Low back pain in the South West LHIN

It should come as no surprise to any health professional or patient in Southwestern Ontario that when it comes to low back pain, our region is a chaotic mess. Patients struggling to access adequate care, languishing on wait lists, with physicians powerless to provide them any help. The situation is a combination of many factors, including the aging demographics of the region, a disorganized primary care and specialist system, and underfunding of physiotherapy and spine surgery operating time. Where it has left us is with surgical wait lists approaching 3 years, with patients falling into severe disability while they await appropriate care.

The South West LHIN has begun work on initiating the Inter-professional Spine Assessment and Education Clinics (ISAEC) program in the region as a means to begin to address the local crisis. The program has been implemented with success at the University Health Network in the GTA, improving surgical wait times and improving patient satisfaction. The model includes an initial assessment by an Advanced Practice Clinician (physiotherapist or chiropractor) in the program assessing and educating the patient, and returning a consultation note with recommendations. Some patients are given self-management education, while some patients will be referred on to a Practice Lead (physiotherapist or chiropractor) at LHSC who would make recommendations for more complex patients (imaging, injections, or surgical consultation). It is being proposed as a pilot project in the South West LHIN, starting with a small group of physicians in 2017-18, and expanding to the entire region for 2018-19.

I agree with the principles in theory, but given the current complexity of the problem in the South West LHIN, there are a number of added issues that must be considered.

We need to be very careful not to create multiple competing referral streams that all inevitably compete for the same surgical resources. CBI Westmount has already initiated a referral program in conjunction with a couple of the spine surgeons, where physicians can refer their patients to be seen within a short period of time. An ISAEC program working alongside the CBI program would end up at a bottleneck of the same scarce surgical and injection resources.

Here’s what I would propose:

  • A LHIN-led analysis of the current referral burden to all spine surgeons in the South West LHIN. This may include a complete re-design of the existing referral forms, which are currently inadequate for conveying relevant information from the referring physician to the surgeon. The referral form could include an area for the referring physician to designate why they believe the patient is a surgical case, with an educational component to the form that would dictate what constitutes a surgical referral and appropriate management/evaluation of back pain. Once an appropriate referral form is agreed upon, it may be necessary to ask referring physicians to re-refer patients using the appropriate form to be able to properly work through the existing glut of patients. This would also allow for the LHIN and surgeons to determine the exact magnitude of the surgical backlog and what surgical resources will be required to reduce surgical wait times expeditiously.
  • An analysis of the capacity in the South West LHIN for back injection services and existing wait times for epidural and facet injections. A majority of potential surgical cases are being sent for diagnostic injection by the surgeon, which ends up causing a frustrating delay for the patient because of the inadequate local resources. The LHIN needs to work with local interventional radiologists to ensure stable capacity.
  • Offer educational sessions for local family physicians on the CORE Back Tool, similar to the sessions presented by Dr. Hamilton Hall. I personally found this program to be transformative in how I diagnose and treat mechanical back pain, decreasing the number of unnecessary referrals. Identify physicians who refer a disproportionally high number of patients to spine surgeons, and encourage those physicians to attend the educational sessions.
  • I would suggest that the ISAEC model be revised for the South West LHIN whereby referrals are made by physicians directly to the Practice Lead, and that all interested local physiotherapists and chiropractors are provided complimentary education in the ISAEC model.
  • Work towards having ONE spinal surgery stream in the South West LHIN that flows through the Practice Lead, rather than allowing multiple competing streams to develop.
  • Ensure that patients with acute back pain, who do not have private benefits, have adequate access to a brief course of physiotherapy with a focus on transition to self-management and home exercise programs.
  • Focus on increasing the ability of family physicians to competently diagnose, triage, and manage acute and chronic mechanical back pain, rather than pushing resources towards creating more chronic pain clinics.
  • Develop a free local Spinal Stenosis Boot Camp, similar to the program offered at Mount Sinai, to support the increasing prevalence of spinal stenosis among the elderly. Participate in this program should be mandatory (with appropriate exceptions) for those seeking either surgery or ongoing epidural injections for pain relief.
  • Opening up FHT-led chronic pain self management programs to non-FHT patients, and advertising these widely.
  • Ensure that our local libraries have an abundance of copies of “A Consultation with the Back Doctor” by Dr. Hamilton Hall. This book has been invaluable for my patients with chronic back pain to understand the nature of mechanical back pain, and gives many patients the confidence to self-manage their pain.

Just a few ideas for now, but we need to have open discussions about our current local challenges before we move forward with an ISAEC pilot program.

Bibliotherapy: What are your favourites?

I’ve done some work on my practice website compiling bibliotherapy titles for most mental health conditions, along with some online resources as well.

https://www.drmarioelia.com/mental-health

For those of you with any experience in this field, I hope you can provide some feedback in the comments here:

  1. Which of the titles listed have you found particularly helpful for your patients? Include as many as you want! Do you have any negative experiences with any?
  2. Do you have any favourite titles that I haven’t come across? (Don’t hesitate to include any in a category that I have yet to include).

Once I get a good amount of feedback, I plan to include some annotations in the list to clearly identify which titles have the highest recommendation from mental health professionals.

Thanks in advance for your help with this!

Part II: TB screening prior to long term care admission: time to choose wisely

I’m happy that my initial post sparked a discussion about the existing policy across Ontario that every new patient admitted to long-term care has a chest x-ray done within 90 days of admission.

I was shown this study from 2013 in the Canadian Journal of Public Health that detailed a TB outbreak in an Ontario long-term care home from 2010-2011, which is believed to be the only published report of a TB outbreak in a long-term care home in Canada. I would encourage anyone with an interest in this topic to read the study as it is quite interesting.

The index case for the outbreak was a 40-year old health care worker who presented with symptoms in April 2010. She had previously had a negative TST in 2007. Three residents developed active TB, diagnosed in July 2010, October 2010 and January 2011, respectively.

There were a number of issues identified that may have contributed to the outbreak. Baseline TST results were only available for 40% of staff members, while 96.5% of residents had a documented TST. The TST in residents is of limited use, however, as prevalence of latent TB infection (LTBI) in residents >65 years old in long-term care facilities in Canada may approach 20-30%. The residents with active TB also presented with subtle changes of weight loss and chronic cough which likely delayed a prompt diagnosis.

The recommendations made following this outbreak included (among other recommendations): mandatory baseline and annual TST for staff and volunteers, and to suspect TB in any resident with fever, cough > 3 weeks, unexplained weight loss, hemoptysis, lack of appetite, or night sweats.

Both recommendations are completely reasonable, and would potentially serve to reduce the risk of a future outbreak.

But here’s the recommendation that is completely out of thin air: “Baseline posterior-anterior and lateral chest X-ray for new residents”. 

There was no suggestion from the case report that the 3 active TB residents may have had active TB at the time of admission that would have been picked up on chest x-ray. One of the residents most likely had LTBI that activated at some unknown time. Given that 20-30% of the residents have LTBI, we cannot predict which of those patients will go on to develop active TB, nor can we reasonably or safely treat all of the LTBI patients with INH (recall from the case report that one of the active TB patients died of INH hepatitis).

As I mentioned in the first post, insisting on a chest x-ray of asymptomatic patients at the time of admission is completely arbitrary. If the patient is asymptomatic, they are just as likely to have asymptomatic active TB 6 months into their admission as they do at the time of admission. But we don’t insist on another chest x-ray at 3 months, 6 months, or 12 months. Wouldn’t their LTBI be just as likely activate at those time points?

I would argue that one of the most harmful aspects of the current screening program is that it creates a false sense of reassurance for physicians who may assume that their residents are low risk for TB because of their normal chest x-ray.

We need a change in the legislation and policy. Change the screening criteria to the following: at least one lifetime chest x-ray, and a completed set of screening questions to rule out any symptoms of TB at the time of admission. Part of the education around this change in protocol would raise awareness to physicians and staff about the high prevalence of LTBI, and the importance of being vigilant to look for subtle signs of active TB in residents. This heightened awareness would serve to reduce the risk of further outbreaks more than any chest x-ray screening program could ever achieve.

TB screening prior to long term care admission: time to choose wisely

I recently had a patient who was accepted for admission into long-term care, and I completed the usual paperwork detailing their active problem list, past history, medications, vaccinations, and last chest x-ray (for TB screening purposes).

A few days later, I received a call from the long-term care home. The patient’s chest x-ray was not done recently enough. I checked the file. It was done 110 days ago. They wouldn’t accept my patient for admission unless they had a chest x-ray from the past 90 days (if under 65, they require a TB skin test if they have never had a previous positive test). “It’s in the provincial legislation” was the rationale. No room for any negotiation, it had to be done.

Every family doctor in Ontario has been in this exact same situation, likely multiple times a year, held hostage to order a test that intuitively seems of very little use. But I wanted to do a deeper dive on this issue to see where the genesis of this policy is, and to see whether changes should be made (spoiler alert: changes should definitely be made).

First, the legislation. Any health unit or long-term care home that makes reference to the legislation cites the same two pieces of legislation, the Long Term Care Homes Act from 2007 and the Retirement Homes Act from 2010. Here are the excerpts that make reference to tuberculosis:

The Long Term Care Homes Act 2007
(10) The licensee shall ensure that the following immunization and screening measures are in place:
1. Each resident admitted to the home must be screened for tuberculosis within 14 days of admission unless the resident has already been screened at some time in the 90 days prior to admission and the documented results of this screening are available to the licensee.
4. Staff is screened for tuberculosis and other infectious diseases in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices. O. Reg. 79/10, s. 229 (10)
Retirement Homes Act 2010
(8) The licensee of a retirement home shall ensure that,
(b) each resident is screened for tuberculosis within 14 days of commencing residency in the home, unless the resident has been screened not more than 90 days before commencing residency and the documented results of the screening are available to the licensee;
(c) each member of the staff has been screened for tuberculosis and all other infectious diseases that are appropriate in accordance with evidence-based practices or, if there are no such practices, in accordance with prevailing practices; and
(d) the screening for each of the infectious diseases described in clause (c) has been done using procedures that accord with evidence-based practices or, if there are no such practices, with prevailing practices. O. Reg. 166/11, s. 27 (8).

A couple of things to note. The legislation makes no specific mention of chest radiography, and does not explicitly state what form of “screening” is compulsory. Is screening for risk factors sufficient, or is it necessary to order a test of some sort?

What do the guidelines say? The Canadian Tuberculosis Standards were last updated in 2013 with the 7th edition, and chapter 15 is the relevant section for this topic (Prevention and Control of Tuberculosis Transmission in Health Care and Other Settings). Table 6 outlines the recommendations for TB screening in long-term care:

tb1

“Baseline posterior-anterior and lateral chest radiography on admission for people >65 years old from identified populations.” Which populations? “People known to belong to an at-risk population group listed in the section ′′Identification of patients with active respiratory TB within hospitals′′. Here’s that list:

tb2.png

So nearly all patients admitted to long-term care would meet at least one of these criteria, bring born prior to 1966. The rationale for the 1966 criteria is that the TB incidence rate in Canada prior to 1966 was similar to that in a high TB incidence country. The guidelines therefore state that these patients should have a baseline chest x-ray, but do not specify when this has to be done. There is absolutely no mention in the guidelines to any 90-day cutoff. According to the guidelines, for the TB skin test for those under 65 years old, a negative skin test in the past 12 months is sufficient.

What does clinical common sense dictate? One would think that a clinician should be able to look at the guidelines, look at the patient’s risk factors, and determine whether it is reasonable to repeat a chest x-ray given recent possible exposures. If a 90 year old patient had a chest x-ray during a hospitalization 4 months ago, and hasn’t left their home since, requiring them a repeat x-ray to rule out TB is lunacy. There is no reasonable explanation for why this can’t be left to clinical discretion. Keep in mind that a significant portion of admitted patients to long-term care homes have been hospitalized in the last year, likely receiving at least one chest x-ray, and have been waiting months for admission.

The selective insistence on overly prescriptive TB screening in long-term care homes has always struck me as odd. Yes, patients admitted to long-term care are higher risk for TB than their age-matched cohort. But we don’t insist on chest x-rays for high-risk individuals who are hospitalized for a non-respiratory cause. We don’t insist on chest x-rays for incarcerated individuals unless they will be in jail for over 1 year. We don’t insist on chest x-rays for all individuals spending time in a homeless shelter or drop-in centre. So why are we so militant with screening in long-term care, especially when most long-term care homes would be designated as low-risk according to the guidelines?

tb3

The answer is clearly a desire for the ministry to avoid any medico-legal risks, but we need to base our decisions on more than just a fear of litigation. There has not been a single case of LTC-associated TB in London-Middlesex in at least the past two years (health unit is tracking down earlier data for me). Having spoken to local infectious disease experts, that is not necessarily a product of good screening, as they aren’t seeing any significant number of elderly patients with active TB detected through the screening process.

The logic of the “90-day chest x-ray” is also significantly flawed. I will grant that patients born in Canada prior to 1966 are higher risk for TB, and deserve a chest x-ray at some point prior to admission. But if they have been continually asymptomatic, why does this particular time point of admission deserve any further scrutiny? They have been asymptomatic for 50 years or more, and had a chest x-ray done at some point to rule out TB. Do we honestly think we are going to pick up TB that has magically decided to re-activate at the exact point the patient is admitted to long-term care? And what about if another patient has a normal chest x-ray at admission, but develops a non-productive, afebrile (likely viral) cough two months after admission? Is it not more likely that this symptomatic patient has TB than the patient who was asymptomatic at admission with a previous normal chest x-ray? The bottom line is that the hypothetical viral cough patient doesn’t need a chest x-ray, nor does the asymptomatic patient require a chest x-ray at admission if a previous chest x-ray was clear (with no other subsequent high-risk exposures since 1966). They’re both exceedingly low risk for TB.

With the way the legislation reads, I understand why Health Units and long-term care homes are interpreting it as they are, here, herehere, and everywhere. The long-term care homes are understandably fearful of inspections from the Ministry of Health that could find that they are not “compliant” with the legislation. The health units understandably want to be conservative in their recommendations, not leading any of their local long-term care homes to be “non-compliant”.

Without either 1) a change in legislation or 2) a public memo from the Ministry of Health clarifying the legislation and how it will be enforced, we’re not going to see any of the health units or the long term care (or retirement) homes make any changes in what is expected of physicians. Until we see a change from the ministry on this, we’re going to continue to be forced to order low-utility chest x-rays, wasting valuable health care dollars. One lifetime chest x-ray (with a physician review to rule out other subsequent high-risk features) should be sufficient for admission to long-term care in Ontario.

My Christmas wish-list for primary care in Ontario

It’s Christmas Eve, and I only have a few hours to articulate my demands (sorry, requests) to Santa for changes I want to see to our primary care system in Ontario. I won’t be going into a ton of detail on each point, because 1) family obligations are waiting, and 2) Santa needs time to put these into action before he arrives tonight.

Off we go…

  1. Increase the fee paid for consults in specialties across the board, and decrease the fees paid for follow-up visits by specialists (with the exception of time-based services, those will remain the same). OMA Economics can do the math to ensure this remains cost neutral. This will incentivize specialists to see new patients to help family doctors, reducing wait lists, while encouraging the discharging patients who can be easily and competently taken care of by their family doctor. Require that any consult billed is preceded by a new referral by another physician. Any diagnostic test performed by a physician requires a referral from another doc for that specific test (echocardiograms, holters, etc.). Any billed visit by a specialist for consult or follow-up must produce a note to be provided to the family doctor.
  2. Any walk-in clinic visit must produce a note to be provided to the family doctor. Yes, I realize a universal EMR would solve this problem with information going in both directions, but in the meantime, we need to improve communication.
  3. I’m still waiting for this wish to come true about transparency of office hours.
  4. Make second opinions by specialists for the same issue non-insurable by OHIP, and allow specialists to bill patients privately for those consultations. The logistics of this are challenging, but we first need consensus among physicians, the public, and the government, on the general premise of the idea, before moving forward with an implementation plan that will require significant electronic infrastructure (for checking consults by other physicians, etc).
  5. Make “physicals” non-insurable by OHIP, unless done for a pre-approved indication (cancer follow-up, weight loss, lymphadenopathy, etc). If a patient still requests a physical, they can be privately billed at OMA rates. Specify what tasks are exactly encompassed within a Periodic Health Examination, based on what methods of screening there is firm evidence for.
  6. Stop the practice of primary care physicians (paediatricians or family doctors) running large ambulatory clinics manned by nurse practitioners, where the physician bills OHIP and pays the NPs a wage or salary for their services. We don’t have the money in our system to pay doctors to be middle-men. A separate OHIP Schedule of Benefits strictly for delegated acts could be a possibility in under-serviced areas where non-MDs are necessary to maintain adequate patient care.
  7. Add shadow tracking codes for family physicians in FHOs or FHGs who correspond with patients via email or telephone (or any non-in-person visit). If they’re dealing with issues outside of a traditional visit, let’s give them credit for it.
  8. Fix the FHO out-of-basket service codes that are not a reflection of adequate access to primary care. An ER physician appropriately suturing a laceration for a patient who felt it was an emergency should not penalize their family physician.
  9. House calls performed by physicians outside of the group to whom the patient is rostered, should NOT be insurable through OHIP (exceptions being those with certification in palliative care). We should not be funding convenience visits for patients who saw an advertisement for “doctors who will come to your house!”

Alright Santa, there’s the list. Make it happen.

Making physician billings public? Here’s my proposal.

It’s an issue that predictably rears it head during any labour impasse between a government and physicians. Provincial governments calling for physicians to disclose their billings, in an attempt to characterize them as overpaid and greedy in the eyes of the public. The media often joins the action, looking for a juicy story. Members of the public will often chime in, asking where their health care dollars are being spent.

In Ontario, Minister of Health Eric Hoskins has raised the issue, offering to potentially exchange public disclosure of physician billings for the binding arbitration process that physicians are seeking. Putting aside the fact that physicians should be entitled to a fair dispute mechanism without having to make these concessions, I wondered whether there is a solution to be found (assuming that Dr. Hoskins is genuine in his offer).

Let me start by stating unequivocally that simply providing a list of total yearly billings sorted by physician should be a complete non-starter. That type of list, like the Blue Book provided in BC, gives us virtually no useful information. Doctor X made $250,000 in 2015. So what? That tells us nothing about what volume and type of service Doctor X provided. It’s a shaming exercise, and nothing more.

The argument often made in favour of disclosure of physicians billings is that it would provide a degree of accountability in the system that is currently lacking. However, providing only a total billing figure by physician does not provide enough detail to make any form of meaningful analysis.

Here’s what I would propose.

An online database where any citizen can search for any physician (search by name, specialty, billing number, or location), and view a itemized listing of what fee codes were billed by each physician by date. This database would not include any dollar amounts, either by code, date, or totals, again because these totals can be inflammatory without providing any value. The OHIP schedule of benefits is a separate document available to view for anyone, which lists the dollar amount for each fee code. The details in that document is where a debate can be had as to the relative appropriateness of each fee amount. The online database I am proposing should be solely focused on outlining what services physicians are claiming through OHIP, for full disclosure.

(An important exclusion to this disclosure would be fee codes involving abortion and medical aid in dying, in order to maintain the confidentiality and safety of the physicians involved).

I want to know how many patients Doctor X saw on Date Z, and what they were seen for. That is the information that we need to identify outliers. Was the volume and frequency of billing reasonable? How much the physician made should be of secondary importance, and can be debated fee code by fee code as a profession, but not by looking at a physician’s total billings. If an investigative journalist wants to data mine to determine what total amount each physician billed for a given time frame, they can certainly do so, but ethically they should be expected to describe the details of the thousands of services provided by the physicians to earn their billings.

I would also propose a database where patients can search, by their health card number, for what services were billed in their name, by fee code, date, and physician involved. There would need to be some additional security measures to ensure that only the patient themselves can access their billing history, as certain billing codes can easily disclose elements of their medical history. The current process for patients to access this information can take weeks, and is quite tedious, discouraging patients from inquiring about any questions about OHIP claims made in their name.

At this point, anyone proposing simply listing total yearly billings by physician is either doing for political gain, or through ignorance of the inadequacies of such a system. Many physicians are indeed open to system of disclosure of billings, but only under a carefully thought-out methodology that provides accountability without inappropriately vilifying hard-working physicians.

A few thoughts from last weekend’s OMA Council meeting…

With most of the Ontario medical community feverishly discussing the Auditor General’s report from Wednesday, I wanted to spend a bit of time reviewing what transpired at this past weekend’s OMA Fall Council meeting.

All of us in attendance knew that it would certainly be an eventful meeting, being the first Council meeting following the tPSA rejection, and with the backdrop of the Coalition of Ontario Doctors’ active petition to call for another General Members’ Meeting. I am always pleasantly surprised when the polarization and hyperbole of social media is replaced with generally cordial and thoughtful dialogue. I thought the meeting was productive, with a litany of provocative motions passed and the OMA board and executive seemingly committed to major changes.

However, reading many of the online posts and comments both during and after the meeting, it felt like I had attended a different meeting than a few of my fellow members. I understand that the primary goals of the Coalition remain the removal of the Executive and the voting of the President by membership (not Council), but painting the entire meeting with deceptive and misleading brushes does everyone a disservice, particularly engaged members who simply want to know the facts.

Failed motions that were posted on social media by members were chosen specifically to feed the narrative that the OMA is out of touch with membership. In many cases, the issue with the motion was simply a matter of word-smithing, and other motions with similar intent passed with near-unanimous support. The overwhelming tone of the meeting was in opposition to Bill 41, with many motions opposing Bill 41 in various iterations. However, when one motion about Bill 41 failed after a vigorous debate because of a concern about how it may be manipulated politically, it was posted online with the clear intent of misleading members into thinking that Council was somehow in favour of Bill 41. On one particular occasion, the original mover of the motion stepped into the social media discussion to point out that the dissenters actually gave a very good reason for opposing the motion. The debates around motions are so important to understanding the context of the issues, and members seeing only what motions were approved or defeated provides them virtually no meaningful information.

I am quite excited to have the Council meetings broadcast online in their entirety. If the events of Council are going to be manipulated by certain groups in how they are presented to members, then the benefits of transparency far outweigh any potential strategic advantage in keeping Council private from the eyes of the MOH. They need to be broadcast to remove the selective editorializing that is happening, because it is far too easy to disseminate misinformation and inflame existing tensions.

One of the more contentious debates was surrounding the Code of Conduct suggested by the Strategic Working Group. Many Council delegates raised concerns about whether inviting the CPSO to be further involved in the personal activities was wise, but the message that I heard from Dr. Athaide was that this was a policy in evolution. Members would be surveyed as to how a Code of Conduct should look (eg. should CPSO be involved, etc.), which was approved through a motion.

It was striking to me how different the overall tone was of this meeting compared to previous Council meetings I had attended. At previous meetings, I was a bit taken aback by how abrasively the Executive dealt with questions from members that they clearly disagreed with. It was very much a “We know best, please sit down” mentality. Now some may argue that they still saw some of that this past weekend, but I certainly felt that it was a marked change in overall tone. Much more conciliatory, much more willing to support motions rather than pick nits. I am still shocked that the Executive gave its support to the motion that called for “equal time and equal money” to opposition groups during any future general members’ votes. There were also a number of votes on motions where the recommendation of the Executive was ignored, which was also a  relatively new development. There is certainly no shortage of independent thinkers on Council, which is great for the strength of our organization.

Two new board members were elected, Dr. Silvana Bolano and Dr. Nadia Alam, both of whom have been sharp critics of the OMA and supporters of reform. Ousted were a current member of the Executive and a former member of the Negotiations Committee. Somehow that doesn’t count as “real change” in the eyes of some. We heard from the Strategic Working Group which provided 114 recommendations for how the OMA needs to move forward and learn from the disastrous events of this summer. We saw the report from Pricewaterhouse Coopers which detailed the chronology of the tPSA events, and a very clear signal from Council that many were hoping for more of an analysis rather than a simple chronology. We saw a motion approved that would see the “Moving Forward, Moving Together” document put together by Dr. Graham Slaughter’s grassroots group of physicians used to inform the work of a future Negotiations Committee. There was news that a governance map would be drawn up for the organization, to outline to members clearly how the labyrinth of the OMA is to be navigated. There were also promises for clearer instructions to members on who their reps are and how they can contact them. A motion passed that would have the OMA outline on their website the progress of all of the motions from Council, and another motion that would have the Board post their minutes on the OMA website.

Now of course these motions were mostly non-binding, but they show at least a general movement towards a more progressive organization. I’m optimistic.

The OMA still has a long way to go before re-establishing trust with many of its members. I hope that members who didn’t have a chance to attend Council continue to follow ongoing developments, and to ensure that the OMA follows through on their promises, but to do so by following sources that are committed to presenting objective information.

To quote an Ontario surgeon who was very active at Council: “I have seen the change firsthand over the past 18 months. It is slow and frustrating, and at times downright obnoxious, but is happening”.