brief update

Lots of good stuff going on, but I’ve been swamped so have not had time to blog.

• Next Thursday, August 6th at 7:30 PM, Bill Solomon and Mike Lunoe will be premiering my work for six marimbas titled bs piece (double canon for bill solomon) at the Berkman Recital Hall, Hartt School of Music in W. Hartford, CT. I’m listening to their latest rehearsal tape right now and it’s absolutely incredible. How they manage to play this without getting lost while syncing with a tape of the other four marimba parts and counting accurately how many times to repeat each measure (17x is not uncommon in this piece) boggles my mind. Kudos to them both for not just taking on my music but for realizing it so perfectly. The score is here. I’ll be posting a MP3 of the performance and possibly even a video once I get it from Mike and Bill.
• Just got an e-mail inviting me to be on the Editorial Advisory Board of the Journal of Minimally Invasive Gynecology, the official journal of the American Association of Gynecologic Laparoscopists. Obviously they’re extremely desperate.
• Composer/performer/MIDI artist Steve Layton is going to be releasing his realization of textbook: music of solitary landscapes in hyperspace (piece for IPS) via iTunes in the coming weeks. Steve’s realization is excellent and took him at least two weeks to accomplish. The piece is over two hours and is continuous, although it will be broken into individual sections for downloading.

we need to come out and say “enough”

I’m still ruminating over the murder of George Tiller yesterday.

As one of the diminishing number of physicians who performed second trimester abortions, I can state unequivocally that it is never a procedure that is approached in a cavalier fashion. Not every gynecologist can perform it, even if trained appropriately. The sad thing is that we’ve done a really bad job at training the next generation of providers. I taught many residents, but of those, many will not provide abortion services for a variety of reasons. Part of why this is is that abortion has been marginalized. People don’t want to talk about it. My colleagues for the most part didn’t want to deal with it. Some couldn’t say the “a-word,” substituting euphemisms like VIP (voluntary interruption of pregnancy). Abortion is a very common procedure. It is a necessary procedure. But it will be an extinct, forgotten procedure if clinicians are not trained to do it safely and compassionately. We need to get it back into the hospitals so that it is again part of routine gyn practice. Abortion training must be made more widely available within residency training programs. It’s idiotic that many ob/gyn residency programs do not offer in-house abortion services, but must send “interested” residents to outside clinics, often on their own time during weekends.

When I was in practice, I did a lot of procedures in ob/gyn. Including abortion. Some of my most grateful patients were those for whom I performed an abortion. I never performed any abortion without being absolutely certain that the patient desired it and that it was her own decision. That’s what “choice” is about, after all. My abortion patients didn’t wake up that morning and decide “What the hell, I think I’ll have an abortion.” This was a very, very difficult decision for any woman to make. People who have not walked in their shoes should not be making judgments or regulations about this most private and personal of medical decisions.

All of us who either performed or continue to perform abortions need to finally stand up, be counted, and say “enough.” Abortion providers have this terrible stereotype of being slimy, scumbags in the margins of the medical profession. We’re not. A lot of us are academics. We’re honorable. Most of us have delivered babies. All of us provide or provided services that are challenging and that many physicians either can’t or simply won’t provide. Rather than honor abortion providers, society (including many physicians) treats them like criminals. This must change. While I recognize the potential danger in coming out as an abortion provider, there is strength in numbers. And just as the Gay community came out and took steps to remove the stigma of being gay, abortion providers should stand up, be proud, and demonstrate that we’re here to stay. Only when abortion is de-marginalized can we start addressing the onerous restrictions on the provision of abortion services and also combat the insidious demonizing of abortion providers. Such demonizing was absolutely behind the assassination of Dr. Tiller yesterday.

in memorium: dr. george tiller

I just read that someone assassinated Dr. George Tiller, an abortion provider in Kansas who was one of the few people who were skilled at and willing to perform abortions above 20 weeks’ gestation. Dr. Tiller was shot while attending church services near his home.

For those of us who perform or performed surgical abortion, Dr. Tiller, along with Dr. Warren Hearn in Colorado, epitomized the highest ideals of medical service. Regardless of one’s stand on abortion, Dr. Tiller was a true professional who performed abortion above 20 weeks despite many obstacles, including onerous regulations, overzealous protestors, death threats, a bombing and the shooting of both of his arms. He didn’t perform abortion for monetary reward; in general, there are far less dangerous ways to earn significantly more revenue as a physician. Rather, Dr. Tiller did what he did because it was necessary, and because midtrimester abortion is best provided by someone who has the patient’s best interests at heart.

This also demonstrates how critical it is that residents and other physicians get appropriate training in abortion services. While I provided second trimester abortion services while in practice here in Pennsylvania, I never performed one above 20 weeks to the best of my recollection, and as a resident would go to 24 weeks, but only using saline and prostaglandin amnioinfusion above 18 weeks. Dr. Tiller provided safe, legal surgical abortion up to, I believe, 28 weeks, which requires a great deal of art and skill to pull off without complications. Now that he is gone, there are far fewer people out there with that skill and experience. Only Warren Hearn comes to my mind, although I’m sure there might be a few others.

Dr. Tiller’s murder is another indication that we need to come together and find common ground. No one is more pro-choice than I am, period. I’ve performed many abortions, introduced medical abortion to my hospital in the days before mifepristone was available, lectured about abortion technique and taught many residents how to provide a safe surgical abortion in a compassionate fashion. I’ve never dissembled about my role as an abortion provider, and am very proud of what I did. Indeed, my patients for whom I provided abortion care were often among my most grateful patients. I’ve marched on DC twice in support of abortion rights, actively supported pro-choice candidates and have always been willing to donate money to the cause of reproductive rights. That said, I’ve also worked to find areas of agreement and cooperation with reasonable people on the pro-life side of the divide. I used to be a member of a local group called Common Ground, and it brought people together from both sides to have dialogue sessions on abortion-related issues. It was moderated with strict ground rules, so no one could interrupt or become disrespectful. In this fashion, people can talk with one another without coming to blows even when there is heartfelt disagreement. None of us were trying to convert one another, and indeed, conversion wasn’t possible. The pro-life participants were just as vehement about their side as those of us on the pro-choice side were about ours. But we got along and gradually had a better understanding and respect for the other viewpoint. It taught me that one can respect and even admire those with whom there is visceral disagreement.

We need more efforts like that. I remember the 90’s when several abortion providers were murdered along with volunteers and other staff. It seemed to be a reaction to having a pro-choice president in office, in that case, Bill Clinton. The murders can’t be justified, but I would suspect that they were born out of extreme frustration from not having a conservative administration in Washington, DC. Since January 20th, I suppose it was just a matter of time.

So I’m very saddened by the loss of Dr. Tiller. Unlike Warren Hearn, I’ve never personally known or communicated with George Tiller. But his work always meant a lot to me, and women who need a second trimester abortion are worse off due to his loss. However, the cause of reproductive freedom is very much alive, and will continue despite this terrible act of assassination. I hope that my colleagues, regardless of their personal stands on abortion, and medical organizations such as the AMA, come out and strongly condemn this murder. And even better if we can all learn from Dr. Tiller’s example and come together to try to find some common ground on a very divisive issue.

boutique medicine

Not too long ago, a friend of mine in Philadelphia asked for a suggestion for a primary care provider (PCP). I referred him and his wife to our PCP, my wife and I having been that doctor’s patients for 18 years. We rarely see our doctor, truth be told, but he’s a Hopkins graduate, a good internist, and always returns calls personally and promptly.

My friend subsequently e-mailed me to ask for another suggestion, as our PCP has apparently switched to a “boutique” practice and there’s no way they could afford the annual membership fee. Such fees usually range from $1,000 – $3,000 each year. You’d think he was joining a country club or something Our doctor’s switch to a boutique practice was news to me, but as we rarely see our PCP, it’s not surprising we weren’t notified. Our strategy was going to be to hold out and hope our PCP would switch back to a non-exclusive practice, once he realized that this new approach was not popular and he was losing money.

Wishful thinking.

I had to call my PCP today for a referral and as usual, he returned my call personally and within a short period of time. I was asked by his answering service, however, if I was a “VIP” patient. I said we’ve been his patients for 18 years. I mean, that should count for something, right? So I spoke with our doctor about his new boutique practice. He told me that tons of people are signing up, and those who don’t can always see his partner as she still takes insurance. Boutique practices by definition are fee-for-service, cash-only. So in order to continue seeing our PCP of 18 years, we have to pony up a large annual membership fee. Thus, like my friend in Philadelphia, we’re looking for a new PCP.

I can’t blame our soon-to-be former PCP, really. Given that the average physician pays almost $70,000/year to argue with insurance companies it makes little sense any more to participate with third-party payors. This guy is a good doctor and he’s now able to continue doing what he had been doing all along and what he likes to do: practice good medicine in a personalized fashion.

Just like I understand why many of my gynecology colleagues have taken up cosmetic surgery, I understand the allure of boutique medicine. But both of these trends offend my sensabilities and epitomize a medical system gone astray. Boutique medicine establishes another tier in our multitiered health care system. If you have money, youre fine. If not, good luck.

And while I don’t expect all physicians to practice the way I used to practice, I do expect some basic tenets to hold. I returned patient calls. I saw them personally. I didn’t charge extra for what I viewed as quality standard medical practice. Who would have thought I should charge to see a patient in a timely fashion or return their calls myself or write a disability letter? I just stupidly thought this is what one does as a doctor.

So medicine has changed. And not really for the better. If you want to have personalized care like many of us used to provide as a matter of course, you have to pay extra for it. If you’re a surgical gynecologist, you might want to supplement your decreasing revenues from managed care by providing cosmetic services. And so on and so forth.

It’s crazy. Every time I get a hankering to go back to practicing gynecologic surgery, stuff like this gives me the kick in the ass reality check I need to contnue doing the fun stuff I’m doing. But it’s still a shame to see what’s happened to medicine.

whither craftsmanship?

When I was a pelvic surgery fellow, I was doing a bowel resection with a general surgeon who was an older, distinguished Persian gentleman with an old world sensibility to him. When it came time to do the reanastomosis, I asked the scrub nurse for a surgical stapler and was stopped by the surgeon, who asked why I wanted to use a stapler to reconnect segments of bowel. I indicated that this is how I had always done it, and it was a faster method overall. The surgeon preferred that I do a hand-sewn anastomosis. When I asked him why, he said “Why do I drive a Mercedes rather than a Ford Taurus? Both will get me to my destination, right? But the Mercedes has craftsmanship.” His point: a technician can use a mechanical device to connect bowel back together. A craftsman takes the time to do it the long way, with artistry and precision.

So that’s how I came to learn how to do old-fashioned, hand-sewn bowel anastomoses. I still preferred staplers. But there’s something to be said for craftsmanship. In surgery, how you do something is often as important, or even more important, than the end result.

I was thinking back to that surgical experience during fellowship as I took stock of all the things in ob/gyn that are not representative of craftsmanship. Unlike any other surgical field I can think of, we as a profession have been oversimplifying and undoing years of craftsmanship. Sometimes perhaps for the better. But overall, for the worse. Examples:

• Replacing the more difficult art of forceps deliveries with a much simpler (yet often more dangerous) technique of vacuum extraction
• Replacing the art of hysteroscopic endometrial ablation with office-based nonresectoscopic endometrial ablation that does not permit visualization of the endometrial cavity
• Replacing advanced operative laparoscopy with robotics
• Replacing ureteral dissection with lighted stents
• Replacing laparoscopic hysterectomy with laparoscopic supracervical hysterectomy

Why am I lamenting all this? Because rather than become fluent in advanced surgical procedures, either through fellowship training or extensive preceptorships, my specialty has tended to ”dumb down“ surgical procedures in order to make them more accessible to the ”average gynecologist.“ Years ago, when endometrial ablation came out, it was looked upon as a way to make a significant dent in the ridiculously large number of hysterectomies performed annually in the US (~600,000/year for benign disease). However, only about 20,000 ablations were done every year, because most folks either never learned the hysteroscopic skills required to perform the procedure, or else just didn’t want to do it. So in its place came an office-based procedure, erroneously termed ”global endometrial ablation (GEA)“ that is a blind procedure but often as efficacious as the hysteroscopic version.

Now, I have nothing but praise for moving appropriate surgical procedures to an office setting. It’s easier for patients and better from a cost standpoint. But it’s one thing to move a procedure to an office setting thanks to innovative medical devices in an evolutionary fashion. It’s quite another to create a new device and technique in order to make a procedure accessible to more gynecologists due to their lack of surgical skills.

I hate to sound like an old curmudgeon complaining about the lack of skills of a younger generation. But just consider what’s happened to gynecology over the years. Can’t dissect the ureter worth a damn? No problem-just ask your friendly urologist to place some lighted stents into the ureters so that you can see them during surgery. Mind you, the stents only serve to make the ureters a better target for inadvertent injury, and the additional procedure adds minor risks and costs to the overall surgery. But it makes some gynecologists feel better. If only they didn’t fear the retroperitoneum and took less than five minutes to identify the ureter, dissect it, and mobilize it out of the way without the need for stenting.

Same with robotics. Again, I’m all for medical advances. But robotics had primarily been adopted by urologists in order to do laparoscopy simply because urologists traditionally have not been laparoscopic surgeons, unlike gynecologists. But what happened? Robotics became not just an expensive marketing tool by some hospitals, but a crutch for some general gynecologists to perform laparoscopic procedures that they couldn’t have done the ”old fashioned way“ (that is, without a $1.5-$2 million robot helping to facilitate the procedure). Robotics may yet be shown to have a rational place in gynecology; I know of at least one colleague who has similar objections to robotics but feels it makes it much more possible to close the uterus in an anatomic fashion during laparoscopic myomectomy. But when I hear about gynecologists using/needing robotics for laparoscopic operations that many of us routinely performed without any robotic systems, I wonder what the future is for my specialty. Same with laparoscopic supracervical hysterectomy. In the absence of any good data supporting an advantage over total hysterectomy, many of my colleagues perform laparoscopic supracervical hysterectomy as a way to make the procedure easier. It does reduce the risk of ureteral injury, to be sure. But do we really need to dumb down gynecology?

Surgery is all about craftsmanship. And skill. While I applaud attempts to make difficult surgical procedures more accessible to a larger number of physicians, it makes me wonder why such a large number of my colleagues don’t feel comfortable with, say, operative hysteroscopy or laparoscopic hysterectomy in the first place. So many things seem to require simplification, but I am not aware of that many general surgery or cardiothoracic surgery procedures that have been simplified in order to make them more performable by the average general surgeon or CT surgeon, respectfully. And just consider the average CT surgeon; would anyone dare imply that he/she isn’t capable of doing a valve replacement or some intricate vascular procedure, and thus would require a simplified operation to be able to treat his or her patient?

We need to do a better job at producing gynecologic surgeons who are capable of performing the more complex approaches to certain operations and procedures. If such procedures can evolve and become simpler and cheaper to perform, then great. But let’s do it for evolutionary reasons. Not in order to make something accessible to surgeons who really should be able to do the original procedure in the first place. If there is a real advantage to ”GEA“ then that’s wonderful. But is there an evidence-based advantage or is it really a case of ”dumbing down“ endometrial ablations?

this is going to be me when I’m washed up as a gynecologist

i pollute the web thanks to a podcast

Dr. Philippa Kennealy is a business coach for physicians who assists doctors with building their businesses, which is more critical now that so many of us have left clinical practice and are trying to find our niche in the business world. She also uses twitter, and we’ve been following one another through twitter for some time now. Anyway, she decided to tape a podcast with me this morning about the application of social media to medicine, which is a topic near and dear to me. I hope I didn’t sound too ridiculous (it was hard to tell over the phone, in large part because Philippa is just too nice and I don’t know if she would tell me if I were being bombastic or whatever). In any event, the podcast is here. I really hope I didn’t say anything stupid (I haven’t listened to it yet, so it’s very possible, if not likely).

commercial support for CME is pretty much dead. and that’s a good thing.

Seriously. And it’s a change that’s been needed for a long time.

Having worked in the continuing medical education industry for several years, I used to get asked all the time for my opinion as to where CME is going. And my answer always was that within a few years, there would no longer be any significant commercial support for medical education, meaning that like nurses and lawyers, we physicians would have to pay our own way for continuing education. You see, a good deal of CME, especially online CME, is delivered free of charge to physicians largely through pharmaceutical company grant support. While such support has certainly provided a great deal of educational opportunities for physicians like myself, there’s a glaring problem with this type of financial support. And that would be conflict of interest. Whenever a drug company funds an educational program, it’s generally not out of altruism. Rather, it is done to fulfill specific business objectives. Drug companies are not in the education business; they’re in the drug business, and their revenues are dependent on doctors and hospitals dispensing their products. As a result, a drug company is not going to sponsor an educational program about a disease state for which it doesn’t provide a therapeutic product. And they aren’t likely to fund a program that involves content that may tout the benefits of competing treatments while mentioning the downsides of the grantor’s own products. From a business perspective, they shouldn’t. But from an educational perspective, a potential conflict of interest with regard to physician education can have significant effects. Medical treatment should be based upon objective evidence and, when appropriate, clinical judgment and experience. Treatment should not be a function of which drug company happened to sponsor a successful educational program that ultimately lauded that company’s drugs.

Granted, there are certainly major regulations that guide the development of commercial CME, and these guidelines promote fair balance and objectivity. CME developers are not technically required to adhere to grantor suggestions for expert speakers and content developers. But let’s face it, if a small medical education company receives a grant from a drug giant, are they likely to object vigorously if that grantor suggests particular speakers for the program they’re funding? To say no, while laudable, is potential suicide, as that small company is not likely to be receiving any further grant support from that drug company. This is one area where the current guidelines from the ACCME (Accreditation Council on Continuing Medical Education) fall short. While no medical education company is required to accede to grantor requests regarding content, they aren’t forbidden from exercising their own judgment and complying with such requests.

That doesn’t mean all industry-supported CME programs are commercial in nature and of no educational value. Many such programs do indeed provide objective, evidence-based education. But the problem is that some, and perhaps a large number, are indeed tainted. Having drug companies fund medical education is like having the fast food industry support studies on their products’ nutrition. Would anyone really trust the results of a McDonalds-sponsored study of Big Mac consumption on serum cholesterol levels?

Another problem with commercial support is that we tend to have a ton of CME programs on disease states for which there are blockbuster drugs. I can’t count how many CME programs I’ve seen about cardiovascular disease and diabetes. By the same token, I’m still waiting to find commercially-sponsored programs that deal with pediatric depression, malaria and other disorders for which major drug companies just don’t make products in the US. 

In the past, when I would tell people that the day was coming when drug companies would stop funding most CME programs, they would usually look at me as if I had two heads. Well, recent trends suggest that the day when commercial support for CME goes away is very close. Indeed, Pfizer no longer will support CME programs except those developed by academic medical centers, on the theory that universities are less likely to be tainted with their money than independent medical education companies. I hate to break it to them, but the universities could be just as bad if not worse, but time will tell. And many academic medical centers, most recently Stanford, are now refusing commercial support for specific CME programs; the grant money has to go into a general pool, so that the university gets to decide what educational programs are needed.

I think this is a good trend. And it’s happening faster than I had predicted. Ultimately, CME needs to be individualized. The truth is, no one has ever shown that CME leads to better clinical care and outcomes. While one would think that taking CME would end up benefiting patient outcomes, that doesn’t appear to be the case. And if you think about it, how likely is a single educational program to really change physician behavior? I think it’s extremely unlikely. We’re a stubborn bunch and don’t change our practices that readily until there is a consistent volume of data supporting such a change. And even then, some physicians will not change what they do.

But none of this has kept the CME grantors from demanding ”outcomes analyses“ as a requisite part of any CME program. Sure, if a company is going to fund a CME program, it makes sense that they should be able to receive proof that the program is making a difference to physician behavior and clinical outcomes. The problem is that actually proving this is very difficult unless one is dealing with a closed medical system or can demonstrate clinical practice changes through a chart review. Using survey-based tools to assess changes in physician behavior is ridiculous. Ask any of my colleagues if he/she is doing the right thing after taking a CME program. What do you think the response will be? Truth is, we all tend to overestimate our clinical acumen. That’s the nature of human beings, and the last time I checked, most doctors were human, sometimes too human.

So where is this all going? I think we’re getting to a point where most CME companies will be gone or else have switched into a different area, most likely promotional education. CME will be provided in the interim largely by academic medical centers under drug company support (such support remains the majority source of CME funding), but eventually commercial support will essentially disappear since it makes little business sense to continue funding CME. Aside from being able to air off-label uses of their products and establish goodwill, there is little upside to a pharmaceutical firm from funding CME. And when commercial support goes down the tubes, doctors will largely have to pay for their CME. Medical societies might step in to some degree, but the cost will get passed on to their membership in the form of dues increases. But at least then, we might have untainted CME for a change, and that would be a good thing.

On the other hand, innovative education, such as Web 2.0-based collaborative CME, probably won’t happen under this model. But in my experience, it wasn’t going to happen under a commercial grantor-supported model, either, since trying to convince these large corporations to fund something really novel is like getting water from a stone.

an enlightened attitude about abortion

I had dinner tonight with two Canadian colleagues, and near the end of dinner (after regaling each other with the usual gynecologic surgery “war stories”), somehow the topic of abortion came up. For starters, unlike some experiences I’ve had with gynecologists in my own country, I was not shunned nor was the conversation suddenly uncomfortable for the other physicians. Even better, I was told that in Canada, there are simply no laws regulating abortion; none whatsoever. Instead, it is considered something outside of the legal and legislative domains; it is a matter between a woman and her physician. 

Amazing. This was literally one of the few times I didn’t feel slightly ill at ease when talking about one of the most common gynecologic procedures with my fellow gynecologists. Usually someone looks at me when the subject comes up and says something to the effect of “Oh David, do we have to talk about that?” or “Mind you, I’m ‘pro-choice.’ Really. But I don’t do voluntary interruptions of pregnancy; they’re kind of associated with a certain reputation.“ Or else they just stop talking and politely find an excuse to walk away. These folks never mention the ”a-word.“ Every medical euphemism gets used instead: ”voluntary interruption of pregnancy,“ ”VIP,“ ”elective terminations.“ But never the word ”abortion.“ I think I have a scarlet ”a“ on my forehead, even a decade after stopping clinical practice altogether.

So it was refreshing that up here they wouldn’t interfere with the most private decisions, indeed some of the most difficult decisions, a woman makes in conjunction with her physician. They don’t determine, for example, when a fetus becomes a person. They also don’t legislate moral and religious questions such as when does life begin, questions that lack sufficient medical or scientific answers.

In a week when the Republican candidate can’t recall his previous vote against requiring insurers to pay for birth control (when they already cover Viagra) and then claims to not have thought about the issue at all, and a week when my candidate inexplicably claims that second-trimester abortion can be restricted by states when the indication is ”mental distress,“ it’s refreshing to be in a country, albeit temporarily, that at least recognizes that women have brains and should have control over their bodies.

Barack, just between you and me: my family and I are volunteers for your campaign in the Philadelphia suburbs. I am about as strong an Obama supporter as you’ll ever see. But with all due respect, what were you thinking? States should be able to prohibit second-trimester abortion unless there is a physical disorder that would result from the pregnancy?  I get it…you’re trying to pick up some right-wing voters. But good luck with that; they don’t trust you on abortion and probably never will. Worse: some of us progressives are now questioning your commitment to our issues in light of your FISA vote, your comments on abortion, and your sudden support for faith-based initiatives. Going to the center during the general election is one thing, but going into Rush Limbaugh-ville is scary. 

For starters, please stop using the phrase ”late-term abortion.“ There is no such medical term. A term pregnancy is 37-42 weeks in gestation. So isn’t late-term what we would usually call ”post-term pregnancy,“ namely 42 weeks and above? We don’t do abortions at that point. I don’t think I’ve done one above 20 weeks personally, and know of very few folks who do them even at 28 weeks (and those few generally do them in cases of severe fetal defects incompatible with normal life). Also, for anyone to suggest that a woman wakes up one morning at 24 weeks of pregnancy and decides then that ”What the hell, let’s go have an abortion” is both insulting and ridiculous at the same time. When we use the term “acute situational anxiety of pregnancy” as an indication for abortion, we’re talking about women who, after a complicated and very difficult decision process, clearly indicate that their lives would be abnormally and unduly burdensome due to a pregnancy. We’re not talking about a temporary inconvenience that some women are callously avoiding, much like the way that Corporal Klinger tried to avoid being in the military on M*A*S*H by faking a gender disorder. We’re talking about much more than that. To say that “mental distress” should not justify a second-trimester abortion is not within your purview as a presidential candidate, as an attorney and legislator, and most importantly, as a non-clinician.

I expect McCain to say something ridiculous vis a vis women’s rights, like trying to duck the fact that he voted down legislation to compel insurers to fund contraception. I expected Barack Obama to be much more sensitive to the rights of women when they are faced with an unexpected and undesired pregnancy, much like how I expected Obama to stand up for privacy rights and against the telecommunications companies that colluded with the Bush administration to spy on private communications. I’ll still vote for you and will of course continue to vigorously volunteer for your campaign as much as I can with limited free time. But please don’t disappoint me again. Do I have to visit Canada to encounter a more advanced attitude towards women? Can’t I at least expect this attitude in my own country as part of the change I can believe in? Right now I’m tired, and am not sure what to believe anymore.