I don't understand the whining?

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health123 said:
FFP I completely agree. This is the point I am trying to make. I think physicians on this forum respond emotionally rather than looking around and recognizing what's happening in reality. If the medical board can't/won't regulate APRNs, then there should at least be a curriculum and testing (USMLE) set like medical school for ANY individual wanting to diagnose, treat a patient. period. whether pa, np, etc.
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The last time they tried to do that, a bunch of nps took a watered down imitation of step 3 designed for nurses with a lower threshold for passing and half of them failed. This was at Columbia, if I recall correctly
 
anes said:
Let's agree to disagree. You cannot convince me that a nurse who went to nursing school, takes nursing exams, and has the title nurse in their title, Isnt practicing nursing. Is an "independent" crna practicing medicine (even if they do the exact same case the exact same way as an md)? I think most people will agree that they're not practicing medicine. They're nurses who trained as nurses, went to nursing school, took nursing exams, went to NURSE anesthesia school, and took NURSE anesthesia exams.

You can set whatever curriculum you like. Go to nurse practioner school, even take USMLE steps 1 through 3. Unless you actually go to medical school and complete a physician residency, you are not a doctor.
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That is all very nice but, whether you want it or not, they already do a bunch of stuff you do (just look at all those family practice APRNs). I want to point out that I am talking about the independent ones, those who practice without any supervision. So one can let the nursing board regulate them, or one can say (like in any other country) that the practice of medicine and medicine-like activities is regulated by the board of medicine, period. We already do that for PAs, which don't practice independently.

One can join the future, or fight the future, regardless it will come. I would rather have the board of medicine define that future, not militant nurses from the board of nursing.
 
Psai said:
The last time they tried to do that, a bunch of nps took a watered down imitation of step 3 designed for nurses with a lower threshold for passing and half of them failed. This was at Columbia, if I recall correctly
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It was, psai

Also the medical boards don't take on regulating independant practice nurses for the same reason we have independent practice nurses. Logic and safety don't matter as much as lobbying power and the nurses have more pull. It's that simple.

Independent practice nurses are selling their patients on the idea that they are qualified to make the final discernment for a health decision (terminology of nursing/medicine is just semantics at that point). The problem is how they justify it. They compare themselves to how much more knowledge and experience they have than an RN which is debatable looking at their curriculum steeped in management and nursing theory. The true mark of health decision making, the friggin' gold standard, is a physician and frankly the nps don't hold a candle to a physician. They know it and we know it, but in a society where legislation is more important than logic and where everyone gets a trophy.....docs don't get to say it without being "unprofessional"
 
Promethean said:
I think that this is what is frustrating to so many NPs and the reason I have no interest in that route.

Being an NP has got to be confusing. You aren't really nursing anymore, but you aren't really being a physician. You are constrained by your training and background to pay lipservice to nursing, but what you are doing has nothing to do with what you learned in nursing school. Nursing is implementation, and implementation is important, but not valued. So there is a desire for a broadened scope in order to finally gain access to the withheld respect that was due all along.

The NP gets stuck in the middle.

Nursing wants to keep you, as a pin in its cap, because it isn't happy with what it is. Medicine wants no part of you and shuns you for not having gone through the proper channels. Everyone conspires to pretend that the work that NPs and other advanced practice nurses are doing has anything to do with nursing. It suits all the vested interests to deny that NPs are practicing medicine, but without the depth of theory and practical training to do it with the full competence of a physician. What a mess!

EDIT: Before anyone blasts me for describing what NPs do as medicine, recall that practicing medicine without a license is a thing. NPs are doing that, except that they do have a license. The degree of competence they bring has a lot to do with the individual and the training they did pursue, but in no case does it hold a candle to that of a fully trained physician. It is refreshing to hear an NP who is aware of this and intellectually honest enough to admit it aloud. For those docs who are concerned about the APRN lobbies that want to claim privileges they haven't earned, maybe make a few allies of those of them who didn't drink that koolaid.
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Forgive my ignorance, but which physicians practice medicine without a license? Residents generally have training, if not unrestricted licenses. Interns are fulfilling criteria(1-2 years of residency) to obtain their license.

Let me ask you this question. Can I, as a physician, decide to call what I do the practice of nursing because I give the same medications and perform intubation the same as a CRN?
 
FFP said:
That is all very nice but, whether you want it or not, they already do a bunch of stuff you do (just look at all those family practice APRNs). I want to point out that I am talking about the independent ones, those who practice without any supervision. So one can let the nursing board regulate them, or one can say (like in any other country) that the practice of medicine and medicine-like activities is regulated by the board of medicine, period. We already do that for PAs, which don't practice independently.

One can join the future, or fight the future, regardless it will come. I would rather have the board of medicine define that future, not militant nurses from the board of nursing.
Click to expand...

I'm not arguing that they don't practice independently. I agree, they do. I argue that the should NOT practice unsupervised. I'm also arguing that you ccannot call what they do the practice of medicine.

A future where an NP is considered equivalent to an MD, even if regulated by our medical board is not a future I want to be a part of. That future is a spit in the face of physicians who undoubtedly sacrificed much more time, money, emotions, sleepless nights and quality of lifE.

what's happening is concerning, because you're dumbing down medicine. Who in their right mind would go to medical school with that kind of outlook? I know I wouldn't, shoot I'd become an NP.
 
I understand the frustration all of you are expressing. But, we're in this system and we're in it together. I know a CRNA who originally was a Critical Care Nurse Practitioner who does OR (without anesthesiologist oversight) and comes back up to ICU and is the hospitalist there (no MD during her shift). She calls MDs only when she's not sure of something (which is rare), and this information I get from the MDs who trust her with all their patients. She's a huge asset to the hospital and this is a Metropolitan hospital in Los Angeles. I'm only saying this so you will know the extent of "mid-level" infiltration and dependence for that matter. As such, I think there should be a standard of expectation set for mid levels to practice in this manner.

As for the previous posts who say we practice in the "nursing" model. Can someone tell me what that means? I don't think any NP knows what that means. The last time I heard that, it was during RN school. NPs don't practice in the nursing model. Whoever told you that is lying. We use medical school books, get lectured by MDs, etc. MDs should wake up and see what's really going on. All I'm saying is if NPs are allowed all this autonomy, we should be held accountable for it. And the best people to do that are the medical boards.
 
health123 said:
I know a CRNA who originally was a Critical Care Nurse Practitioner who does OR (without anesthesiologist oversight) and comes back up to ICU and is the hospitalist there (no MD during her shift).
Click to expand...

I'd literally drive past that hospital if I had an emergency and keep going to the next.
 
health123 said:
I understand the frustration all of you are expressing. But, we're in this system and we're in it together. I know a CRNA who originally was a Critical Care Nurse Practitioner who does OR (without anesthesiologist oversight) and comes back up to ICU and is the hospitalist there (no MD during her shift). She calls MDs only when she's not sure of something (which is rare), and this information I get from the MDs who trust her with all their patients. She's a huge asset to the hospital and this is a Metropolitan hospital in Los Angeles. I'm only saying this so you will know the extent of "mid-level" infiltration and dependence for that matter. As such, I think there should be a standard of expectation set for mid levels to practice in this manner.

As for the previous posts who say we practice in the "nursing" model. Can someone tell me what that means? I don't think any NP knows what that means. The last time I heard that, it was during RN school. NPs don't practice in the nursing model. Whoever told you that is lying. We use medical school books, get lectured by MDs, etc. MDs should wake up and see what's really going on. All I'm saying is if NPs are allowed all this autonomy, we should be held accountable for it. And the best people to do that are the medical boards.
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I agree, they should be regulated by a board. But definitely not by the MEDICAL board. For the medical board to regulate them, and allow independent practice means that NP=MD.

So this CRNA that does independent CRNA practice now goes into the ICU and is the HOSPITALIST there? Is this an official title? If so, shame on that hospital. Do the patients know that she is independently taking care of them in the ICU, with no physician oversight? I live in Los Angeles. Please tell me the name of the hospital so that if I ever get sick, I don't go there.

On a side note, had I known all of this before going to medical school, I would have gone to nursing school. Become an independent NP 4 years bachelors of nursing, 2 years NP school = 6 years. I did 4 years bachelors, 4 years medical school, 4 years residency, 1 year fellowship = 13 years.... what an idiot I was.
 
Mman said:
I'd literally drive past that hospital if I had an emergency and keep going to the next.
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Why? There are no studies to show that the care this CRNA, NP, Hospitalist/Intensivist nurse would provide inferior care.
 
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I know a CRNA who originally was a Critical Care Nurse Practitioner who does OR (without anesthesiologist oversight) and comes back up to ICU and is the hospitalist there (no MD during his shift).
Meet Dr Lexus
image.jpg
 
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Technology has made "playing doctor" especially with bread and butter patients too easy.

I call it the 90/10 rule. Meaning 90-95% of things can be handled with by non doctors these days.

Just look at cvs and Walgreens pharmacy with their "clinics" for routine medical issues staffed by NPs usually.

Just at "solo" GI centers staffed by Crna only. I doubt u see ASA 4 dialysis, severe OSA 350 pounders having "simple GI scopes". Rather they are generally pretty healthy and generally not that fat.
 
Promethean said:
I do get it that residency is much harder, that the hours are longer, that the responsibility is greater. I watched groups of interns that I had met on the med/surg unit where I used to work go through their residencies and fellowships to become attendings. I saw much, though not all, of what they went through. I didn't live it personally, but I really do have some sense of what I am getting myself into.
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I could have said the same thing as a teenager years ago watching the TV show "ER." There's no thinking, decision making, liability, or responsibility involved in watching people work.
 
anes said:
I'm not arguing that they don't practice independently. I agree, they do. I argue that the should NOT practice unsupervised. I'm also arguing that you ccannot call what they do the practice of medicine.

A future where an NP is considered equivalent to an MD, even if regulated by our medical board is not a future I want to be a part of. That future is a spit in the face of physicians who undoubtedly sacrificed much more time, money, emotions, sleepless nights and quality of lifE.

what's happening is concerning, because you're dumbing down medicine. Who in their right mind would go to medical school with that kind of outlook? I know I wouldn't, shoot I'd become an NP.
Click to expand...
Is anesthesia as practiced by independent CRNAs (who do what we do) medicine? One cannot call the same thing different names just because it's done by two different kind of people.

If barbers still operated, it would be surgery, not "barbering". Heck, we call it surgery even when gynecologists and FPs operate. 😛
 
It would be very easy for a Crna to do what you say she is doing, working in the OR, probably doing Asa 1-2 cases, while the Anesthesiologists triage all the tough cases to themselves. Then she goes up and works as a hospitalist in the icu, doing what, God alone knows, probably available for intubations and hypotension and running codes. That doesn't make her a doctor equivalent. We have hospitalist NPs and I'm telling you it's not a good thing. Here is an example.....


Last month there was an elderly obese lady showed up in our ER with an ankle fracture. She was seen by the ER PA and admitted to the hospitalist service. Seen by the hospitalist NP and referred to a podiatrist for ORIF of ankle fracture. Now this patient was scheduled for surgery on a Saturday morning by this podiatrist and the first real doctor to see this patient was my partner, an anesthesiologist in the preop holding area. Well, he takes her history and calls her cardiologist and somehow finds out that she has had multiple PEs in the past. The husband pulls out an old echo report from last year, from another hospital, with PA pressures in the 100 systolic range. The podiatrist says, I don't know anything about her heart, I just want to fix the fracture! This could just as easily have been a Crna doing her anesthetic. Prop sux tube and pop block, right! Anyone can do that! Thank GOD we had an MD who actually took a history and examined this lady. Might have saved her life by doing a fem-sciatic block and have the pod put a plate and some screws in. The same pod who wanted to put a thigh tourniquet on another patient who had multiple stents in her femoral and pop arteries for a ankle ORIF!

Medicine is being dumbed down in an effort to make it cheaper and the future ain't looking too good for us when we are going to be 75 and being "cared" for by nurse doctors and PAs.


Sent from my iPad using Tapatalk
 
Last year, the NRMP showed that Plastic Surgery and ENT were some of the hardest fields to enter. Only about three-fourths of 4th year US medical students successfully matched into those programs. The numbers were even more abysmal for other students, like foreign medical graduates. They were able to get into those spots less than half the time.

By contrast, the least competitive programs had match rates of nearly 100%. For 2014, the surprising wallflower was Diagnostic Radiology. It was nearly impossible for future radiologists to not get into a radiology training program last year. Even FMG's had almost a 75% likelihood of matching into radiology.

While predictably Pathology and Internal Medicine were shunned by many medical students, look who rounded out the top five in the most unwanted residencies--Anesthesiology. It was actually easier to match into anesthesia than, horrors!, Family Medicine. This was especially true for FMG's, who had about a 75% chance of getting into anesthesia compared to 50% for Family Medicine.

Of course this shouldn't come as a surprise to anybody who's been paying attention. Demand foranesthesiologists have been falling for some time now. The number of practicing anesthesiologists have increased at twice the rate of the general population growth for the last decade. Meanwhile the anesthesia residency program directors keep cranking out more new graduates every year. According to the NRMP, the number of PGY-1 spots in Anesthesiology has increased from 797 in 2010 to 1,049 last year.

The writing may be on the wall for the future of anesthesiologists. It is rapidly becoming a saturated medical specialty with too many providers scrambling for too few good jobs. Factor in the competition from non physicians, the anesthesia job market is on the verge of crashing under its own weight. Good luck to all the medical students on Match Day who want to go into Anesthesiology.

ZMD
 
Anesthesia Has Become A Zero Sum Game

Anesthesiologists are under siege. Compensation is being attacked by payers from the insurance industry and federal government. CRNA's are rapidly encroaching on the livelihood of anesthesiologists. Why do you think the American Society of Anesthesiologists is trying so hard to promote the term "physician anesthesiologist"? If there were plenty of anesthesia jobs around, we wouldn't care about the nurses scrapping for our throwaway cases. But there aren't an infinite amount of jobs available. It has become a zero sum game where somebody who has a job is keeping somebody else unemployed. It's eat or be eaten.

ZMD
 
Physician anesthesiologists can expect that fewer of us every year will continue to work in the model of personally providing anesthesia care to individual patients. Clinical practice is likely to skew even more toward the anesthesia care team model, already dominant in every part of the U.S. except the West Coast, with supervision of nurse anesthetists and anesthesiologist assistants.

http://www.kevinmd.com/blog/2015/03...esthesiologist-assistants-just-get-along.html
 
BladeMDA
So, what is the end result of all this? The doom and gloom seems to be for both sides. Colleges are graduating too many CRNAs per year. Their market will inevitably saturate. Anesthesiologists are getting their jobs taken away from CRNAs. So their livelihood is at stake. Which is it? Can there be a coexistence? From the many posts, it seems like anesthesiologists like working with CRNAs, but deep down inside they dislike them. Whatever the case and considering the future, what route would you recommend today to a pre-medical individual who likes anesthesia? CRNA or Anesthesiologist?
 
health123 said:
BladeMDA
So, what is the end result of all this? The doom and gloom seems to be for both sides. Colleges are graduating too many CRNAs per year. Their market will inevitably saturate. Anesthesiologists are getting their jobs taken away from CRNAs. So their livelihood is at stake. Which is it? Can there be a coexistence? From the many posts, it seems like anesthesiologists like working with CRNAs, but deep down inside they dislike them. Whatever the case and considering the future, what route would you recommend today to a pre-medical individual who likes anesthesia? CRNA or Anesthesiologist?
Click to expand...


Both sides end up as losers in this war: Anesthesiologists lose jobs, prestige and income while CRNAs face reduced wages, longer hours and mandatory call.

I will refrain from making any comments about your future career choice other than to say look closely at the specialties with the toughest MATCH as USA Med Students are bright young adults.
 
BLADEMDA said:
Both sides end up as losers in this war: Anesthesiologists lose jobs, prestige and income while CRNAs face reduced wages, longer hours and mandatory call.

I will refrain from making any comments about your future career choice other than to say look closely at the specialties with the toughest MATCH as USA Med Students are bright young adults.
Click to expand...


I agree overall. Looking at specialties with the toughest match and making a decision from that is hard to do. 10 years ago radiology was probably close to the bottom of that graph when in the 80s you couldnt pay people to go into radiology. 25 years ago ortho was close to the top and now its a tough match. Of course some of the others will probably continue to be the most competitive, unless of course the state of healthcare changes things in a way where the surgical subspecialties will take a dive. Who knows. At this point we'd all be better off just opening up our own farmers insurance branch, or getting that MBA.
 
IkeBoy18 said:
I agree overall. Looking at specialties with the toughest match and making a decision from that is hard to do. 10 years ago radiology was probably close to the bottom of that graph when in the 80s you couldnt pay people to go into radiology. 25 years ago ortho was close to the top and now its a tough match. Of course some of the others will probably continue to be the most competitive, unless of course the state of healthcare changes things in a way where the surgical subspecialties will take a dive. Who knows. At this point we'd all be better off just opening up our own farmers insurance branch, or getting that MBA.
Click to expand...

I graduated in 1992. Ortho was very difficult even then. So was derm, ent, plastics. Some things haven't changed. AOA. publications, etc.
 
bashwell said:
GomerBlog is a satirical website though! 🙂
Click to expand...


CHARLOTTE, NC – An Urgent Care clinic in Charlotte, NC is the talk of the industry after piloting a new program meant to lower costs and increase patient efficiency. A trained monkey, Giggles, was recently taught how to handle 95% of urgent care business by prescribing Z-Paks and learning how to send patients to the ER.


“TIme to pass out those Z-paks”
“Giggles is a smart monkey,” explained his handler, “he has a knack for knowing which patients need Z-Paks and which ones seem to be above the capability of our clinic to take care of them.”

The way it works is that Giggles will see a patient and walk around him or her a few times. He may touch the patient’s cheek or jump on the patient’s bed. After his specialized exam, Giggles will either grab a treat out of his handler’s left hand, signifying that the patient needs a Z-pak, or his right hand, signifying that the patient needs to go to the ED.

The clinic’s parent corporation, the German company Simians, is excited about the prospect of these clinics taking over the industry. “The cost savings is enormous,” explained CEO Herr Gerstman. “We typically pay a physician over $100/hr, but the monkey plus his handler costs us merely $20/hr. The savings can then be passed on to customers and us.”


Giggles’ girlfriend, Betsy, is also being trained to work registration and collect copays. She has a feisty streak, according to her handler.

“Betsy is great at collecting money but sometimes she can get real upset,” he explained. “Betsy has been known to fling her excrement at people when they don’t have insurance or if they don’t have cash or a credit card on them. Once we work out the kinks in her behavior, I think we will implement this idea at registration as well.”

During the transition to full monkey-based care, the clinic still employs PAs or NPs to handle the occasional patient with a Z-Pak allergy or for the times during the day when Giggles’ needs to relieve himself.
 
PITTSBURGH, PA – Dr. Harry Bonecutter, a prominent orthopedic surgeon at Pittsburgh Health, identified a strange noise emanating from a patient which he could not identify. The incident occurred in his office during a routine preoperative visit for a total knee replacement. Typically Dr. Bonecutter would forego using a stethoscope, but now patient satisfaction surveys asks patients, did the physician listen to the heart and lungs?



“I found my stethoscope under a pile of muscle magazines and big league chew. I hadn’t used it in years,” said Bonecutter. “When I placed the stethoscope somewhere near the patient’s heart, I heard a very strange sound. I immediately called in the Striker rep to help identify the sound since this was out of my field of expertise.”

The rep made a few suggestions that it could be heart sounds, and did help confirm that the patient had a regular heartbeat. Surprisingly, the reps are called in more frequently than you might have thought.


“Yeah, sometimes they call us in for food recommendations, or in the morning to pick out a tie, or if they need general advice on life,” said rep Jim Tysons.

“At first we just made recs for hardware during surgery, but then the orthopods started using us for anything.”
 
FFP said:
Is anesthesia as practiced by independent CRNAs (who do what we do) medicine? One cannot call the same thing different names just because it's done by two different kind of people.

If barbers still operated, it would be surgery, not "barbering". Heck, we call it surgery even when gynecologists and FPs operate. 😛
Click to expand...
Once Nurse Surgeons come about, we'll suddenly say they're practicing "nursing surgery," no doubt.
 
BLADEMDA said:
Physician anesthesiologists can expect that fewer of us every year will continue to work in the model of personally providing anesthesia care to individual patients. Clinical practice is likely to skew even more toward the anesthesia care team model, already dominant in every part of the U.S. except the West Coast, with supervision of nurse anesthetists and anesthesiologist assistants.

http://www.kevinmd.com/blog/2015/03...esthesiologist-assistants-just-get-along.html
Click to expand...


Can't agree with above--look at the midwest, Indiana, Wisconsin. These are very much primary provider states.
 
health123 said:
I understand the frustration all of you are expressing. But, we're in this system and we're in it together. I know a CRNA who originally was a Critical Care Nurse Practitioner who does OR (without anesthesiologist oversight) and comes back up to ICU and is the hospitalist there (no MD during her shift). She calls MDs only when she's not sure of something (which is rare), and this information I get from the MDs who trust her with all their patients. She's a huge asset to the hospital and this is a Metropolitan hospital in Los Angeles. I'm only saying this so you will know the extent of "mid-level" infiltration and dependence for that matter. As such, I think there should be a standard of expectation set for mid levels to practice in this manner.
Click to expand...
That's a dangerous hospital with slack MD's if they allow an NP to manage their ICU without oversight.

Although honestly, and I've said this numerous times, anesthesiologists who disappear from 3pm-7am on weekdays and 24/7 on the weekends as well as leaving all the OB to the CRNA's because they don't want to mess with it are part of the problem.
 
imfrankie said:
Can't agree with above--look at the midwest, Indiana, Wisconsin. These are very much primary provider states.
Click to expand...


For now they are. As long as the payer mix remains 50% or greater non CMS / Charity the all MD model works.

Here are things that can cause a big shift:

1. AMC takeover
2. Change in payer mix (more CMS and/or Charity)
3. Public Option (the all MD model would be over)
4. New CEO who does away with the subsidy (assuming this applies to you)
 
I'm in private practice and do my own cases. Gotta say... There's a lot of dumb doctors out there. There's even more dumb mid levels - but the one crna here is good.... I'd want her when the chips are down over one of my partners. I hate saying it but it's the truth. I'd like to thank my program for the smack down so I don't suck. I'm embarrassed some of these people call themselves Drs much less anesthesiologists- we have to train better people and not just push the dummies through residency. It's so bad im considering going back to teaching n academics n saying f the Benjamin's. It's on you guys.... All the academic anes here to get after your residents to be better.
 
BLADEMDA said:
Last year, the NRMP showed that Plastic Surgery and ENT were some of the hardest fields to enter. Only about three-fourths of 4th year US medical students successfully matched into those programs. The numbers were even more abysmal for other students, like foreign medical graduates. They were able to get into those spots less than half the time.

By contrast, the least competitive programs had match rates of nearly 100%. For 2014, the surprising wallflower was Diagnostic Radiology. It was nearly impossible for future radiologists to not get into a radiology training program last year. Even FMG's had almost a 75% likelihood of matching into radiology.

While predictably Pathology and Internal Medicine were shunned by many medical students, look who rounded out the top five in the most unwanted residencies--Anesthesiology. It was actually easier to match into anesthesia than, horrors!, Family Medicine. This was especially true for FMG's, who had about a 75% chance of getting into anesthesia compared to 50% for Family Medicine.

Of course this shouldn't come as a surprise to anybody who's been paying attention. Demand foranesthesiologists have been falling for some time now. The number of practicing anesthesiologists have increased at twice the rate of the general population growth for the last decade. Meanwhile the anesthesia residency program directors keep cranking out more new graduates every year. According to the NRMP, the number of PGY-1 spots in Anesthesiology has increased from 797 in 2010 to 1,049 last year.

The writing may be on the wall for the future of anesthesiologists. It is rapidly becoming a saturated medical specialty with too many providers scrambling for too few good jobs. Factor in the competition from non physicians, the anesthesia job market is on the verge of crashing under its own weight. Good luck to all the medical students on Match Day who want to go into Anesthesiology.

ZMD
Click to expand...
Blade you're an icon here and I fully defer to you in all things clinical and the realities of being out in practice, but your data analysis here doesn't hold up.

The amount of selection bias that goes in to IMG/FMG NRMP application (re: specialty) is tremendous, and we don't know denominators. Just because a higher percentage of "all others" matched anesthesia than FM doesn't tell us anything other than that -- a higher percentage of "all others" matches anesthesia than FM.
 
repititionition said:
Blade you're an icon here and I fully defer to you in all things clinical and the realities of being out in practice, but your data analysis here doesn't hold up.

The amount of selection bias that goes in to IMG/FMG NRMP application (re: specialty) is tremendous, and we don't know denominators. Just because a higher percentage of "all others" matched anesthesia than FM doesn't tell us anything other than that -- a higher percentage of "all others" matches anesthesia than FM.
Click to expand...


I borrowed the data from the great ZMD; please feel free to take it up with him.

http://www.blog.greatzs.com/2015/02/how-hard-is-it-to-match-into.html
 
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