to mitigate the most serious risks, recognizing that the elimination of all risk is not possible.

means, 'We'll spend $ only on the MOST SERIOUS RISKS and only if it's INEXPENSIVE because there's not enough $ to go around.' The other points are background noise to obfuscate the main point.

Key words to soothe the public: optimize, safety

2) Comprehensive patient outcome and quality data, including hemovigilance, will guide decision-making and help define acceptable risk.

means, 'We don't have a clue how to decide what acceptable risk is, but, trust us, because we'll use comprehensive, quality data and muddle our way through.'

Key words to soothe the public: comprehensive, quality, acceptable

3) Reliable information and tools will be readily available to balance risks, costs and benefits in a manner which optimizes donor safety and patient outcomes.

means, 'You can trust us to decide what's safe. '

Key words to soothe the public: reliable, readily, balance, optimize, safety

The soothing words didn't appear by accident but were carefully crafted. They're not quite weasel words to mislead readers into thinking that a meaningful, specific statement was made. But they do aim to mislead in that they're designed to create the overwhelming impression that RBDM leaders are on top of things, have all bases covered, and put safety first, not saving money.

They make the case that, by not spending money on ineffective, costly measures, blood safety will be enhanced. Hard to argue against that, assuming we know ahead of time what's ineffective (we didn't with surrogate tests for HCV). The rest is sheer 'trust us' territory and, if past is prologue, why would we?

Update #1 (17 July 2014)
In reply to Anonymous who wrote on the reality of scarce resources (see Comments below):

I agree the health care system must prioritize as funds are finite. That's a given. But you set up a false hypothetical in that everyone can agree not to fund your example.

It's the heavy emphasis on costly (cost is easy to determine) prevention measures where things can go awry, especially as history shows experts don't always know what's effective, or even true prevalence, witness HCV when it was non-A, non-B hepatitis.

In Canada, governments have long tried to curb the cost of transfusions, particularly plasma derivatives like IV immune globulin, which have many off-label uses, e.g., the BC PBCO's utilization management program.

Then there's looking at larger priorities for tax dollars in terms of $ spent on the Afghan war, fighter jets we don't even have yet, Canada's Senate, and on and on.

How to spend health resources effectively and fairly is challenging. That's why our TM experts should be challenged on their plans, especially when they choose to wrap it in quasi-weasel-language like transformational innovation.

Update #2 (17 July 2014)
In reply to Anonymous, who wrote, 'We seem to be getting arrogant again in thinking the science alone can manage risk':

My gut reaction is to quip, 'Getting arrogant again? Nope. We never stopped being arrogant.' But you make a point worth discussing.

Today's health professionals, including TM experts, stress evidence-based medicine (EBM), most recently CBS CEO Graham Sher on the issue of paid plasma collection in Canada:

• Purchased plasma safe, essential (8 May 2014)

We have created a safe and secure system that today is the envy of much of the world, and we did this using science, evidence and risk-based decision making as our core principles. It is important that these principles continue to be the driving force behind public policy and the blood system.

But EBM is not without its flaws, as explained in this 2011 Boston Globe op ed:

• Trial and too many errors: ‘Evidence-based’ medicine can be built on opinion and selective evidence

As the author notes, “Evidence-based medicine is only as strong as the evidence used to support it. The stark reality is that evidence can be weak, biased, or even fraudulent.” Amen.

For a comprehensive, straightforward, balanced look at the issues facing blood safety, one not into the current group-speak lingo propagated in many of the other cited papers, see:

• Aprili G. Safety in transfusion medicine. Blood Transfus 2008 Jul; 6(3): 121–6.

Updated 23 July 2014
In reply Anonymous (x2), about latest news on Ontario's plan to ban paid plasma clinics in Canada:

• Bill to safeguard blood reintroduced in ON legislature

Intriguing part is ON Dept of Health inspectors 'swooped in to seize records'. Those operating Canadian Plasma Resources clinics said the raid virtually halted operations.

Why a raid to seize records? Can't wait for more details. Stay tuned.

Updated 27 July 2014
In response to the Comment below about two quotes by CBS CEO Graham Sher, I've decided to write a new, separate blog. This one is getting a bit long.

FOR FUN
The theme made me think of Pete Seeger's Turn! Turn! Turn! The lyrics and final verse are adapted word-for-word from Chapter 3 of the Book of Ecclesiastes:

• Turn! Turn! Turn! (Judy Collins)

And here's the man himself, age 93:

• Turn! Turn! Turn! (Pete Seeger, 2012) 

To everything, turn, turn, turn.
There is a season, turn, turn, turn.
And a time to every purpose under heaven.
A time to be born, a time to die.
A time to plant, a time to reap.
A time to kill, a time to heal.
A time to laugh, a time to weep. 

As always, the opinions are mine alone and feedback is most welcome.

If you could read my mind (Musings on 'acceptable risk' & who pays the price)

This month, seeing as it's the 'dog days of summer', I'll muse on multiple related items about transfusion risks and economics that made me ponder days gone by. The blog's title comes from an old Gordon Lightfoot song.

Everywhere you look these days, transfusion journals and newsletters are filled with discussions on cost-effective and how organizations need to find ways to reduce costs while maintaining or improving blood safety. The clichéd business jargon of the 1990s is pervasive in the TM literature, now used by physicians in suits (as opposed to lab coats) to whom it has come, albeit late.

I've long been an advocate of risk management as applied to test rationalization in the transfusion service and taught students about the health care piggy bank not being bottomless. Choices must be made and, when we fund some tests and procedures, it automatically means others cannot be funded.

But something about the current discussion on cost, benefit, and risk as applied to protecting the safety of the blood supply disturbs me.

1. AIDS AT 30

June's issue of AABB News features '30 years of fighting AIDS' and focuses on major advances in blood safety resulting from nucleic acid amplification testing (NAT).

Michael Busch notes that 99.999% of HIV cases are being detected and "The risk curve is approaching zero, but it's never going to be zero exactly."

AABB president James Aubuchon  is also quoted in 'AIDS at 30':

"We should congratulate ourselves on what we have accomplished...in our approach to infectious diseases and these accomplishments have allowed us to turn our attention to other problems such as bacteria in platelets and TRALI."

Presumably "our approach to infectious diseases" includes applying the precautionary principle to blood safety.

2. RISK-BASED DECISION MAKING

A consensus conference on risk-based decision making for blood safety was held in Toronto in Oct. 2010 and will be discussed at the 2011 AABB meeting in San Diego. The proceedings were published in July.

• Leach Bennett J, Blajchman MA, Delage G, Fearon M, Devine D. Proceedings of a Consensus Conference: Risk-Based Decision Making for Blood Safety. Transfus Med Rev. 2011 Jul 13. [Epub ahead of print]

Also see

• Wilson K. A framework for applying the precautionary principle to transfusion safety. Transfus Med Rev. 2011 Jul;25(3):177-83.

In this paper, Wilson, who also participated in the consensus conference on risk-based decision making, offers the following factors as a standardized way to decide which type of precaution, if any, to implement for a given transfusion risk:

1. Is the extent of the exposure large?
2. Is the consequence of the exposure serious?
3. Is the consequence of the exposure irreversible?
4. Is there minimal cost associated with the removal of the exposure?
5. Is there a minimal negative health effect associated with removing the exposure?

Assuming that definitive data are available (not always possible), using these guidelines presumably means do something if a big exposure, serious and irreversible consequences exist (e.g., HIV infection). How cost and negative effects on the donor supply influence decisions and interact with the other factors is less clear.

The precautionary principle, while improving blood safety, has inevitably produced increased blood costs and led to 'push-back' in the form of questioning whether it has gone too far.

As noted in an earlier blog, "The principle implies that there is a responsibility to protect the public from harm if research discovers a plausible risk, especially if it is a severe risk. But the proof of harm need not be certain, and cause and effect do not need to be fully established."

To me, the report on the consensus conference (Risk-Based Decision Making for Blood Safety) indicates the direction of future decision making:

• Cost is becoming increasingly important and the precautionary principle as applied to transfusion medicine will be shaped to fit what is financially desirable.

3. COST REDUCTION

Ongoing evidence exists that blood suppliers are in trouble and need to reduce costs.

• Three Florida blood banks to merge to provide the "the safest blood supply at the lowest possible cost"
• Florida blood banks fight a turf war over blood donors

June's AABB News also features a report on the 9th Annual National Blood Foundation Leadership Forum held in April 2011 in Miami. Richard Gundling, VP of Healthcare Financial Management Association, is quoted as saying that

• organizations that merge or form partnerships "can benefit from higher margins, greater expense control and economies of scale."  

The July issue of Journal of Blood Services Management (published with Transfusion) includes this article:

• 'A roundtable discussion: from thoughts on supply and demand to what keeps us up at night' 

A sample comment:

Each merger is unique, but in general, mergers are driven by a rationale to lower costs, grow geographically and access hospital markets that are crossing current blood center lines. Often it's about pricing strategies. (Stacy Sime, President and CEO, LifeServe Blood Center)

4. HISTORICAL PERSPECTIVE

In this 1998 CMAJ article written on the eve of CBS taking over the blood system in English Canada ("Concerns mount as transfusion medicine loses its lustre"), Noel Buskard and other luminaries in Canada's TM firmament discussed not only the legal risks involved in transfusion medicine but also a trend toward

• "a 'pharmaceutical model' in which the physician is based in-house, reports to a CEO-style business manager and doesn't have a connection to patients or other institutions."

What would the physicians quoted in this 1998 article think of the current emphasis (ascendancy?) of the economics of transfusion medicine, especially when juxtaposed with managing risk? If they want to thrive in the current system, I imagine they would keep pretty quiet.

Today the guys who get air time at AABB and other conferences are those who promote strategies to achieve cost-effectiveness.

From Jeffrey McCullough's presentation (Consensus Conference on Risk-Based Decision Making):

• In response to a variety of developments over the past 25 years, the culture and structure of blood organizations have evolved. These organizations have moved from a medical model involving individualized decision making resembling patient care to a systems-based pharmaceutical manufacturing model, with new approaches to quality assurance. Organizational structures have been transformed; and new kinds of leadership are now valued, such as manufacturing and business expertise.
• Governed by the principle that “safety of the blood supply is paramount”, these organizations have achieved significant improvements in blood safety. However, that paradigm is evolving and potentially conflicts with other principles, such as the notion that “decisions…will be made within a health risk management framework, which places on an equal footing the 3 critical elements of cost, benefit, risk”. (Words in quotation marks are from referenced sources)

REMEMBERING

• An outspoken patient advocate - Dr. Noel Buskard angered authorities, but was beloved as teacher, clinician

Noel Buskard was the medical director of Vancouver's Canadian Red Cross blood centre during the early years of the AIDS tragedy in which 1000s across Canada and around the globe were infected with HIV and hepatitis from blood transfusions. He quit the Red Cross in 1991 saying it had developed a "fortress mentality" when confronted with the AIDS tragedy.

Noel was the President of the CSTM (1998-2000). For speaking publicly about safety issues throughout his career, he was awarded the 2001 Whistleblower Award from the B.C. Freedom of Information and Privacy Association.

For a fascinating trip down memory lane, see

• 1984: Noel Buskard saying there is no evidence of AIDS being transmitted by a blood product in Canada and discussing the cost-benefit ratio in giving hemophiliacs factor VIII. (CBC news video)
• An Annotated Chronology of the History of AIDS in Toronto: The First Five Years, 1981-1986 (based on Toronto newspaper reports of significant events that occurred in Toronto and elsewhere)

5. PATIENTS - RISK BEARERS WHO PAY THE PRICE

Lest we forget:

• 1994: The Tragedy of Factor VIII concentrate (CBC news video)

Reading the current papers on blood safety and talk of 'acceptable risk', and balancing risk and cost, I cannot help but remember this interview of the daughter of a Manitoba hemophiliac, Ed Kubin.

Many moons ago when I worked at the Winnipeg Red Cross, Ed and his brother Barry would regularly pick up their supplies of cryoprecipitate from the lab. (Yes, it was just pre-factor VIII concentrate)

Writing this blog brings to mind this gem by Canada's Gordon Lightfoot

• If you could read my mind

I'm pretty sure you can read my mind on where I stand on the issue of 'acceptable risk' and who pays the price.

BOTTOM LINE
So, what is it about the current discussion on risk management and the safety of the blood supply that disturbs me? It's that those doing the talking seem to be leaning towards cost being the main determining factor, despite the lip service paid to safety.

We know that credible evidence is needed to show that an intervention to prevent a given risk may add to blood safety, but evidence need not be overwhelming, according to the precautionary principle. Did the AIDS and HCV tragedies not teach us that? Unfortunately, emerging threats to the blood supply do not often come with good data on how large the true exposure is and evidence is often unclear in the early days.

If cost is given too much weight, as seems likely, we are doomed to commit the errors of the past. And it isn't the docs making the decisions who will pay the ultimate cost.
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As always the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice.  This blog was updated 7 Aug. 2011.