Saturday, March 18, 2017

Exploitation Of Opiate Addicts - Same Song Different Century



Most people don't know or care about the past history of addictive drugs in America.  The best examples of this are the people who want to legalize all drugs and don't realize that there was a long history before regulation and that there were legal over-the-counter forms of opium and cocaine.  Contrary to the Utopian way that it is portrayed today, regulation of addictive drugs occurred because of problems and not the other way around.  The only way that you can think that the legal aspects of drug control created the problems rather than the drugs themselves is if you completely ignore what really happened.  The quote by Osler is particularly poignant with regard to that history.  The quote is from his classic text The Principles and Practices of Medicine and a chapter he wrote in that text on opiate addiction.  The year was 1894.  It occurs in the context of a marked increase in opium use.  The isolation of morphine from opium in 1804 and the commercial production of morphine in 1826 as well as the invention of the hypodermic needle in 1855 were thought to be contributors to the opiate epidemic of the late 19th century.  Although morphine had been injected into areas close to nerves previously, the hypodermic needle allowed unprecedented ability to inject morphine very close to affected nerves.  Within a short while morphine injections to treat various forms of neuropathic pain were common.  The statement about women being higher risk may reflect the estimated risk that women were twice as likely to become addicted to opiates from precriptions by their doctors.

The new method of treating nerve pain with injected morphine was thought to be a major advance in the treatment  of chronic pain.  Despite frequent injections it took some time for physicians to recognize the fact that people were getting addicted to morphine.  Musto in one of his excellent texts titles a chapter:  "The Belated Recognition of Addiction to Hypodermically-Administered Morphine" (1)  Although that title may seem laughable today the historical mistakes have been repeated again.  Just a few examples include "tamper proof" addictive medications that turn out to not be tamper proof, tramadol as a "non-addictive" option to opioids. and the idea that benzodiazepines are safe and non-addicting.  All have all been disproved on a historical basis.  The historical approach to addictive drugs has been a naive one - even before the era of intense marketing to physicians, massive lobbying efforts and direct to consumer advertising.

There seem to be very few people who are knowledgeable about the regulatory landscape for narcotics in the United States over the past 150 years.  It is an interesting parallel to the origins of the current opioid epidemic and it rests on the principle that increasing access to addictive compounds will result in more members of society with addiction.  It also has implications for the disease concept of addiction well before there was any established neuroscience.  The argument in those days was whether opiate addiction permanently altered the physiology of the nervous system to the point where the need for ongoing drug was inevitable.  There has been plenty of evidence to support that and the evidence has been there for a long time.  As early as 1875, a German physician Eduard Levinstein collected follow up data on patients he had weaned off opiates and found a relapse rate of 75% (ref 1 p 74).  In 1914, physicians at the Tombs prison in lower Manhattan estimated that it would take two months to get opiate addicts off drugs and unless they were isolated from drugs for another year the prospects for cure were low (ref 1 p 107).  That sums up my experience with opioids even today.  The main difference is that people are now on maintenance opioids for at least that long and get the message that they need to take these drugs for the rest of their life.

In the early 20th century, some American physicians looking to "cure" opiate addicts were fairly pessimistic about the prospects.  By 1920 there was one estimate that there were a million opiate addicts in the United States.  The population at the time was about 107 million people.  Two options were considered at the time - indefinite maintenance on opioids and the elimination of all non-medical use.  There was a relatively small number of physicians referred to as dope doctors whose practices consisted of maintaining large numbers of people in addiction by ongoing opiate prescriptions.  As regulations proceeded from the belief that federal control over narcotics and prescription practices of doctors was unconstitutional in 1900 to the enactment of the Harrison Act on March 1, 1915 outlawing the non-medical prescription of opiates - there were a small number of physicians engaged in the practice of maintaining addiction.  That practice was declared illegal by the Harrison Act until it was modified years later to allow methadone maintenance.  The evolution of medical practice over that time was interesting.  In less than a generation, opiates and cocaine went from being over-the-counter medications to being highly regulated.  Medical and pharmacy practice was impacted and there were political battles along the way.  Post Harrison Act there are still physicians engaged in the now illegitimate practice that are described in the popular culture in the 1950s and 1960s.  Legitimate and illegitimate prescribing of controlled substances is always a fine line.  In the 21st century, the main problem is the number of patients who are trying to game the system and get opioids and stimulants.

It is still illegal to prescribe an addictive medications to an addict.  The only exceptions are methadone and buprenorphine.  Methadone prescriptions for addiction treatment can only occur in licensed methadone clinics.  Buprenorphine can occur in outpatient medical practice but a special license it required and the total number of patients treated is regulated.  But what about the patient who claims that they can take an addictive medication in a controlled manner?  It may not be the primary addiction, but there are many patients with alcohol use disorders and opioid use disorders who believe that they have Attention Deficit~Hyperactivity Disorder (ADHD) and claim that they can take stimulant medications.  There are many people with stimulant use disorders who claim that they can take prescription stimulants in a controlled manner and insist on it.  How many doctors continue to prescribe these medications to patients who they know are addicted?  My speculation is that there are currently millions if not tens of millions of people being maintained in addiction by physicians who think that they are being helpful as their primary motivation.

I started this post with the intent to comment on a the specific practice of buprenorphine maintenance.  I commented recently on the problems with buprenorphine maintenance and why it is a far from ideal solution to the centuries old problem of opioid addiction.  Since that post I have become aware of a new problem.  In many areas there are very few buprenorphine prescribers and many opioid addicts.  There are many excellent physicians who are addictionologists and addiction psychiatrists out there trying to make a difference.  Running a buprenorphine clinic is a fairly intensive exercise that typically involves counseling and frequent toxicology screens.  Many of these patients have significant medical and psychiatric comorbidity.  That said, there are apparently some buprenorphine prescribers that are motivated to make a significant profit from this practice by charging patients $500 to $1,000 for brief monthly visits with additional charges for the toxicology and counseling.  These charges are all in cash and in my opinion are problematic.

The problem with these charges is that they directly impact the relationship with the physician.  A straight economic argument is often made.  That argument goes something like this: "What would this person be spending of they were still using heroin?"  That number is highly variable based on individual physiology and geographic location but a rough cost estimate would be $1200 - $5,000/month.  On straight cost basis an expensive buprenorphine clinic comes in at the low end of the estimated monthly cost of daily heroin use.  But that misses the point.  When people are in recovery, many of them are working at low paying jobs with minimal or no insurance.  They need a cost effective solution to opioid treatment and that includes buprenorphine maintenance.  If they see a physician and need to pay $500-1,000 cash essentially for a prescription it will lead to immediate thoughts about why they are bothering to stay sober.  It will lead to resentment toward the physician or at the minimum a loss of physician credibility.  It leads to a question about physician motivation.  People with addictions are no different than anyone else seeing a physician.  They have to realize at some point that the physician is interested in them and helping them rather than just making a profit.  There are clearly some physicians out there who don't get that point.  The outcry has been palpable with a backlash on buprenorphine prescribing that is visible on several social media groups.  The toal membership of these groups is over 10,000 people.  Many of these people are clearly interested in tapering off buprenorphine at some point rather than life-long maintenance.

The dynamic of taking advantage of people with addictions in the US goes back to the early 20th century.  The landscape  has changed based on what is considered to be a legitimate prescription to people with addictions. In the 21st century we are currently operating under the premise that we may have a treatment for opioid addiction, but there are many limitations.  Physicians would do better heeding Osler's warning at the top of this post. modifying his quote about hypodermic syringes to include the equivalent today - high potency opioids.  In the case of people with know addictions, treatment needs to be ethical and patient focused.  We have seen a rapid move to "evidence based" treatment for opioid addiction based on medications and little else.  That is really not a solution to the problem of known addiction or the ongoing drug epidemics in the US.

Prevention is the best current approach to addiction.
    



George Dawson, MD, DFAPA


References:

1:  Musto DF.  The American Disease: Origins of Narcotic Control.  3rd ed.  Oxford University Press.  New York, 1999.

2:  Musto DF.  Drugs In America: A Documentary History.  New York University Press.  New York, 2002.










Friday, March 10, 2017

The Best Strategy To Address The Proliferation Of Prescribers



MPS Newsletter Ideas of Reference 2017, Number 1, Volume XLX






When I got home this evening I opened up a copy of the Minnesota Psychiatric Society newsletter Ideas of Reference.  I was greeted by the above graphic and an accompanying story on the differences between psychiatrists and psychologists.  There were even some bar graphs on the relative biomedical training comparing psychiatrists, nurse practitioners, physician assistants, and a proposed trivial training period for psychologist prescribers.  I can only surmise that there is some initiative to create psychologist prescribers.

It should be obvious to any casual reader of this blog that as a medical psychiatrist and neuropsychiatrist, I don't think that anyone has better training than psychiatrists to prescribe medications and diagnose mental disorders and associated medical and neurological disorders.  My first letters on this matter date back to 1988 with the CAAP v. Rank legislation in California that proposed that psychologists should have admitting privileges to hospitals.  The same national group was getting active in trying to convince state legislators to allow psychologists to prescribe medications.  To somebody who has been steeped in biomedicine, why somebody with no training would want to take a crash course to prescribe a niche of medications while knowing nothing about general pharmacology or physiology is a mystery to me.  The early advocates were explicitly concerned about making money.  There is nothing wrong with that, but it should be equally understandable why a highly trained person might find that approach somewhat appalling.

Over the years, I tried with no success to rally the troops not so much against any political group but always arguing for a tight professional organization whose goals was to bring all psychiatrists up to speed in order to practice state-of-the-art psychiatry.  As a professional organization that is all you can do.  The American Psychiatric Association tries to pull it off, but there are too many political conflicts of interest.  For years the APA has clearly been more aligned with managed care organizations and the American Board of Medical Specialties and the American Board of Psychiatry and Neurology against the membership.  People may deny it but that has been the net effect.  Instead of the goals of independent life long learning and state-of-the-art psychiatry, the vigor of the organization has been dissipated on shaky political alliances and special interest politics.  Instead of defending the organization and its members there have been concessions to people grandstanding in Congress.  There have also been concessions to the cost rhetoric of both the government and managed care organizations and the current collaborative care rhetoric as psychiatric reimbursement from those organizations has become trivial and the infrastructure required to treat severe disorder - destroyed.

For the last 30 years, there has been a constant war of attrition in state legislatures everywhere against the idea that you probably should have medical training in order to prescribe medications.  There is a break with reality in that physicians with the highest level of training also have the highest levels of accountability.  Any interested citizen living in a state where there are a lot of nonphysician prescribers should ask themselves if all of those prescribers are held to the same standard or not?  What level of training does it take in a crash course to equal my 8 years of medical training?  How do politicians with no knowledge of medical training themselves make these decisions?  Is the decision based on public safety - their usual standard for investigating physicians - or is it something else?  I would submit that it is always something else?

Getting back to the title of this post I will comment on a few strategies that are probably too little and too late at this point.  These are things I have been talking about for 30 years frequently to the annoyance of colleagues who prefer a head-in-the-sand approach:

1.  State-of-the-art psychiatry:  I was buoyed by a presentation on neuropsychiatry at the Madison conference this year and think that teaching and talking about these concepts needs to be more widespread.  There is no better way to up your game than to take the thinking in the field to an entirely different level.

2.  Politics:  Physicians in general depend far too much on the kindness of strangers.  The amount of money that physicians have given to politicians looking for a modest break (like maybe there should be a limit on who is qualified to prescribe medication) is legendary at this point.  That is billions of dollars wasted just so the Obama administration could sit physician representatives down in a room and tell them their job was to sit there, shut up and support Obamacare.  Physicians and psychiatrists cannot afford to squander blood, sweat, and treasure on people who only know how to exploit physicians.  That includes anyone supporting maintenance of certification (MOC), maintenance of licensure (MOL), managed care organizations, or pharmaceutical benefit managers.  That includes anyone supporting  the various reasons why physicians have to sit down at the end of a busy day and spend another 3 to 4 hours on paperwork before they can go home.      

3.  Know who your friends are: Any manager who suggests that you need to be on a team comprised of nonphysicians when you are perfectly fine practicing independently is not your friend particularly when some of these people with no accountability start to tell you how to practice medicine.  They can do that because they have the full support of the administration.  Managed care companies that burn physicians out and hire more and more "prescribers" are not your friend.  In this case the focus is on a nonmedical profession prescribing.     While shocking it is also the logical conclusion of decades of more and more non-physicians who are often practicing in specialty clinics and seeing patients in regular rotation with subspecialists.  The entire trend is driven not by expertise but by the managed care mantra of how to ration care but still make money.  The current collaborative care model supported by the APA is a recipe for getting rid of psychiatrists either entirely or replacing them with somebody who can sit, look at a guideline and say something on the phone.

The team approach is also a management tool to make it seem like all team members are equal.  If one of the specialists with a particular skill set is gone the patient can be seen by anyone.  The encouraged egalitarian approach by management is clearly biased away from any particular expertise and toward generic and presumably less expensive prescribers.

4:  Competition:  When all of the geniuses in state legislatures max out the number of "prescribers" any psychiatrist out there needs to ask themselves: "Now what?"  Well if anyone had been listening 30 years ago, psychiatry would be in a much better place right now.  Instead, everyone jumped on the managed care bandwagon and three decades of decidedly poor quality care.  The only hope that I see is doing what every other successful specialty does to survive managed care - get out and form your own specialty groups that compete on quality rather than the lack of competition.  There are some physicians groups who become independent and try to out managed-care the managed care companies.  By that I mean that they optimize billing, hire their own non-physician prescribers, and when the patient's financial resources are depleted - send them back to the managed care company.  That is not a quality approach that will allow physicians to distinguish themselves from the typical managed care model. 

5: High ethical standards:  You can't impress anyone sitting in an office and prescribing Prozac.  You are even less impressive if you are charging a lot of money for a brief appointment.  You are least impressive if that appointment involves the prescription of an addictive drug.  You can't get by with the managed care assembly line approach and do good work.  Offer a high quality product for reasonable value and nobody can compete with that today - because there are few (as in hardly any) high quality products.  Do not be surprised if no managed care company wants to contract with you.  Do not be surprised if government payers will not reimburse you at levels that allow you to stay in business.  It is definitely more ethical to work on your own than accept trivial reimbursement for stereotypical poor care.    

6:  Understand rhetoric:  Physicians as a group really don't understand rhetoric or politics very well.  They think that they are insulated from the fray and avoid confrontations.  They never understand that bullshit and fake news works by leveling the playing field at some level for anyone who is arguing that they have equivalent knowledge or skill.  In the worst case scenario, I have heard many physicians praising prescribers for some quality or another that generally had nothing to do with technical skill.  The only way to preserve the integrity of a profession is to not engage in these pointless arguments and invest that time, energy, and mental work in advancing the profession at the national and local level.  How many district branches have journal clubs, scientific meetings, and clinical discussions on state-of-the-art treatment on a routine basis?  Not many I would guess and yet there is always time for these political squabbles.  The commonest reason I hear that these learning activities don't occur is that everyone is "busy" and doesn't have enough time.  Everyone is busy because their time is wasted managed care companies, the federal coding and reimbursement scheme, the mandatory and inefficient electronic health record, redundant maintenance of certification exercises, and pharmaceutical benefit managers.  

7:  The myth of the "prescriber" shortage:  There should be no doubt in anyone's mind that the most commonly prescribed classes of psychiatric medications are overprescribed.  The idea that we need more "prescribers" to provide even more of these medications flies in the face of that very fact.  Do we need more ADHD experts to provide more stimulants or more anxiety experts to provide benzodiazepines?  The answer is clearly no.  There are only two interests being served by the prescriber shortage myth at this time and those are the health care systems that would prefer to equate all mental health treatment with the prescription of medications and the people manufacturing and selling the medications.  A health care system that is flush with prescribers can certainly do a lot of billing and it is good for public relations, but it is unable to provide any quality psychiatric treatment.

 Psychotherapy services and practically all psychiatric services have been adversely affected by the prescriber shortage myth.  Right now there is a far greater shortage of behavior therapists for anxiety and post-traumatic stress disorders than there is of prescribers.  In the case of patients with severe psychiatric illnesses and addictions these same health care systems that advertise prescribers do not provide adequate treatment environments for the psychiatric treatment of severe disorders and addictions.  All care is funneled into a 10 or 15 minute appointment every three months focused on initiating or maintaining a medication - whether that is the best course of action or not.

Psychological testing is also discriminated against.  The clearest example is the association of learning disorders with ADHD.  Most studies show that at least 1/3 of people with ADHD have associated learning disorders.  There are currently some managed care companies that not only have no psychologists to do this testing, they only allow for testing based on "medical necessity" whatever that might be.  Psychologists that do testing are essentially managed right out of managed care companies or are so unavailable that it takes months or longer to do the testing.  My speculation is that any quality improvement program on this issue for any managed care company would indicate either inadequate levels of testing and/or overdiagnosis of ADHD.  It could easily be accomplished by looking at the number of ADHD prescriptions and determining if any testing had been done.  It turns out managed care companies are the worst at determining the level of prescribing, psychotherapy and psychological testing needed to treat any population of people with mental illness.

Those are a few of my ideas just looking at the graphic.  I am sure that I will have some more posts on this in the future.  My main point this evening is that it is certainly understandable to try to fight this battle with special interest politicians but it is generally a battle that cannot be won at that level. Politicians will deplete time and money and give you nothing in return.  There are just too many people who think that they should be able to prescribe medications irrespective of their training relative to the training of physicians.  The only way to beat them is to excel and pull away looking at them in the rear-view mirror.

One thing is for sure -  if I come to your clinic to see a Cardiologist - I better be seeing a Cardiologist and not a prescriber.


George Dawson, MD, DFAPA



Supplementary:

In thinking a little bit more about the current MPS approach, I came up with an alternative.  I would ask MPS members to send in all of the medical problems and diagnoses they have made in the course of their practice on a month to month basis and compile them on the web site.  That would go a long way toward differentiating medical and psychiatric practice from non-medical mental health practice.  I would include diagnosing and treating complications of medical treatment.  That would make more of an impact than the current infographic.


Attribution:

The graphic at the top is from the referenced source.  I am a member and Past President of the MPS and a Distinguished Fellow of the APA.  Use of this graphic is for commentary purposes and does not imply endorsement of me by the MPS or APA, although that should be fairly obvious.

As far as the graphic goes I realize that I am not the target audience here, but even with that premise the graphic appears to seriously dumb down what I do on a daily basis.  That is one of the central problems in trying to condense and compare 8 years of education and training to someone with essentially no training at all in medicine.










  

Saturday, March 4, 2017

Managed for Mediocrity - Corporate Medicine in the 21st Century





I had in interesting conversation with a colleague the other day.  The focus was on the concept of population based medicine.  It has been a buzzword in managed care and HMOs for the past 20 years.  I have seen many physicians who were promoted to administrators in these organizations who had to start talking the population based medicine hype as part of their role as administrators.  Looking at Medline references the definition goes back to 1995, but I heard it long before that.  If you Google the term you will find a definition that is attributed to the American Medical Association:

An approach that allows one to assess the health status and health needs of a target population, implement and evaluate interventions that are designed to improve the health of that population, and efficiently and effectively provide care for members of that population in a way that is consistent with the community’s cultural, policy, and health resource values.

In trying to confirm that definition for the past three days through AMA staff and their web site - I have been unable to locate the specific document.  The problem with this definition should be apparent to any physician.  Physicians are trained to assess and treat individuals.  They are trained to treat people with diseases and illnesses.  They spend the majority of their time doing this.  The idea that this kind of approach is going to be implemented by a physician or even a group of physicians is overreaching and absurd.  It is very convenient for managed care companies, pharmaceutical benefit managers, and governments who want to ration resources across communities and intentionally discriminate against others.  What could be a better rationale for having fewer and fewer people being seen by physicians and more people taking inexpensive screenings or just being told that there are no resources.  It is also useful to mass market very expensive pharmaceuticals to people who will get minimal to no benefit from them.  Corporate management removes physicians from those decisions, but in some cases makes it seem like the physicians approve.  The best example is a corporation limiting choices and then making it seem like the physician is approving the course of action.

The business and government led movement to homogenize medicine has additional fall out that I am sure few people outside of medicine know very much about.  Physicians are managed to see a number of billing codes per day and those codes are typically optimized to collect the maximum billing per encounter.  They need to be because the payers are already gaming the system to pay the lowest possible amount per billing code.  That tension between the non-medical forces on three sides: payers, coding specialists, and physician managers creates a pathological assembly line of brief expensive visits where not much happens.  Have you ever been told by a physician or nurse that you can be seen for only one problem at a time and if you have a second or third problem you will need to set up new appointments? This is the pathological assembly line approach taken to its absurd conclusion.  Any slight glitch in appointment times or a patient suddenly requiring more intense treatment than anticipated throws a wrench into the works.  Some patients in the waiting areas can be backed up for hours.

Homogenization has another intended consequence - it makes it seem like all of the physicians in the clinic are the same.  That is always true to some extent, but there are always major unappreciated differences.  Some physicians gravitate toward specialty areas based on their interest and experience.  Some physicians have a natural talent to deal with certain problems and procedures.  Other physicians know that they should avoid certain areas of medical practice and for that reason stay out of specialty areas.  On this blog, I have posted that many physicians have told me over the years that they really like psychiatry but that they could never tolerate treating a certain type of personality or trying to determine the level of suicide risk when seeing patient with that problem.  There are differences within the same specialty.  Some psychiatrists are better at handling the medical aspects of psychiatry.  Others do a better job with psychotherapy.  Prior to homogenization, those differences were allowed to exist and they were developed across the entire professional lifespan of physicians.  When that happens in any group of specialists, these skills are recognized and patients with those problems are directed to the physician with those skills.   Today billing codes, patient visits, and electronic health record templates  preclude any differences between physicians and have them all producing the same rapid low quality product.

Physician evaluations are often set up to not recognize the unique contribution of the physician to the department and to insist instead on some kind of meaningless corporatized individual improvement plan.  The maintenance of certification (MOC) and maintenance of licensure (MOL) in some states is way to send the message that individual physicians don't have any particular expertise and in fact have to pass an arbitrary general exam in order to maintain certification - even if they have specialized in the area for 20 years, are recognized for their expertise, and know more about it than the physicians who designed the exam.

Physicians themselves know that I am speaking the truth about specialization because in many cases they still have this inside information.  They try to get at this information and use it to recommend care to family members and other patients.  If my spouse needs surgery, you can bet I am going to find the surgeon who does the most procedures and the one recommended by his or her colleagues.  Non-physicians do the same thing to some extent by talking to relatives and neighbors who have had surgery and asking them if they would recommend that surgeon.

There is probably no better term for this corporate tactic than suppression.  Current health care management actively suppresses physicians at multiple levels.  That is obvious in the initial interview in any health care organizational if the physician is savvy enough to ask directly about the expectations of the corporation.  They may discover unrealistic productivity and call expectations.  They may find out that although they were hired for some administrative, research or teaching position that there will also be at least a half time productivity expectation that involves seeing a lot of patients.  The associated administrative time cuts into their other role.  They will find that there is no time for the necessary phone calls for pharmacy and insurance hassles, documentation, or even meetings with an administrative agenda that are of no benefit to the physician.  Annual reviews are another place to observe corporate suppression in action.  One of the greatest tools ever created to suppress physicians and give them the message that they need active guidance by the less accountable is the 360 degree evaluation.  Today that typically involves soliciting anonymous negative comments from fellow employees and including that in the physician's review.  Many solid performing physicians many find it disquieting to put in a solid performance both in terms of productivity and other functions like teaching and presentations and leave their annual evaluation feeling like they have just been slandered.  In some cases, administrators may go as far as suggesting a performance improvement plan based on the fiction in the anonymous comments.

All of that is a far cry from the professionalism that used to exist among physicians practicing in groups and hospitals.  The current tactics certainly create more than enough leverage against physicians to keep the businessmen and politicians firmly in control.  The price is clearly a less vibrant, creative, and enthusiastic physician workforce.  The burnout syndrome has been written about extensively in the past several years and the single-most important cause of that burnout is bad management.

There is of course an asymmetry to the management tactics.  They are never applied to the managers themselves.  How would you manage the productivity of managers - the number of bad ideas they can come up with in a month?  Some of them make mistakes that approach a legendary scope in terms of losing money by restructuring employee schedules or signing licensing agreements with electronic health record companies.  They can make decisions that lose millions of dollars and shrug it off like nothing happened.  They can solicit employee complaints because it is currently the corporate ethos to do so and solve none of the problems.  There is no shortage of health care companies that hemorrhage professional employees because of their cookie cutter bad management approach.  It is probably logical from management's perspective because they see physicians and other professionals as production workers who could not survive without active guidance.  They fail to recognize that all of this active interference removes the best minds for treating the problem and relegates them to a secondary role.  In some cases, it appears that the administrators are practicing medicine.
     
These days bad management is about the only management that is out there.                      



George Dawson, MD, DFAPA




Attribution:

Graphic is from Shutterstock (Grayscale Town by Ganzaless) per their standard licensing agreement.   The use of the image does not imply any endorsement of this blog.