Health Train with Fewer Cars

  

I have been advised that short blog posts with bullet points is best for readers, and writers. So here is the first edition of precise bullet pointed remarks

• I have been very active exploring Google + and the use of the ‘Hangout” in which up to 10 people can participate simultaneously with video, audio, chat, and share YouTube Videos. If you need an ‘invite’ either send me an email, or make a comment.
• Stanford University is offering a Medicine 2.0 Congress during September. I hope to see you there:  Medicine 2.0  Preliminary Program
• Social Media is what you make it. There is no paradigm..some use it for purely social reasons, some create art, music, businesses, train, educate, learn, find strangers with similar interests. I try to check in daily on all the SM platforms.
• I write to opine, not to please,impress, nor to build huge friend or follow lists. If my writing builds those, so be it.
• My blog is sometimes serious, credible, humorous, outrageous, ranting, and usually surprising.
• Health Train Express is now in it’s 8th year of existence, with a total of almost 1,000 blog posts.
• About once a month I update my blog roll, adding or deleting blogs. If there have been no new posts for 90 days or more the blog is deleted. If you would like to be added, make a comment or send me an email  fastwriter.levin@gmail.com 

See you on the net !

del.icio.us Tags: social media,twitter lists,facebook,google plus,linkedin,skype,google talk,4G,iPad,iPhone,Wifi,Morse code

Meaningful Use Virtuality

 

Now that the ‘debt ceiling has been penetrated, at least for the moment, we can turn our attention back to health. Of course health is being advertised as one of the factors driving the United States into a third world country, as the cost of correcting illness and maintaining quality life exceeds 16% or more of our GDP.

Despite this obvious state of affairs, our congress continues to approve expansion of government bureaucracy, departments, regulatory affairs and more.  The New Affordable Care Act not only rearranges health coverage but also produces a mammoth increase in  bureaucracy.

As time has progressed incentives are beginning and meaningful use becomes more meaningful to ‘earn’ the incentives.

The linked Infographic: A brief review of ‘what is meaningful use’.

 

del.icio.us Tags: debt crisis,meaningful use,affordable care act

Family Practice Rocks and other Cheers !

 

As I walk around my study, between thoughts about my blogs and social media lurking I am struck by the enthusiasm and total immersion of family medicine and it's cheering squad. Many young family medicine residents speak about a 'revolution' and regret the passage of what some of we older physicians lament....a long gone vision of an iconic Marcus Welby, indelibly marking our memories.

Featured statements such as, "Either you're at the table or you're on the menu." and other quotes from the blog, of the California Academy of Family Physicians (CAFP) as stated by Dr Roland Goertz, AAFP President, "Our time is now."

I have been a super specialist in the scheme of things....an ophthalmologist, now retired. I was strongly buffered and insulated from the vagaries of general medicine thanks to  family medicine doctors.. I know why I ran away from a great 'specialty' to ophthalmology after five years of general medical practice. I also read about these issues everyday. I was not  dedicated enough to stay with family medicine for my entire career. Late in my career after a heart surgery I made a temporary move back into family medicine, and found that I still enjoyed it greatly.

I think that specialists have been disloyal to general medicine as a whole, and have failed miserably to support general medicine as if specialists were a thing apart from medicine as a whole.

Granted medicine should not be lumped into one category, since each specialty is highly unique, requiring it's own paradigm clinically and administratively.

Admittedly there has always been 'the elephant in the room” a tension between specialty and PCP, not just in outpatient but in hospital between specialties, relevant to privileges and  relatively isolated from direct patient care, such as radiology, pathology anesthesiology.

As Jay W. Lee states; in regard to ACOs; Remember managed care in the 1990s? Remember how few physicians were truly engaged in the process? We do not have time to wait and see whether PPACA will live or die in our judicial system. We do not have time to sit back and hope that this will just pass us by like managed care did in the 1990s. Our time is now. Our leadership as family physicians is more crucial than ever before. We must not sit idly by and allow others to shape the health care system. We must revolt against the status quo.

"So..."
Last year, an inspired group of residents started a Family Medicine T-shirt Revolution. These t-shirts said things like: "Use all parts of your brain; be a family physician" and "Americans are dying to have a family doc." Their focus was on raising awareness, particularly among medical students, about the importance of family medicine and cautioning against being intimidated by academics, who have steered many bright students away from primary care.

           

Family Medicine’s Chief   Quarter Back

And remember as well that specialists are not all that happy either. Family practice is however set upon to provide much non medical administrative support for which there is no reimbursement, act as the 'triage' monitor the public health.

If family medicine goes away, it will also mean bad things for specialists. FPs deserve hardy specialist support. It has been sadly lacking in many cases.

PCPs must have a stronger place at the table of the RVU Committees.

So I say 'hug your referring physicians' and demand that their RVUs and CPT codes be adjusted accordingly..Don't be divided and conquered.

As I walk around my study, between thoughts about my blogs and social media lurking I am struck by the enthusiasm and total immersion of family medicine and it's cheering squad. Many young family medicine residents speak about a 'revolution' and regret the passage of what some of we older physicians lament....a long gone vision of an iconic Marcus Welby, indelibly marking our memories.

Featured statements such as, "Either you're at the table or you're on the menu." and other quotes from the blog, of the California Academy of Family Physicians (CAFP) as stated by Dr Roland Goertz, AAFP President, "Our time is now."

I have been a super specialist in the scheme of things....an ophthalmologist, now retired. I was strongly buffered and insulated from the vagaries of general medicine by family medicine doctors.. I know why I abandoned a great 'specialty' for ophthalmology after five years of general medical practice. I also read about these issues everyday. I was not strong enough, nor dedicated enough to stay with family medicine for my entire career. Late in my career after a heart surgery I made a temporary move back into family medicine, and found that I still enjoyed it greatly.

I think that specialists have been disloyal to medicine as a whole, and have failed miserably to support general medicine as if specialists were a thing apart from medicine as a whole.

Granted medicine should not be lumped into one category, since each specialty is highly unique, requiring it's own paradigm clinically and administratively.

Admittedly there has always been 'the elephant in the room” a tension between specialty and PCP, not just in outpatient but in hospital between specialties relatively isolated from direct patient care, such as radiology, pathology anesthesiology.

As Jay W. Lee states; in regard to ACOs; Remember managed care in the 1990s? Remember how few physicians were truly engaged in the process? We do not have time to wait and see whether PPACA will live or die in our judicial system. We do not have time to sit back and hope that this will just pass us by like managed care did in the 1990s. Our time is now. Our leadership as family physicians is more crucial than ever before. We must not sit idly by and allow others to shape the health care system. We must revolt against the status quo.

"So..."
Last year, an inspired group of residents started a Family Medicine T-shirt Revolution. These t-shirts said things like: "Use all parts of your brain; be a family physician" and "Americans are dying to have a family doc." Their focus was on raising awareness, particularly among medical students, about the importance of family medicine and cautioning against being intimidated by academics, who have steered many bright students away from primary care.

And remember as well that specialists are not all that happy either. Family practice is however set upon to provide much non medical administrative support for which there is no reimbursement, act as the 'triage' monitor the public health.

If family medicine goes away, it will also mean bad things for specialists. FPs deserve hardy specialist support. It has been sadly lacking in many cases.

PCPs must have a stronger place at the table of the RVU Committees.

So I say 'hug your referring physicians' and demand that their RVUs and CPT codes be adjusted accordingly..Don't be divided and conquered.

 

del.icio.us Tags: rvu,cpt,rbrvs,primary care,specialists,family medicine rocks,family medicine revolution,future of family medicine

Vermont’s Bold Experiment: A Rebuttal

As commented on The Health Care Blog

Vermont's Bold Experiment

         

Hsaio 1989                                  Hsaio 2010

Harvard Professor William Hsiao is fond of the phrase “bold experiment'.

In the late 1980s Hsiao supervised and analyzed a study of expenses in medical practice which specifically analyzed services by physicians accounting for physician time, overhead, capital outlays, malpractice and other physician overhead items.

He developed the RBRS scale based upon RVUs (relative value units). The formula was based upon a survey and analysis of practices among different specialties, in different locales in the United States. The current system of fees is based upon these units coded for by the CPT codes (current procedural terminology).

I am very familiar with this since my ophthalmology practice was one of those in the 1989 survey. My opinion is that whatever input was put into that study....the output was pre-determined.. My evaluation of the figures garnered from the study bore little resemblance to what I found in my typical solo ophthalmology practice.

The RVBRS methodology set off a wave of high specialty fees vs primary care physician fees, based upon Hsaio's flawed methodology Move forward 30 years to 2011 where the disparity between PCP fees and specialty fees is now even greater. For one thing there are many more procedures available to specialists as the explosion in technology took place. By comparison there have been few changes available to PCPs. I am not even sure if the RVUs were adjusted over the past 30 years.

The increasing divide between specialty and PCP reimbursement can be squarely placed at the feet of “Harvard superstars”.

Harvard's academic staff is always available for another study, or to evaluate and/or pontificate about things surrounding the Boston region. Vermont borders on and touches a good part of Massachussetts.

Vermont may be bold, however it is far different in demographics and/or challenges delivering health care.

Let's assess the following:

Vermont: Total Population (2010 census) 625,741

New York Total Population (2010)  19,378,102

Texas Total Population (2010)  25,145,561

California Total Population (2010) 37,253,958

Census Map by County-- Vermont (pdf)

Using Vermont as a ‘representative’ case for health reform is comparing apple’s to oranges, or at least disingenuous. Any statistician can easily negate the results of this ‘pilot example’.

Other confounding metrics are:

1. Vermont has largely been untouched by multiculturalism

2.It is predominantly a rural state.

3.The population is not mobile, nor immigrant, it is uniform and fairly homogeneous.

4.What is bold about Vermont is that it is highly atypical.except for a few      other states such as Wyoming, Montana, No. & So. Dakota,

del.icio.us Tags: hsaio,census,vermont,rvs,cpt,health reform

Why Would Anyone Want to become a Physician?

Good question, given the current atmosphere of doom and gloom amongst my colleagues and peers.

Well first of all like most folks when one has worked at the same job for 10-20-30-and even 40 years the human spirit does need replenishment. Many pubic servants (and that is what we are), police, fire department personnel, correction officers have some things very much in common. Stress ! Stress related disability is actually a compensated employment related disability category.

Medicine is stressful….but not so much about the art and science of  medical practice.  Some things are life threatening, but for most MDs the day is routine. Perhaps in some specialties such as cardiology, surgery, ophthalmology where the outcomes are critical to life and function stress levels may be chronically higher.  However the education and training process tends to self-select those built for that type of environment. And some people thrive on stress.

Stress and anxiety increase in situations over which any person has little if any choice in the outcome. And that is precisely what is eroding physician satisfaction with their chosen career.

Daniell Ofri MD writes in the New York Times in Tara Parker-Popes syndicated health column about “Why would Anyone want to become a Doctor?”

I don’t know Dr. Ofri or even what kind of medicine he practices. The basic truths are there. (in my opinion).

There are many avenues to reduce the stresses, spiritual, time outs, and frequent breaks, shorter work weeks, eliminating specific stress related non clinical tasks, second careers. These avenues are available to private practice physicians. Even a horizontal move to perhaps a group practice.

Becoming a physician not only creates a vast knowledge base in health care, but also many other skills that are transportable to other occupations. Even without an MBA doctors who have run their own business have considerable skills in business management (yes there are a few of us out there).  Like me some turn to writing, some are gifted in the arts, music, theater, performance art, philosophy and others.

I remember a mentor (an Uncle) who practiced medicine until he was over 80 years old.  He told me (interesting approach given today’s pre-med students)..not to work in a hospital prior to med school, take a wide variety of courses in humanities, liberal arts and save the sciences for medical school, except for the essential pre-requisites. Knowing the basic soul of a man was a key ingredient in leading one back to health.

And when my day is done and I give myself the  inevitable “career talk,” I tell myself that there is nothing else I’d rather do in my life than medicine. If I had it to do all over again, I’d end up right here. — telling them that there’s nothing else I’d rather have done.  After all my role is not yet complete.

Life has it’s seasons, mine is now being a physician and a patient advocate, and bring  us together in the pursuit of safer medical care, keeping corporatization of medicine at bay, resisting the significant and insidious cancer of government and insurance directed medical care and reflecting whatever wisdom I have obtained on to the next generation of doctors.  I am happy they have come along to take care of my patients.

Wisdom is not the memorization and regurgitating facts. It is the ability to step back, observe mistakes, change behavior patterns, and pass that along to willing listeners in medicine, politics and social planners. To do less when one has the time and willingness and remaining passions would be shameful.

(for me)

gml

Philosophers and Economic Reality

 

“Change, before you have to…” Jack Welch

“We live in a society that loathes uncertainty – particularly the unintended consequences that sometimes result from a catastrophic event or in the case of PPACA, landmark legislation”, this according to Mike Turpin in today’s edition of The Health Care Blog.

And accordingly this is the thing which prevents an active recovery, and also why the huge infusion of stimulus funds, is not being distributed by the holders of the capital.

Common sense overrides the edicts of big government. If I had just been through an economic disaster, or my neighbor became unemployed or my business was tottering, would I spend a largesse handed to me or bank it against another rainy day?

My family voted this week to purchase health insurance for all of us. So I went to my checkbook to pay the premium, only to find my balance was in the red.  Forget paying the premium !  So, wishes and mandates are overruled by economic realities, and the facts of life.

Sound familiar, of course it does. How about PACA ? Did congress realize the crushing and growing national debt when they passed this law? Of course they did, and that is what makes their behavior reprehensible.

The law itself place a plan on the table which can be implemented gradually, and I don’t believe the planners expected the roll out to be as scheduled. It can lie dormant for many years, a decade or more.

Responsible health policy makers need to act now to truncate the law and require balanced budgets, payoff of the national debt and assure a worthwhile quality of life for Americans.

The discussions of forestalling ‘retirement to age 70’ will have a secondary effect of many Americans winding up on disability, no matter what statistics say about longevity and senior health.

While some 60-70 year  old people function at a high level, the average American does not put in the hours they did at age 45, nor do they have the capacity   to work full time.

Statistics and philosophy just go so far in planning the future.

del.icio.us Tags: ppaca,health reform,retirement age,disability,health policy debt ceiling

Health Works Collective

There is a new kid on the block, HWC, otherwise known by the title of this post.  What does this have to do with Health Train Express? Well since there are limited hours in my day I will be publishing Health Train Express less often. Regular readers may have noticed the frequency of  the posts here have diminished.

I was  invited to add some exclusive content to HWC. This week the first article is on the entrance of Google Plus into the Social Media Stream for Physicians, along with the demise of Google Health.

It may be that snail mail, memorandums, yellow sticky pads, and even email or plain old chat have been dealt another blow.

eBooks are now also ‘The Rage’ as some large book franchises like Borders Books are in ICUs being resuscitated as we write.

No Sentimentality
There is no use getting sentimental about these trends, said Jame Gleik in yesterday’s New York Times, “Stop Being Sentimental about Books.” He should know. He has written a 2011 best-seller The Information : A History , a Theory, a Flood .
Go with the flow of history, Gleick says,”An object like this (A book) – a talisman, is like a coffin at a funeral. It deserves to be honored, but the soul has passed on.”

    

Will this be true for medical journals, and  medical texts as well?  Once upon a time, chat, email, were innovations whose time may be passing replaced by newer trends. As time advances the library of the past has morphed as well giving way to added space for terminals, and fewer book shelves. Access to libraries are immediately available in the classroom and laboratory by Wi-Fi connectivity.

These changes are fueled now by new anthropomorphic advances in computing hardware, Only imagination limits what is possible. The smartphone gives immediate access to voice, chat, video, application software for disease, medications, treatment algorithms, CDC warnings, FDA alerts, and EMR access to patient’s medical records. 

I began writing a blog almost eight years ago for a specific purpose as an easy platform to write about Health Information Exchange.

Since that time, ONCHIT, RHIOs, EMRs, HIT, HIE, HITECH, ACOs, The Patient Affordability and Care Act, and a major economic recession have passed over us in a wave.

Healthcare, medical practice have changed right under our feet, a very noticeable event, that somehow or other occurs all the while our patients continue to become ill, diagnosed, treated, sometimes healed. The uninsured have some hope of medical care.

I am cautiously optimistic that physicians will survive amidst the turmoil of change.

 

del.icio.us Tags: health works collective,emr,hitech,hit onchit,rhio,smartphones,libraries,ebooks,pubmed

Health Care Conundrum

It requires an unusual mind to undertake the analysis of the obvious.

The daily review of health blogs, social media, and Health 2.0 pundits gives birth to today’s Health Train Express.

I can not but help quoting some profound statements.

It requires an unusual mind to undertake the analysis of the obvious. Alfred North Whitehead, Science and the Modern World

It’s much more important to know what sort of patient has the disease than what sort of disease the patient has.  William Osler, MD, 1648-1919 

There’s no other profession as personal as the medical profession. If physicians continue to allow non-physicians and businesses such as hospitals and insurance companies to control them, they will lose their patients and will be nothing more than over-educated, hired technicians.

The family doctor was an institution. If there has been a change, the physician is not primarily to blame. On the contrary, it’s a tribute to the profession that the older idealism persists in such an unfavorable environment. The fault – if fault there be – is that the profession is now practiced in an industrial world dominated by business.
Walton H. Hamilton, MD, Medical Care of the American People, 1932

These snippets are from Richard Reece’s Medinnovation Blog of this week. It is a refreshing look at why we are going down the wrong path.  It’s a mixture of common sense, and disbelief at what physicians have allow, controlled by government and insurance companies.  Freedom and liberty come at a price, It must be aggressively defended, in all aspects of America.

The promises of entitlements also overflow from patients to their caregivers, physicians, as we become also dependent on the largesse of government guarantees.  This I was taught as a medical student at George Washington University, mid-20th Century in a building built in the late 19th Century. We had no computer labs, internet, iPads, or iPods.  Am I saying those advances are not good? No, I am not. It does reveal that somehow we functioned quite well in a more balanced system.  Were some patients and the aged uninsured? Yes, however the self-correcting mechanisms of charity care by doctors and hospitals, local cities, friends, family and faith based organizations, as well as county hospitals took up slack…adequate health insurance carrier income balanced the negative balance on hospital and physician books. In todays health environment doctors are now rarely giving free care, more patients are sent to collections (an almost never event in the past century). I would even call it shameful that physicians have had to descend into the pit of parasites earning a living off less fortunate people at a time in life when some patients are even more vulnerable.

I am often amazed that there are not more physicians irate and in the face of government and insurance companies….outside the business realm of attempting to collect earned monies

del.icio.us Tags: Obama,reform,family doctor,rural medicine,medinnovation blog,entitlement

Google + Replaces Google Health

 

How convenient

Google + is the new girl on the block. Just like a new face in school, everyone wants to get to know him/her. After a few days you will either love or hate the new one.

I spent the greater part of the weekend learning about this 'stranger'. It was about like waiting for a chance to meet the mysterious new stranger as I waited and pleaded with those who already had access to the “G+”. Twitter came in great handy as I asked everyone for an introduction to the seductress. It seems she had already been in many bedrooms, living rooms, and even perhaps in the backseat of a few vehicles.

Everyone seemed quite willing to share the temptress, she has several personalities, friend, family, professional, acquaintances and more.

She was flexible enough to allow you one or all categories. Warm, friendly and outgoing she is a social butterfly and loves to hangout....in fact that is one of her best attributes, being able to see her, talk to her and even write all at the same time.

It was easy to get to know her she is designed to warm you up, as you feel your way into her inner recesses and explore her strengths and weaknesses. She is new, so her network of friends is still a bit thin, however this lady will be the queen of the prom very quickly.

G+ is easy to get to know....she is an easy read, no instruction book needed here...just a tap here or a swipe there and G+ responds. There is nothing mousy about G+. I could not break her and I tried, no bugs, no error messages, and she did not turn cold nor freeze up during my advances.

My other loves, Facebook and Twitter will have to wait to see me more often. My new playmate will fascinate me for some time to come. I think friends like me will want to hangout with G+ and perhaps some API developer will integrate Twitter, G+ and Facebook. Maybe Bill Gates, Steve Jobs, or Rupert Murdoch will buy all three.

The only thing she is missing is a mobile app. Has anyone taken her for a ride on a tablet?

I may have to give up working and call in sick to be with G+. I did have the social whereabouts to leave a message on Twitter and Facebook that I would be out of town for awhile, not to worry, I will probably be back after sampling the G+. Mark Zuckerberg....eat your heart out !

I am willing to share, so send me an email or a tweet @glevin1 if you want an invite. Oh by the way, she now has over ten million suitors.

In the next Health Train Express I will be discussing the potential impacts on medicine and healthcare.

If Airline’s were run like Healthcare

 

Fasten your seatbelt, it’s going to be a bumpy ride, if you can get there at all. If you wish to read Jonathon  Rauch’s popular article in National Journal Review, read on…..comparing Airline Travel and Health Care.  otherwise watch the video.

del.icio.us Tags: airlines,healthcarebluebook,jonathon rauch

A Marxist Turned Libertarian on The Health Train

 

In preparing for today’s journey on the Health Train my travels took me to a video by Thomas Sowell. Dr. Sowell was born a poor African-American black man (as opposed to a poor white African American (which is a real possibility, although statistically unlikely),  whose innate intelligence, drive, and smart choices enabled his gifts. He chose to follow the ideas and the man who mentored him rather than the institutions that brought them together.

Thomas Sowell indicates that his mentor was Milton Friedman, a name well known to those interested in economic theory.  Here is the video….it should spark some controversy and lead you to learn more about Mr. Sowell and more important, the simplicity and detail about how Government Medicine works and why it does not work well.

Dr. Sowell’s opinions are at times controversial. (Wikipedia)

Dr Sowell has been a senior fellow at the Hoover Institute of Stanford University (1980-present)

Sowell has been criticized for various remarks such as a comparison he

del.icio.us Tags: marxist,libertarian,thomas sowell,hoover institution

made between President Barack Obama and Adolf Hitler in an editorial for Investor's Business Daily^[26] after the creation of a relief fund for the BP oil spill. This has been criticized by liberal groups such as Media Matters^[27] and the Democratic National Committee.^[28] However, Republicans such as Sarah Palin^[28] and Representative Louie Gohmert^[29] have endorsed Sowell's comparison. Sowell was also criticized for an editorial in which he stated that the Democratic Party played the Race card, instigating ethnic divisions and separatism, and argued that a similar situation occurred between the Tutsis and the Hutus in Rwanda.^[30][31]

Which List Do You Want to be On?

 

Tweeting has added a new dimension for connecting to others with similar interests. The short 140 character only slightly exceeds my short attention span. I can quickly absorb and scan through tens of ideas between patients, while waiting in the doctor’s lounge to start a surgery, and G-d forbid waiting for an attorney to give a deposition.

A tweet attracted my attention from @MtnMd, ,Founder&Chief Medical Officer of eMedicalMall, technology company serving medical community & patients to improve health care. @ MtnMD also posts a blog,

 Sprocket, a compendium of lists divided into categories of credibilty. Sprocket is now added to my followed blogs, I find it useful as a starting point to expand my meager knowledge base of social media stars in medicine.

del.icio.us Tags: MtnMd,eMedical Mall,Sprocket,blog lists,twitter lists

Medical State of Mind

 

Medicine has gradually been drawn into a state of mind where legalese and bureaucracy have replaced medical and scientific results.  “Evidence based medicine” has surpassed scientific results, or empirical outcomes as the arbiter for treatment choice.  Anecdotal clinical opinion has been replaced by ‘hearsay’, and humans are enhanced or even replaced at times by machines.

Evidence Based Medicine can best be graphically modeled by the ‘evidence pyramid’ a term borrowed from the food pyramid:

The pyramid best outlines the progress in medicine, and the addition of 4 new levels of critical analysis of treatments. 

Clinical medicine is never stationary,nor should it be, without which there would be no progress.

Has blogging enhanced medical practice?  I say yes, and the evidence is the exponential use of the social media, which allow practitioners to share knowledge on a daily basis, not only in science, and clinical practice, but in the management of medical business. It can be accomplished from the office, home, even on the street. The same resources are present almost no matter where you are working.

3D imaging is becoming available which will enhance mobile CT, MRI, and Optical Coherence Tomography and  remote telemedical applications.

Nanotechnology is now better understood and wishful ideas about it’s applications are becoming a reality in drug delivery systems, manufacturing of better, stronger and more durable products. These will slowly infiltrate our biomedical devices in the operating room, endoscopic equipment and electronic equipment, including computers.

Physicians and patients alike will have another ‘gee-whiz’ device.

L-R  Physician, Patient

Drug Delivery System

Hopefully this new ‘paradigm’ will bear fruit, and not deceive us.

borrowed from ‘Humbug”, the skeptics guide to fallacies thinking.

 

 

del.icio.us Tags: evidence based medicine,meta-analysis,skeptics,nanotechnology

a field manual to fallacies in thinking 

  .