Wednesday, February 24, 2010

Why the upcoming health reform summit could make for good television

pplphoenix1qq4A somber President Obama, in the days following the Scott Brown victory here in Massachusetts, appeared to be a leader coming to the stark realization that he ought to revise his approach… or run the risk of alienating more and more Americans frustrated with incumbents of both political parties.  He appeared pensive, shaken, humbled.  And pundits pondered whether a principled president would emerge to press on regardless of the political consequences… or whether a pragmatic leader would rise up, in Clintonesque fashion, like a phoenix from the flames to fight one more day.

We’ve learned over the past few days that this particular president appears to be more the former than the latter case in point.  He has released his own proposal (a mildly warmed over Senate version of the no-public option plan) and has indicated that parliamentary procedures could allow him and the Democrats to prevail by not requiring any Republican votes.  Scott Brown be damned.

On Thursday, there will be a televised debate (probably not free form) on health care reform and Republican strategists are, I’m sure, wondering whether to play helpless victim to a wild-eyed president and government gone sadly wrong… or to go down fighting and pretend it all really matters (even though they most likely can’t avoid the parliamentary entanglements).  The real question is: which will play better during the Fall, leading up to the November elections.  The Democrats have taken a position, boldly so, and we’ll know tomorrow just how the opposition party decides to play it.  I predict they will go down fighting.  And that it will be good television.

Saturday, February 20, 2010

No Phone Zone

This is becoming a big deal.  Talking, texting, emailing, blipping, blogging, facebooking, you-name-it-ing on your cellphone while you drive.  My mother watched the Oprah show about the numerous people killed or severely injured due to this new plague, this new addiction, and called me asking me to consider the message.  The No Phone Zone message.

I'm taking this seriously.

What a difference a week makes...

This was me one week ago today.

And maybe 20 minutes later, when the sun began to set...

Friday, February 19, 2010

What does it say…


… about an organization when so many great individuals spend so much of their lives working there?  Yesterday afternoon, we honored five individuals who retired after many years of service to the VNAB’s Hospice division.  Pictured from left to right: Dottie MacKay (Administrative Assistant,11 years), Marty Roberts (RN, 10 years), Mary Chase (RN, 16 years), and Millie Doherty (RN, 15 years).  Also retiring was Pat Rossetti (RN, 5 years) who is not pictured.  On the far right is Diane Bergeron, Hospice Executive Director.

At the gathering, I heard many great stories, some funny and some poignant, about careers dedicated to helping others.  About accompanying patients and their families during a most extraordinary time… a time of vulnerability and sorrow and loss.  A privileged time.

Best wishes to our retirees.  It has been our privilege to know you as friends and colleagues.  We will miss you.

Quick grab from the Blackberry camera

If I come across a sky like this and have a camera with me... I just can't help myself...

Thursday, February 18, 2010

Innovating. Again.

Picture1The Visiting Nurse Association of Boston (VNAB) has long been a leader in creating new programs designed to keep members of the community independent and at home… while improving clinical outcomes and sharply reducing medical costs.  In the coming months, we’re launching another innovative initiative designed to serve patients with heart failure and, in a second phase, those with chronic obstructive pulmonary disease.

According to VNAB’s Joan Roth:

  • It is estimated that 5 million in the US have heart failure (HF) with approximately 550,000 new cases diagnosed per year
  • HF accounts for 875,000 hospitalization each year
  • It is the most common hospital admission diagnosis in the 65 and over population
  • There is more Medicare spending for the diagnosis and treatment of HF than any other diagnosis
  • The mortality rate is 33% at one year, 50% at five

Utilizing the Heart Failure Society of America Comprehensive Heart Failure Practice Guidelines and the American College of Cardiology Heart Association Guidelines for the Diagnosis and Management of Heart Failure in Adults, the VNAB is adopting specific guidelines for nurses and therapists around assessment, treatment, transition planning and rehabilitation.  Joan and her team have created specific outcomes goals to track progress and to inform future program planning.  Such goals pertain to reducing hospital readmissions, improving patient ambulation, improving medication management and others.

Internal training begins soon and external communication shortly thereafter.

More to come on our COPD program…

Growth in Health Related Jobs

According to the US Bureau of Labor:

  • Medicine continued to be the bright spot in the economic downturn, adding 21,500 jobs in December 2009, with 8,900 in physician offices.
  • Another 2,500 were created in outpatient medical centers, and 8,000 were added to the home health care industry.  Hospital employment increased by 1,400.
  • The economy as a whole lost 85,000 jobs, and the unemployment rate held steady at 10%.

Care is shifting from inpatient settings to outpatient and home based.  The growth in home care positions outpaced hospital-based positions by a factor of almost six to one!

I remember the original…

And this one is worth watching.

Wednesday, February 17, 2010

Communication and the Obvious Analogy


Another snowstorm was expected in the Northeast and we had to get back to Boston.  Following the weather feeds from NECN and, it seemed as though we were due to arrive right in the heart of it.  Fun.

To schedule an earlier flight?  To stay put on the American Airlines flight at 3:55?  To go later?  It wasn’t a clear-cut choice.  Maureen from the shuttle bus was also headed to Boston and she was on the 1:30.  Why not?  Let’s go for the earlier flight.

We were able to snag the final two seats on the 757 and settled in to our seats on a sunny and warm Miami afternoon.  At 1:25, the pilot came on and told us of a problem with the wing and the necessary repair.  That’s all he told us.  The flight attendants knew nothing else.  No estimate of severity.  No estimate of duration.  We sat and waited.  I looked at my Blackberry and saw that the storm was hitting; not a major one… but perhaps one that might impact air traffic and our flight?  Hope not.

A half hour later, the pilot told us the repair was finished and that the technicians were completing paperwork.  Great.  We’ll be off soon.  How long can the paperwork take?  Pretty long, we learned.  Another half hour later, the flight attendant picked up the mic to tell us that they simply had some paperwork to do and to hang tight.  We waited.

Eventually we took off… and it was an uneventful, smooth flight home.  As we descended into Boston, through the stormy, gray cloud cover and into the heart of the storm… we prepared for turbulence and the typical snowstorm landing.  We descended and descended and seemed to be nearing ground.  The aileron motors churned as the plane fought the wind and we knew we were close, despite the lack of ground lights and any indication of bearing or location.  And then: “This is your captain speaking.  We have not been cleared for landing and have been asked to continue to circle.”  And here’s the best part: “The crew will keep you informed of our progress and when we have been cleared.”  Best part because we heard nothing, other than one request to remain strapped to our seats, after that.  And so we circled and circled.  For a long, long time.  I felt badly for the infant who was screaming a few rows ahead of us.  After an hour, I felt worse for us.

Not knowing the progress was frustrating.  The flight attendants were nowhere to be found as they complied with the request to be buckled in and so we were left to speculate.  Were we “circling” as in a giant circle over Logan or were we 600 miles off shore?  Was the storm getting worse?  Better?  Any idea of how long this might last?

We heard nothing.  Even if the pilot came on the loudspeaker to tell us that he didn’t have an update but would be sure to let us know if he did… that would have helped.

It occurred to me that organizations who are going through significant changes, particularly stormy ones, need strong and frequent communication.  Even if you have to tell people you’re not sure about a few things.  Not hearing is frustrating.

It’s an obvious analogy.  But it’s good to remember this.

Tuesday, February 16, 2010

Health Reform - A Report from the Conference

A panel of experts, including Bill Dombi from the National Association for Home Care and Hospice and others, pondered the future of health reform given the ground shaking Massachusetts election results of last month. From my notes, the most interesting points were:

  • The Democrats are now completely focused on the upcoming November elections and trying to determine how to "play the loss"; they're also waiting to see what the Republicans do in response to the President's challenge that it's now their turn to offer a solution.
  • One panelist (David Introcaso) stated that "it's all about politics now, not policy."
  • All of the experts agreed that the White House has been inconsistent in its messaging regarding next steps and how much of a legislative priority this will now be for them.
  • Perhaps there will be progress on the provisions on which this is significant agreement (transparency, preventing fraud and waste, creating quality-based incentives, ACOs, insurance reform, etc.)
  • Bill Dombi stated that: "Washington is exhausted right now on this issue" as this has been "such a heavy lift"; the panelist discussed whether there will be enough energy and political will there to resume this issue and press forward. Some thought yes, others no.

Sunday, February 14, 2010

Quint Studer on Performance Management in Health Care

Quint Studer wrote the book. Literally. Click here for more information.

He was the speaker at this morning's pre-conference session. Here are a few of his pearls of wisdom.
  • In private industry, competitors don't share secrets (Apple doesn't describe its strategies and tactics to Microsoft) but in health care, knowledge transfer is considerable... and expected.
  • We don't push performance to the same extent in health care as do other industries. We tolerate poor performance to a much greater extent.
  • Finance people make the best CEOs. They live by objective goals and measure themselves and others relative to performance against those goals.
  • Health care suffers from the affliction known as 'terminal uniqueness"... and when confronted with benchmark data and best practices, we say things like "that won't work for us because we're different".
  • Health care undertrains its leaders, providing 6.5 hours of training per year for managers; Fortune 100 companies provide 55 hours per year.

Two from the feeble Blackberry camera

Nothing feeble about this place, though.

Saturday, February 13, 2010

South Beach Scenes

We took an early flight so that we could spend some time wandering around South Beach before tonight's start to the Home Care 100 Conference in Key Biscayne. Some scenes from today...

Friday, February 12, 2010

Now refer to us on-line

Remember the first time you bought a book from Amazon? Downloaded music via iTunes? Purchased airline tickets from Expedia?

Increasingly, we're all getting more and more comfortable doing things via web interfaces. Actually, more and more of us are strongly preferring it. That's why some transactions, initially thought to be too complicated, too sensitive, too personal for internet processing have made it to the internet. And that's why increasingly we're taking out loans, buying cars and interacting with our medical providers via computer screens.

Recently, the Visiting Nurse Association of Boston launched a web-based referral option. It's available at and early data suggests that referring providers like it. Why? Easy, fast, and safe (fully HIPAA compliant).

For those of you who still prefer the old fashioned way, call us at 617-426-6630. We still have humans...

Thursday, February 11, 2010

Tuesday, February 9, 2010

The Suffering of Not Knowing

I sent an email to Jacques the day after. It was a expression of sorrow and sympathy though I had no idea if this had actually impacted him or his family. I assumed it did. I assumed it had to. I never heard back.

Yesterday and today, the chaplains of VNA Hospice Care conducted a service of "Support and Solidarity" for our coworkers, friend and patients whose lives have been permanently changed as a result of the earthquake in Haiti. Jacques has been very much on my mind. So much so that I called him to check in.

He told me of his cousin, a man who had visited here during the Christmas holiday and who has not been seen or heard from since. During my entire conversation with Jacques, I never caught the man's name... and now I wish I had.

Jacques told me of how his cousin's family members have searched frantically. How they have hoped for miracles, such as the one announced today of the day 27 survivor found alive. Wishing that he will show up dazed but ok in a hospital bed somewhere. But they fear the worst. More so each passing day.

They do no know where he now rests, which seems to be the more likely question now. Jacques, with a lilting voice and poetic tone, told me of the forms of suffering befallen his people. He spoke of "... the suffering of loss, the suffering of wishing life was again as the day before, the suffering of rebuilding without hope. But all these kinds are final. They persist, but you go on. For my cousin's family, there is the suffering of not knowing. And that only persists."

Monday, February 8, 2010

Doing something about maternal depression

The question: Given dramatically escalating health care costs driven, in part, by ever expanding diagnostic and treatment possibilities in high tech acute care settings, what's an industry to do?

The answer: Innovate by creating new programs in lower cost settings designed to improve lives and cut costs in the long-term.

The example: From a recent VNAB press release...

The Visiting Nurse Association of Boston (VNAB) was recently awarded a grant from United Way of Massachusetts Bay and Merrimack Valley. The grant will fund the Boston Home Visiting Collaborative: Enhancing Child and Parent Outcomes through In-Home Cognitive Behavioral Therapy Program. The long-term goal of this new program is to increase identification and treatment of maternal depression among families with children prenatally through age five receiving home visits in Allston-Brighton to promote the social and emotional well-being of young children and their families. The VNAB expects to receive $726,000 over a two year period to fund the program. "We are very excited that the United Way selected the VNAB to be the lead agency in this newly funded program," said Keren Diamond, Senior Vice President of Operations.

"As a primary provider of home and community-based care in the Greater Boston area, the VNAB has the knowledge, experience and infrastructure to lead this project. We are pleased to add this cutting edge treatment to our already strong Maternal Child Health Program." According to the National Center for Children in Poverty, maternal depression affects 5-25% of women, a figure that in low-income families reaches 40-60%. In addition, the NCCP estimates that 70-80% of low-income women suffering from maternal depression, do not receive treatment for it. Untreated, maternal depression can lead to long-term problems for young children, including cognitive delays and aggression, particularly if a child is exposed during their first year of life. The VNAB will partner with other community providers in the Alston-Brighton neighborhood to identify participants for the program. Partner agencies include: Crittenton Women's Union (Boston Neighborhoods Healthy Families), Boston Public Health Commission (Healthy Baby, Healthy Child), Family Nurturing Center (Parent-Child Home Program) and Jewish Family and Children's Services (Visiting Moms).

"United Way is committed to minimizing children's exposure to risk factors, such as maternal depression, that limit their chances of long-term success," said Peg Sprague, Senior Vice President, of Community Impact at United Way of Massachusetts Bay and Merrimack Valley. "The Boston Home Visiting Collaborative is a great example of our efforts to drive greater impact by coming together and coordinating efforts as a community."

Saturday, February 6, 2010

Conforming to our own standards...

It's not uncommon for companies to stress the imporance of complying with specific standards for usage of logos, all in the good name of brand protection.  I remember working for Harvard Pilgrim Health Care when ambitious and creative staff used to peel apart the name of the company from the famous red shield in the logo and use the shield as bullets in Powerpoint presentations.  It looked cool.  It drove the marketing people nuts.

As a pre-holiday message to employees at VNAB, I accidentally stepped into a micro-fray when I photographed the Christmas tree in our front lobby and captured the sign showing our logo in the background.  The original blog post is here, which led to a note from one observant commenter that our own logo was out of whack.  Here's the comment:

Why is it that the roof on the VNA logo is misaligned? The chimney should be aligned with the left two squares. Better question: Why has it been this way since the rebranding and never corrected?
Good question.  So we looked into it and fixed it.  Here's an excerpt from an email I just sent to all employees:
I received an interesting comment on my blog from someone who pointed out that our own logo on the sign by the front desk in Charlestown hasn’t conformed to our own standard. It takes a good set of eyes to see that the chimney was not aligned properly with the two leftmost squares in the logo’s home symbol. It turns out that the company who prepared this sign for us made a mistake… which they were happy to fix. And so, all is now right with our logo!
Thank you to the keen eyed observer who pointed this out to us and also to Jeff Smith for working with the company to get this fixed.
Sometimes it’s the little things…
Before and after:

Facebook and privacy

Political campaigns are being waged, products launched, family reunions staged, and old friendships rekindled. On Facebook. It's no wonder then that the fastest growing demographic of this popular social media site is forthsomethings. And it's us fortysomethings who may have a higher sensitivity to privacy issues than our Facebooking kids. Still though, it's not a bad idea to review some important rules of the road, common sensical as some of them may be, for maintaining your privacy. Boston Globe technology wonk, Hiawatha Bray, has laid them out here.

President changes tune on health reform

Just hours after Scott Brown was sworn in as US Senator from Massachusetts, President Obama made some comments signaling a major softening on his health reform push. "And it may be that ... if Congress decides we're not going to do it, even after all the facts are laid out, all the options are clear, then the American people can make a judgment as to whether this Congress has done the right thing for them or not," he said. "And that's how democracy works. There will be elections coming up, and they'll be able to make a determination and register their concerns."

This relative about face (remember his earlier quotes about pushing on no matter what...) might frustrate congressional leaders from his own party who have gone out on a limb to support their leader.

"The next step is what I announced at the State of the Union, which is to call on our Republican friends to present their ideas. What I'd like to do is have a meeting whereby I'm sitting with the Republicans, sitting with the Democrats, sitting with health care experts, and let's just go through these bills. ... And then I think that we've got to go ahead and move forward on a vote," the President said on Thursday.

Worn thin by the constant opposition charges against Democratic proposals, it will now be the Republican's turn to develop real alternatives. The major question remains as to whether they will take the opportunity to offer substantive proposals or will they be content to have defeated the President's initiative and then shift focus elsewhere. I'm guessing elsewhere. Can you say growing Federal deficit?

Thursday, February 4, 2010

Haiti… a few weeks later

We’ve all watched the video clips, the newsfeeds, the nightly broadcasts.  Photographers have sent back horrifying and moving images of profound devastation.  Relief efforts are underway.  Family members still wait.

January 12th.  A 7.0 magnitude.

But it wasn’t all that long ago that video clips, broadcasts and images from our own country horrified and moved.  I had an opportunity just days after Hurricane Katrina struck the Gulf Coast to tour the destruction.  I was unprepared for what I saw.  Here are a few of the images I took.

I toured the communities and spoke to their residents.  And I’ve had an opportunity to stay in touch with some of them afterwards.  More than once, I’ve heard stories about chaos during the first weeks, hordes of relief workers coming in to help but without the skills and capacity to actually do so, scams and con schemes by those looking to capitalize, and a sense that once the eyes of the nation turned away, the residents were left alone with the real work of rebuilding.

I’ve been thinking a lot about that experience since January 12th.  Hurricane Katrina seemed so extreme, so vast… but now in the wake of what happened in Haiti, I have a new frame of reference, a new definition of disaster.  The magnitude of impact, the number of lives lost, the lingering uncertainties are all still difficult to fully comprehend. 

But I remember what they said in Pass Christian and Gulfport.  They said that they still needed the help weeks and months later.  Some still do today.  I hope that as the world moves on, as the broadcasts slow and newsfeeds diminish, we’ll still care about Haiti.  We’ll still help.

Spending and spending…

When health reform burst onto the scene in the presidential campaign and then during the first year of the Obama Administration, the two primary goals were to increase coverage and to control costs. 

Well… now that overhauling the system is officially on hold, we shouldn’t forget that health care spending continues to increase at an alarming rate.  Governmental estimates show that health spending increased 1.1% to account for 17.3% of the GDP last year. That’s the biggest annual increase in 40 years.

Also of note is that governmental spending (Medicare and Medicaid) is growing faster than outlays by the private sector and in two years, governmental spending on health care will surpass private sector spending for the first time.  The weakened economy hasn’t helped as unemployment has fueled some of the governmental spending.

Current estimates show that health care could top 20% of the GDP in ten years.  20%!

“You don't take a photograph, you make it.”

So said the master.  For about the last hundred years, I’ve kept the annual Ansel Adams wall calendar nearby as a source of constant inspiration.  And though I’ve been fortunate enough have stood and photographed in the same exact spots where he once did, the end results are not comparable.

If your objective is to photograph beauty, then you are simply capturing the art in front of you.  If your objective is to make art, then you need inspiration.  Ed sent me the post below, from photographer Eva Polak.  Check out her website here.  Eva is an “impressionist photographer” and I believe you’ll agree that she does not simply “take a photograph.”

According to Eva, here’s how you find inspiration:

Whether you have been creating photographs for years or only for few weeks, finding inspiration is not always easy. We all experience periods of creative blocks when we get stuck and all our good ideas come to a halt. Inspiration seems to elude us. So, what can we do to help a creative energy affect us day after day? Is there a way to stay inspired? For me there is a definite “Yes” to these questions.  Throughout the years I developed some systems and strategies to ensure I remain creative and make things happen. The followings are my favourite ways to keep igniting my creativity.

1. Keep a Notebook

Keep your notebook with you whenever possible, so that you can write all your ideas, notes, inspirational quotes, dreams, goals, etc. Be consistent and add items to it often. In time it will become a great source of inspiration but also a reminder of your goals to keep you focused and motivated.

2. Take your Camera with you Wherever Possible

There are possible photographs all around us. You never know what you will see. Be prepare.

3. Read Biographies of Artists that you Admire

A biography is a great source of inspiration. You can learn, not only facts from someone’s life, but also discover important insights while gaining a deep appreciation for challenges these artists faced and the accomplishments they achieved. You may find parallel experiences in their life, be inspired by their persistence, and be motivated by their success.

4. Experiment

Take risks and try photographic styles or techniques you’ve never done before.  Use different camera settings. Play “What if…” game. Don’t be afraid to make mistakes. Just explore and have fun.

5. Start a Personal Project

Set realistic goals and plan your photo shoots. This requires a lot of discipline, so start small and you can always build up.  Evaluate your results from time to time, but remember this is your project, your ideas and your photographs.  Don’t let anyone discourage you.

6. Visit Art Galleries

Going to see an exhibition can enrich your imagination. You will get new ideas to focus on and see your own art in a new perspective.

7. Learn Something New Everyday, Every Week, Every Year

Start reading books about art and photography. Subscribe to newsletters, podcasts and feeds. Take a class, attend a workshop, join a photography group. These activities will trigger new ideas, increase the level of your skill and boost your confidence.

8. Visit New Places

You don’t have to go overseas to find something exciting to photograph. Explore your neighbourhood. You will discover all sorts of places that you didn’t even know existed.

9. Look after Yourself

A healthy body equals a healthy mind. Exercise, eat plenty of fruits and vegetables, drink a lot of water. Take some time out to relax.

And above all have fun!

Eva Polak is fine art photographer based in Auckland who specializes in impressionist photography. Author of two books “At the beach” and “Impressionist Photography Techniques” – visit her site at

As simple as following a recipe… right?

Give me Julia Childs’ best recipe and I’ll follow it to the letter.  But I’m quite certain that the end result would be quite different from what you would have found on Julia’s dining room table.

Today, at a meeting of our senior staff, we reviewed one of our exciting new clinical centers of excellence.  The presentation was given by Judy Sojack and at one point, I asked her to provide a sound bite on why this new program in wound care treatment demonstrates VNAB’s innovation and why it would be of interest to a referring hospital CEO and managed care company CEO.  I heard about ensuring excellent and consistent training of staff and the adoption of aggressive outcomes goals.  I also heard how our wound care performance is already class leading.  Objective data comparing us to other home care agencies demonstrates that in spades.

The highlight of Judy’s comments came when she described wound care as “similar to cooking”.  Here, in Judy’s words:

Wound care is like cooking…..

It applies principles of biology, chemistry and physics. Wound care protocols are similar to recipes or formulas. There are hands-on skills which must be mastered.

Like cooking, wound care is an art as well as a science. Each wound is different because each patient is different. Their medical problems, functional capacity, health attitudes and personality influence their ability to heal. The individual architecture of each wound requires a customized approach to care. Creativity often contributes to a successful outcome.

The science of wound healing can be taught in the classroom, but the art of wound care must be taught at the patient’s side. Expert role models must guide clinicians in acquiring the hands-on skills and developing holistic, creative plans for wound healing.

VNA of Boston is committed to developing a wound care program that applies principles of wound healing and research based interventions, in conjunction with a holistic, multi-disciplinary approach to wound healing. We are working to ensure that our clinicians have advanced wound care skills and can partner with our physicians and patients to achieve successful outcomes.

Judith Sojack RN, BSN

Tuesday, February 2, 2010

Uncompassionate care… and the lessons it teaches…


This happens. 

Having worked in a variety of health care settings, including leading a large group practice, I know that sometimes you strive to provide the best customer service and the most compassionate care possible.  But that doesn’t always happen. 

It’s incumbent on providers and administrators to build systems with appropriate checks and balances so that situations such as the one below never happen.

In an email to all VNAB employees last week, I touted the importance of good communication.  This is what Paula Dercolo wrote back:

Hi Rey,

I recently accepted a new position within the VNA (January 4th).  Prior to that, I was the South End Team Coordinator for two years.  While the transition was both demanding and challenging, I jumped in with my eyes wide open and ready to go.  Because of a situation I experienced last week, “communication” has taken on a whole new meaning for me.  As I sat in the waiting room of my MD’s office, I listened in on a conversation that a woman was having with the receptionist.  She was a 47-year old who was in to see the doctor the day before.  She was sent to the hospital (by her physician) for further testing and was told to come back to the doctor’s office the following day.  The receptionist proceeded to tell her because she did not have an appointment, the doctor could not see her.  The woman started to cry.  She was diagnosed at the hospital with MS the day before, wanted to speak to her physician about her new diagnosis, and needed to have her pain medication adjusted.  She tried - to no avail – to see the doctor that day.  She stated “even though I don’t have an appointment, and you people told me to come back today, I can wait”.  The receptionist said “the best that I can do is schedule you an appointment tomorrow.”  The woman left the office crying, no pain medication, an appointment card in her hand and her life altered forever.  No matter how hard she tried to communicate this to the receptionist, she would not budge.  I wonder if the MD is aware of how his employees communicate to his patients.  As I develop my new role here at the VNAB, I will remember this woman for a very long time.