Vol. 123 April 15, 2015 What Does “Board Certified Physician” Mean? What Does It Have To Do With The 2016 Presidential Candidates?

April 15, 2015

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 “Nowadays, medicine is an open-resource team approach. I get all this information in the room with a patient in seconds, and then I use my experience and my knowledge to pull together a plan”

– Dr. Jonathan Weiss, a triple-board-certified physician explaining why he is against a test every ten years to maintain board certification;
NY Times, April 14, 2015, D3

A “board-certified physician” is one who has voluntarily applied for and passed a test of medical knowledge in one of 24 general specialities or over 30 subspecialties.. A non-profit American Board of Medical Specialties (ABMS) composed of physicians was established in 1933 to administer the tests to physicians who apply for the certification after completing their residency training. Each approved specialty board issues a certificate to successful candidates (It hangs on the wall in your physician’s office). Unlike the bar exam for lawyers, physicians are expected to pass the test the first time, though a second attempt is sometimes necessary in some specialties. Most hospitals and many health insurance companies require board certification as a sign of competence as part of their credentialing. States do NOT require board certification for licensure.

One of the founding specialty boards in 1933 was the American Board of Ophthalmology (ABO), which brings us to the 2016 Presidential candidates.

Rand Paul, MD, a recently announced Republican candidate for President, took and passed his ophthalmology boards in 1995.  In 1997 he and 20 other practicing eye doctors protested the ABO’s changing of its certification from “lifetime” to “must be renewed every 10 years.” They argued that this Maintenance of Certification (MOC) test every ten years was “time-consuming for the practitioner, expensive ($1,500-$3,000), and irrelevant to patient care”. They formed a new board, the National Board of Ophthalmology (NBO), that would issue life-time certification for $500. Rand Paul was the lead organizer. He, his non-physician wife Kelley, and his non-physician father-in-law became members of its Board of Directors. NBO was never recognized by the ABMS, was dissolved by the State of Kentucky in 2000, was recreated in 2005 ( that just happened to be 10 years after Rand Paul was initially certified by ABO), and finally was dissolved again in 2011. It certified about 60 physicians in its lifetime.

Rand Paul is not the only critic of the ABMS and the Maintenance Of Certification (MOC) concept. Others have questioned the ABMS certification exams’ ability to evaluate actual clinical decision-making and clinical competence. Others have suggested that the exams’ heavy emphasis on memorized medical facts and pharmaceutical details is irrelevant, when nowadays such details are just a click or two away from the doctor in the exam room via electronic device. In 2013 a prestigious-sounding organization, the Association of American Physicians and Surgeons (AAPS) brought a “restraint of trade” suit against the ABMS for its MOC requirement.

I was impressed by that name, until I Googled it. The AAPS is an ultra-conservative organization established to fend off  “the evils of socialized medicine”. Its positions include “HIV is not the cause of AIDS”, “abortions are associated with breast cancer”, and “childhood vaccinations cause autism”. Rand Paul and his father Ron, also a physician and a past presidential candidate himself, are both members of the AAPS.

“So what” you might think at this point.
Rand Paul’s beliefs and actions indicate to me that he has an excellent ability to create, maintain, and operate within his own reality, one which ignores accepted evidence. Perhaps one could say that very same thing about any politician with whom you disagree, but I don’t disagree with every thing that Rand Paul says.  Physicians are trained to make decisions often using inadequate data. I am surprised that Rand Paul, as a trained physician, can successfully maintain a belief construct that is so at odds with established facts.  Also, he tried, and failed, to develop an alternative governing body of his profession when he disagreed with its policies. It was NOT about trying for better patient care.

These are undesirable attributes in a President of the United States. It also makes Hilary’s real estate shenanigans in Arkansas, her use of more than one email address as Secretary of State, Jeb Bush’s claim to being Hispanic, and Elizabeth Warren’s claim to being Native American look pretty penny ante by comparison.


Vol. 122 April 1, 2015 Athena Health Buys Myspace!

March 31, 2015

hub“Even as the public decries government spying programs and panics at the news of the latest data-breach the daily traffic to sites like Facebook and Twitter—especially through mobile devices—not only stays high, but continues to grow. Both the collective behavior of social sharing, and the technology for analyzing and interpreting social data, are already widely in place. The trick is to actually merge the two—which does not necessitate a whole new system.”

– Victoria Wangia, Professor of Health Informatics, University of Cincinnati
quoted in “The Facebook Model for Socialized Health Care” by Edgar Wilson, The Health Care Blog, 2/26/2015

Athena Health, a major provider of electronic health records (EHR) NOT to be confused with Anthem, has announced its purchase of MySpace, the pioneer social network.

MySpace (original spelling) was the first social network on the internet, but has steadily lost users to its competitor Facebook. Myspace (current spelling) was bought by Justin Timberlake in 2008. Despite efforts to revamp and redirect, Myspace user registrations continued to decline, and it has become a limited network for musical performers. Mr. Timberlake is confident that this move with Athena Health will broaden the scope of his company positively, “I am looking forward to making a more significant contribution to society than singing “D**k in a Box” on Saturday Night Live’s Christmas show”.

Jonathan Bush, CEO of Athena Health and related to both presidential Bushes, says he is making this move because it is time that health care providers make more innovative use of the social networks. Athena Health, based in Massachusetts, already provides electronic medical record (EMR) capability to health care providers nationwide. AthenaClinicals, its popular cloud-based electronic medical record and billing program, is available on desktop and mobile computers via AthenaNet. Its 2007 initial stock price of $18 is now at $120.

Using well-tested Facebook-like methodology Athena Health will create a wall, “The Health Wall”, in everyone’s Myspace account which will be renamed AthenaFace. This will add new meaning to “updating your status”. “Sick”, “Well”, “Recovering nicely”, “Waiting to find a doctor”, and “A little worried about what is happening to me” will be examples of clickable boxes.

Pop-up ads and informational banners will be health-oriented. Such as:
“Check your immunization score FREE”,
“Need help figuring out your Health Insurance deductible, Obamacare tax credit, or fine?”,
“Find the Nearest Medical Marijuana Dispensary”, and
“Special discounts on fitness club dues”.

AthenaFace representatives neither denied nor confirmed plans to link up with Groupon, another semi-floundering internet company, that provides discount coupons for a whole variety of services and products.

Record entries will be encrypted and saved, of course, though users will have the “Snapshot option” of having certain parts of the record being deleted within 30 seconds of being read. “The Health Wall” will accept postings of pictures and videos which will certainly enhance the robustness of the medical record for skin rashes, wounds, gait disturbances, and seizure disorders.

Efforts to link with relevant mobile apps like “Breathalyzer”, “Fitbit”, “Sleepbot”, “Whazthat!?”, etc. have already begun.  An app to link with Uber for the “Next available doctor to see you” will be in the first upgrade. However, that app, UberDoc, will include a charge. Prices will vary depending on circumstances, so customers will be urged to settle on the price before taking the appointment.

In response to critics who worry about the security of personal information in a combined health care/social network platform Jonathan Bush has stated, “Lots of people are obviously not at all concerned about such privacy issues. They are sexting and sending pictures of their genitalia all over the internet. Why would they care if somebody knew their blood pressure and cholesterol level? ”

But, AthenaFace will have different levels of privacy options that can be set by the user. On the user-sharing side the options will include:
“All”,
“Family and Friends”,
“Just Family”.
“Just (insert name here) ”, and
“Nobody”.

For provider-sharing the options for the customer will include:
“All”,
“Specialists Only”,
“Primary Care Only”,
“Dr.(insert name here)” , and
“Nobody, especially that nosey office nurse who thinks she runs the place.”

Why wait until your physician and hospital catches up with the federal EMR incentives for establishing a patient portal?

Do it yourself with AthenaFace!

Coming soon to your internet browser, but most probably after 2016 … depending on election results.

HAPPY APRIL FOOLS DAY.


Vol. 121 March 1, 2015 Friends Don’t Let Friends … Smoke

February 28, 2015

hub20 established causes of deaths caused by cigarettes:
(Surgeon General Report 2014)
11 cancers – Lip and oral, esophageal, stomach, colorectal, liver, pancreatic, laryngeal, lung, urinary bladder, kidney, and
acute myeloid leukemia
6 vascular – ischemic heart disease, other heart disease, stroke, atherosclerosis, aortic aneurysm, other arterial diseases
2 pulmonary – Pneumonia and influenza, COPD
Diabetes

These diseases account for about 83% of the total excess mortality (higher mortality rates than non-smokers) observed among current smokers.

Several causes of death newly associated with cigarette smoking have recently been added as a result of a study of 1 million men and women over a 10 year period. (NEJM 372;7, Feb 12, 2015)
About 9% of both men and women were current smokers.
42% (women) and 58% (men) were former smokers. (56-70% quit over 20 years ago)
49% (women) and 32% (men) never smoked.

Causes of deaths newly associated with smoking (with relative risk compared to non-smokers)
(1.0 is the mortality risk of a non-smoker)
ischemic disorder of intestines – 5.6 (nearly 6 times that of a nonsmoker)
liver cirrhosis – 3.6
cancers of unknown sites – 3.2   ( 2-6% of all cancers)
hypertensive heart disease – 2.9
all other digestive disorders – 2.6
renal failure – 2.1
all infections –  2.2
prostate cancer – 1.2

Most of the remaining 15-17% of excess mortality of smokers over nonsmokers is accounted for by these newly designated diseases.

The relative risks of death for smokers went up as the number of daily cigarettes smoked went up.
The relative risks went down among former smokers as the number of years since quitting went up.

How do people stop smoking?

YES
Conscious decision “cold turkey” (after being scared to death by statistics like this) – 4-7% success rate
nicotine replacement therapy (NRT) –  gum,patch, aerosol, lozenges
prescription medication – Wellbutrin, Chantix (always needs to be combined with support or cognitive therapy – even just telephone
counseling) 25% success rate at 6 months
support groups – NA, quitnet.com, Great American Smokeout

 MAYBE
hypnosis, acupuncture, mind-body practices, herbals
E-cigarettes – the jury is still out; no consistency of ingredients among brands is one problem in evaluating health risks.

NO
filter cigarettes – do not reduce nicotine inhaling; actually can increase craving
magnet therapy – “a small magnet on each ear”
chewing or other oral tobacco

The addiction to nicotine and to marijuana can be mapped using functional MRIs to the same part of the brain – the part of the brain that “lights up” with cocaine ingestion.  Some treatment programs and several research projects are honing in on this “dual addiction” of cigarettes and joints.

Interestingly, ingestion of the most common food “addictions”, ice cream, pizza and french fries, also maps to this same part of the brain.  Maybe as we get fatter and happier as a nation by using these substances other than tobacco, we will smoke less cigarettes, and live longer!


Vol.120 February 15, 2015 Disillusioned …Again and Again

February 14, 2015

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 “Scratch any cynic and you will find a disappointed idealist.”
― George Carlin

Maybe it is just that time of year, the record snowfall, the frigid temperatures, the lack of sun, but I feel like the world as I have known it is crashing down around my ears. Brian Williams has fallen off his pedestal, Bill Cosby is canceling shows all over the place, Tiger Woods is not coming back, Jon Stewart is leaving The Daily Show, Steven Colbert has already left, the towns are running out of sand and salt, and the trial of Dominique Strauss-Kahn, former head of the International Monetary Fund, has come up with the unique defense of his “aggravated pimping” “at a sex parties with “you can’t tell the difference between a prostitute and a naked socialite”.

So many of the truths we have held dear in medicine, science, politics, and society are being revealed as mere illusions. To wit:

  • Cholesterol need no longer be a nutrient of concern”. So sayeth the “nation’s top nutrition advisory panel” after 40 years of telling us just the opposite! High cholesterol levels in your blood do increase your risk for heart disease, BUT dietary cholesterol contributes only about 10% of that level. Of course, the panel couldn’t just leave it at that. According to them the REAL danger lies in foods heavy with trans fats and saturated fats. However, if you follow recent arguments in the literature closely enough you will see that there is some debate about which are the “good fats’ and which are the “bad fats.” Maybe we’ll have  to wait another 40 years for consensus.
  • Mississippi and West Virginia, among the poorest states in our country, have the best rates of measles immunization, and it is because they are the ONLY states that refuse to accept a waiver from immunizations on the basis of parental beliefs when children enter school. Mississippi’s measles vaccination rate is 99.7% for entering kindergarten students. West Virginia is at 96%. Epidemiologists have established a 94% immunized rate for measles as necessary to sustain “herd immunity”. In California and Arizona ( where thousands of Super Bowl visitors came and went back to their own states) the rates are 90.7% and 91.4% respectively.
  • Spewing sulphur gas into our high atmosphere could help block sun radiation and help cool off a warming earth. Isn’t sulphur one of those toxic pollutants given off by burning coal and other fossil fuels? Well, yes, says the National Academy of Science, but the computer models of blocking the sunlight with released sulphur have such a positive logic about them that “we should test it in some small pilot studies”.
  • Four out of five bottles of supplements taken off the shelves of GNC, Walmart, Walgreens, and Target in New York did NOT contain ANY of the herbs listed on their label. Ginseng pills “for physical endurance and vitality” contained only powdered garlic and rice. Ginkgo biloba for “memory enhancement” contained powdered radish, houseplants, and wheat. That label even claimed that it was wheat- and gluten-free! The FDA can only target products that have dangerous ingredients. It took the NY State Attorney General’s office to reveal this harmless ingredient sham, aka “profit by placebo” (NY Times, Feb. 3, 2015, pg.1)
  • Half of the health information and recommendations given on The Doctor Oz Show and The Doctors is false. Not only did 80 recommendations from each TV show picked at random from the 900 recommendations identified have NO evidence to support them, but many were even contradicted by evidence. In typical academic, “English speak” the authors suggest that “consumers and clinicians should be skeptical about these TV show recommendations”. (BMJ 2014 Dec. 17, 2014, 34)

Is there any hope for us optimists?   Well …

  • Crime rates in Boston have plummeted during this cold snowy weather. Homicide is down by 70%, rape by 50%, and vehicle theft by 46%. I guess everyone is staying inside, wearing lots of clothes,  and skipping the shoveling needed to steal a car. Rates for violent crimes in New York City, which had less snow and higher temperatures, all increased during the same period.

Vol. 119 February 1, 2015 Watching The Super Bowl Could Be Harmful To Your Health

January 31, 2015

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Sudden cardiac arrest among fans is a well-documented occurrence at exciting sports events.

 

 

  • Two fans dropped dead this summer as the Argentina soccer team beat Netherlands in a 4-2 shoot out to break their 0-0 tie. The 16 year old boy collapsed in front of a giant TV screen the mayor had set up in the village square as the winning goal was scored. The 49 year old died during the post-game celebration.
  • A 2010 European study of 190 major soccer arenas revealed that there was 1 sudden cardiac arrest in the stadium every 5-10 matches.
  • An American study of heart attacks after the 1980 and 1984 Super Bowls showed that, on the day of the game and for several weeks after, men had 3 times the number of heart attacks then expected; a jump from 1 to 3 in 100,000. Further analysis showed that the rate was higher in the fans whose favorite team lost and was lower in fans whose team won!

The presumed mechanism is the outpouring of adrenaline during peaks of excitement which causes heart muscle to go into contractile spasm or ventricular fibrillation. Either one is lethal if not stopped. The European study felt the problem was significant enough to make 6 recommendations for soccer stadiums to ensure that stricken fans could get immediate access to life-saving medical care.

Is there anything that you can do to reduce your risk? Unless you are already taking daily aspirin to reduce your risk of a heart attack DON”T start now. Aspirin has real risks of causing intestinal bleeding AND, truth be told, there is NO evidence that daily aspirin prevents your first heart attack (“primary prevention”). Its beneficial effect is well proven only in reducing the chances of you having another one (“secondary prevention”).

Alcohol is a well-known contributor to high blood pressure (not the best thing for a heart), so if you are truly worried you could take that rather drastic step.

Us coach potatoes can take some solace in the fact that we are not the only ones with increased risk for sudden cardiac arrest.

  • Endurance athletes (“continued exercise for 3 hours or more”) have about the same risk, 1 in 50,000, of acute heart attack or sudden cardiac arrest within 24 hours of completion. (1)
  • A 1999 study of 38 Austrian athletes in a 143 mile bicycle race with 18,000 feet of altitude change revealed that 34% of them had elevated heart enzymes in their blood at completion; an absolute sign of heart muscle damage. The winner had the highest level! (2)
  • A subsequent study of participants in the Hawaiian Ironman Triathlon found that 11% had signs of heart damage at the end. Of course, this is not new. Remember that Pheidippides, the first marathon runner, dropped dead just after delivering his message.

It is interesting that these studies involved only men. Because heart attacks are still the number one killer of women and that 46% of the last Super Bowl audience were women, perhaps it is time to broaden the study population.

I used to collect articles about the dangers of running in order to support my resistance to popular peer pressure at the time, so I am personally heartened to know that the risk for sudden cardiac arrest during a sporting event is about the same for both couch potatoes and players.

References:
1.  Jour Am Coll Card 28:428, 1996
2.  Am Jour of Card 87:369, 2000


Vol. 118 January 15, 2015 It Ain’t Just Vaccines That People Decline

January 15, 2015

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Half of U.S. patients don’t take their medicines as prescribed by their physicians.(1,2)

We use to call such patients “non-compliant.” As “patient-centered care” became the mantra for contemporary medicine that “passive, judgmental” term of “non-compliant” was banished and replaced by “non-adherent”, a presumably less derogatory term implying a partnership of patient and physician. (3)

A cardiologist, struck by the number of her patients that did not comply with adhere to their heart medicine prescriptions, asked 20 of them who had survived a heart attack why they didn’t adhere to medications that had proven benefits of secondary prevention of a next event, an event that could cause death. (4) Their comments (listed first below)  were surprisingly similar to feelings expressed to me by parents who decline immunizations for their children (typed in bold italics ).

1. Risk Aversion
“Why take medicine that could wreak havoc on your body.”
In people with negative emotional reactions even a small risk of side-effects seemed to overpower any positive feeling about the proven benefits of a drug. Their perception of risk is greater than their perception of benefit. They are “far more sensitive to possibility than to probability”.(5)
Despite numerous studies showing that there is no probability of an association between measles vaccination and childhood autism some parents still feel that there is always the possibility. Arguing relative probabilities of vaccine side effects versus disease effects with them is not productive.

2.Naturalism
“Medications are chemicals and should not be in your body on a regular basis”.
Vitamins, herbs, and other health supplements of all kinds are often turned to because they are not “chemicals”.
“I don’t want to have any foreign proteins injected into my child”. Natural immunity, of course, depends on our body recognizing and reacting to foreign proteins so that symptoms resolve and our next exposure to the same foreign protein doesn’t make us sick again. “It is the additive proteins that we don’t want” is often the next statement from the parents. Pointing out that there are 315 “foreign proteins” in today’s vaccines  rather than the thousand’s in the vaccines before the 90’s does not reassure them.

3.Denial
“Men don’t like taking medicine because to do so they are admitting that they are not strong. Most people like to think that they are strong and mighty. …Their very sense of well-being after surviving a heart attack and quickly resuming healthy lives may convince them that medications are not necessary.”
Some parents feel that their unimmunized children are safe from disease because the rest of the children are immunized, the “herd immunity protection” argument. Pointing out that herd immunity is effective only when the community reaches the currently unachievable high percentage of immunity (a 94% threshold in measles and whopping cough) has no effect. You would think that the possibility of measles in their unimmunized child in a partially immunized community would override the small probability of side effects from the vaccine. It doesn’t with some parents.

4. Avoidance of Sick Identity
“Has having a heart attack become too easy?” People can spend more time being sick from flu than having a therapeutic cardiac cath within 90 minutes of arriving at the ER and walking out of the hospital 24 hours later.
Has the absence of children dying or being crippled by measles, polio, diphtheria, or croup dulled our ability to imagine our children in such a sick state? Sporadic epidemics of whooping-cough and croup in certain states have been successful in raising immunization rates a bit. If there were an Ebola vaccine, I wonder how the vaccination  non- adherent parents would have juggled that possibility/probability calculation for their children.

5. Difficulty Visualizing Benefits
“The benefits of cardiac medications may be imperceptible and the absence of perceived benefit is a well-documented reason for non-adherence”. Adherence to anti-platelet medications (“blood thinners”) is higher than other cardiac meds perhaps because the patient can easily visualize the “thinned” blood flowing smoothly through an unclogged pipe. That the medication is actually “doing something” is reaffirmed by the prolonged bleeding from a razor nick.
Maybe we pediatricians should develop an app and FitBit that could non-invasively measure antibody levels and send an alert to the child (via his/her own smart phone, of course): “Your antibodies against [insert tetanus, diphtheria, or whatever disease name here] have been declining for years and are now at a level that no longer protects you. Go immediately to your nearest [insert sponsoring drug/ convenience/department store name here] and get vaccinated.”

6. Avoiding Dependency
“Relying on cardiac medications is another form of addiction. I brought on this heart attack by my life style and it is my responsibility to avoid another by changing my life style.” Taking medications may be viewed as a loss of control, as “following orders” , as “being told what to do”.
This rejection of authority rings true in my experience with some parents who decline immunization for their children. It also may explain why pockets of unimmunized children who are not in poor families are sometimes clustered within tree-hugging, organic food eating, aging-hippy communities. Frustrating as this rejection of authority is to the physician, repeatedly battering the head and shoulders of these parents with all the scientific facts proving that vaccinating their child is safer than having them contract the disease is counter-productive.

The discussion with parents who decline immunizations for their children is hardly ever a rational one. Some beliefs and feelings seem impervious to facts. Certainly a parent’s personal knowledge of some child, usually a cousin or a nephew/niece, who had a vaccination and then had a seizure or who “has never been the same since” is a real conversation stopper. That personal experience can generate such deep feelings that I no longer even try to talk them out of that hole. We don’t experience that same depth of feelings if an older adult we know survives a heart attack only to die of a second one months or years later. We often feel, not knowing all the details, that “C’est la vie”.

References:
1. NEJM 2005;353:487-97 Adherence to Medication
2. J Gen Intern Med 2008;23:115-21 Secondary Prevention After MI
3. Ann Pharmacotherapy 2004;38:161-2 Adherence or Compliance?
4. NEJM 2014;372;2:184-7 Beyond Belief
5. Psych Bull 2001;127:267-86 Risk as Feelings


Vol. 117 January 1, 2015 New Year’s Resolutions

December 31, 2014

hub“I can resist everything but temptation.”
-Oscar Wilde

Recent “scientific” surveys reveal that 45% of us in the U.S. make New Year’s resolution but only 8% succeed in fulfilling them. Those under 30 years of age apparently do much better; 16% of them succeed. (1) Here is another statistic that is hard to believe: “38% of 2600 respondents polled by their fitness program failed to accomplish their fitness goals in the past year”. (2) Boy, talk about underreporting!

It makes me wonder, “why bother?”.  But, the social pressure of age-old traditions is unremitting, so here are my 2015 resolutions. (Maybe my first one should  “be stronger against social pressure of age-old traditions”. )

In 2015:

1. I will continue to resist committing myself fully to the social media fray while I patiently wait for the ultimate app, “TwitterFace”, “FaceTube”, “InstantaYou”.

2. I will no longer make wise cracks about brussel sprouts, broccoli, and eggplant dishes now that my grand children like them, but I still don’t eat them.

3. I will start the Paleo diet (no grain, no processed foods, no sugar, no milk – basically “what a caveman would eat”) as soon as Market Basket or Stop and Shop puts saber-tooth tiger steaks on sale.

4. I will try to treat anti-gun control and anti-vaccine advocates with respect since they are probably rational people, even through their arguments are irrational.

5. I will read the computer screen from left to right, line by line, and word-for-word before I call my son when I lose my way, since that is the first instruction he will give me. (It unravels my confusion about 95% of the time.)

6. I will not spend hours this year comparing bills while trying to decide whether Verizon or Comcast has the best “bundle”. (It always seems fruitless no matter how or when I do it.)

7. I will continue to collect articles and study results that promote the health benefits of an afternoon nap, but I will also stop my occasional designation of a nap as my ”accomplishment for that day”.

8. I will wear my new, gifted fit-bit bracelet (Jawbone-UP/24 which apparently measures all my activity and my non-activity) for at least a month, even though I probably won’t understand all of its features by that time. (If all else fails, I will download the manual, if I can find it on their website.)

9. If I find myself using my son-in-law’s or daughter’s Netflix password on my home TV more than once a week, I will get my own subscription.

10. I will complete and publish my compilation of “You may be a Geezer if…” aphorisms.

That’s it.
Nothing magic about the number ten except that it avoids any connotations of the number 12, either disciples or members of a jury.

Feel free to add any of your own resolutions here. Maybe announcing them will generate some needed social pressure on you to succeed.

References:
1. Jour of Clinical Psychology, 1/1/14
2. New.Health.Com/2014/BlueGojjPlatform

 

 

 

 


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