New Hampshire Medical Board’s Prohibition of Medical Title Manipulation

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ProRealDoc

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November 20, 2019
American Society of Anesthesiologists Applauds New Hampshire Medical Board’s Prohibition of Medical Title Manipulation

CHICAGO – The American Society of Anesthesiologists (ASA) commends the New Hampshire Board of Medicine’s unanimous vote to prohibit the use of the term “anesthesiologist” unless licensed by the board of medicine.
This patient safety decision comes shortly after lawmakers in Florida prefiled legislation to similarly prohibit the manipulation of the title anesthesiologist, which confuses patients and the public. The New Hampshire Society of Anesthesiologists and the New Hampshire Medical Society worked diligently to protect the public from New Hampshire nurse anesthetists using misleading and manipulated medical titles.
“Patients deserve to know the medical education and licensure of the professional providing their care,” said ASA President Mary Dale Peterson, M.D., MSHCA, FACHE, FASA. “ASA adamantly opposes any effort to confuse or mislead patients through the manipulation of medical titles. We are pleased the New Hampshire Board of Medicine put patients ahead of the political maneuvering of some individuals.”
Earlier this year in New Hampshire, the Board of Nursing released a position statement authorizing use of the optional descriptors “nurse anesthesiologist” and “certified registered nurse anesthesiologist.” The board action occurred without any formal rules process or public comment period. Since that time, the New Hampshire Society of Anesthesiologists, New Hampshire Medical Society, ASA, and American Medical Association have strongly opposed the nursing board’s action and urged it to rescind its inappropriate position statement.
ASA congratulates the New Hampshire Board of Medicine on its efforts to protect patients and the public.
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ProRealDoc said:
November 20, 2019
American Society of Anesthesiologists Applauds New Hampshire Medical Board’s Prohibition of Medical Title Manipulation

CHICAGO – The American Society of Anesthesiologists (ASA) commends the New Hampshire Board of Medicine’s unanimous vote to prohibit the use of the term “anesthesiologist” unless licensed by the board of medicine.
This patient safety decision comes shortly after lawmakers in Florida prefiled legislation to similarly prohibit the manipulation of the title anesthesiologist, which confuses patients and the public. The New Hampshire Society of Anesthesiologists and the New Hampshire Medical Society worked diligently to protect the public from New Hampshire nurse anesthetists using misleading and manipulated medical titles.
“Patients deserve to know the medical education and licensure of the professional providing their care,” said ASA President Mary Dale Peterson, M.D., MSHCA, FACHE, FASA. “ASA adamantly opposes any effort to confuse or mislead patients through the manipulation of medical titles. We are pleased the New Hampshire Board of Medicine put patients ahead of the political maneuvering of some individuals.”
Earlier this year in New Hampshire, the Board of Nursing released a position statement authorizing use of the optional descriptors “nurse anesthesiologist” and “certified registered nurse anesthesiologist.” The board action occurred without any formal rules process or public comment period. Since that time, the New Hampshire Society of Anesthesiologists, New Hampshire Medical Society, ASA, and American Medical Association have strongly opposed the nursing board’s action and urged it to rescind its inappropriate position statement.
ASA congratulates the New Hampshire Board of Medicine on its efforts to protect patients and the public.
Click to expand...
In that state does the board of nursing have to obey the board of medicine?
 
sb247 said:
In that state does the board of nursing have to obey the board of medicine?
Click to expand...

that's what always ticked me off about NP's. Why, if they are providing patient care and decisions and mostly under supervision by MD/DO's are they governed by a different board? It's not like the board of nursing or NP's are prepared more than MD' to critique certain decisions or plans of care NP's make. That I think, is the one thing physicians should try to lobby to change to get the NP's under control.
 
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scoopdaboop said:
that's what always ticked me off about NP's. Why, if they are providing patient care and decisions and mostly under supervision by MD/DO's are they governed by a different board? It's not like the board of nursing or NP's are prepared more than MD' to critique certain decisions or plans of care NP's make. That I think, is the one thing physicians should try to lobby to change to get the NP's under control.
Click to expand...

Fought and lost more than once decades ago.

As a matter of fact, Advanced Practice Nursing is Medicine light.
As a matter of law they are separate entities with different governing bodies.



Sent from my iPhone using SDN mobile
 
sb247 said:
In that state does the board of nursing have to obey the board of medicine?
Click to expand...
In many OTHER countries. 😉

In the US, things got f-ed up when we accepted the euphemism of "advanced nursing practice" for playing doctor. There is no such thing as "advanced nursing PRACTICE"; there is either nursing (i.e. doing what the doctor says) or medicine (telling others what to do). The former should be regulated by the board of nursing, the latter by the board of medicine.

This country has been lost to political correctness and corporate financial interests.
 
Last edited by a moderator:
FFP said:
In many OTHER countries. 😉

In the US, things got f-ed up when we accepted the euphemism of "advanced nursing practice" for playing doctor. There is no such thing as "advanced nursing PRACTICE"; there is either nursing (i.e. doing what the doctor says) or medicine (telling others what to do). The former should be regulated by the board of nursing, the latter by the board of medicine.

This country has been lost to political correctness and corporate financial interests.
Click to expand...
And that's going to only get worse. I don't envy the young ones who are just starting their careers, but again if you start practicing in the current environment, this means you haven't see what medicine used to be, and you will likely accept this new reality.
We are no longer physicians, we are "providers", expensive, argumentative and elitist "providers".
 
FFP said:
In many OTHER countries. 😉

In the US, things got f-ed up when we accepted the euphemism of "advanced nursing practice" for playing doctor. There is no such thing as "advanced nursing PRACTICE"; there is either nursing (i.e. doing what the doctor says) or medicine (telling others what to do). The former should be regulated by the board of nursing, the latter by the board of medicine.

This country has been lost to political correctness and corporate financial interests.
Click to expand...
IOW, F.U.B.A.R.
which i like to tell the uninitiated who try to make sense of the whole thing..
And people want to give the government MORE control.
They cant even solve an easy what is nursing/what is medicine question/
 
Ronin786 said:
How about defining what nursing scope of practice is. They love to talk about practicing at the "top of their license" but keep it as vague as possible so that they can continue to encroach where they have no expertise.
Click to expand...

Who the **** wants to practice at the top of their license anyways. It is mumble jumbo sound bite that has no substance. When you dissect out the phrase, top never meant to describe their actual qualifications. Top of license means not experienced or qualified. If they were actually experienced and qualified it would be practicing at their license.
 
Ronin786 said:
How about defining what nursing scope of practice is. They love to talk about practicing at the "top of their license" but keep it as vague as possible so that they can continue to encroach where they have no expertise.
Click to expand...

I totally agree. I have always found the attempted rationale of nurses at the "top of their license" illogical.

When I take a look at my own medical license it says "Physician and Surgeon." Since I should be at the "top of my license," I guess I'm now a totally legit surgeon and should go remove that brain aneurysm...

Thank you to the NH medical board for some common sense.
 
The phrase "working at the top of your license" is completely idiotic.

and politicians repeat that over and over..

nurses are nurses and are subordinate and they should be charged with misconduct if they are insubordinate
 
ProRealDoc said:
November 20, 2019
American Society of Anesthesiologists Applauds New Hampshire Medical Board’s Prohibition of Medical Title Manipulation

CHICAGO – The American Society of Anesthesiologists (ASA) commends the New Hampshire Board of Medicine’s unanimous vote to prohibit the use of the term “anesthesiologist” unless licensed by the board of medicine.
This patient safety decision comes shortly after lawmakers in Florida prefiled legislation to similarly prohibit the manipulation of the title anesthesiologist, which confuses patients and the public. The New Hampshire Society of Anesthesiologists and the New Hampshire Medical Society worked diligently to protect the public from New Hampshire nurse anesthetists using misleading and manipulated medical titles.
“Patients deserve to know the medical education and licensure of the professional providing their care,” said ASA President Mary Dale Peterson, M.D., MSHCA, FACHE, FASA. “ASA adamantly opposes any effort to confuse or mislead patients through the manipulation of medical titles. We are pleased the New Hampshire Board of Medicine put patients ahead of the political maneuvering of some individuals.”
Earlier this year in New Hampshire, the Board of Nursing released a position statement authorizing use of the optional descriptors “nurse anesthesiologist” and “certified registered nurse anesthesiologist.” The board action occurred without any formal rules process or public comment period. Since that time, the New Hampshire Society of Anesthesiologists, New Hampshire Medical Society, ASA, and American Medical Association have strongly opposed the nursing board’s action and urged it to rescind its inappropriate position statement.
ASA congratulates the New Hampshire Board of Medicine on its efforts to protect patients and the public.
Click to expand...

 
Members don't see this ad :)
2Fast2Des said:
Uneffingbelievable, these clowns will go to any end to justify themselves. Why do we fall all over ourselves to work with CRNAs again??
Click to expand...

Arrogant, manipulative, radicalized nurses. AANA has been like this for years. It is all about stoking their egos. It is never about the patients.
 
2Fast2Des said:
Uneffingbelievable, these clowns will go to any end to justify themselves. Why do we fall all over ourselves to work with CRNAs again??
Click to expand...

ANESTHESIOLOGIST merely describes a nurse trained in providing anesthesia services.” (Id.) In rendering its decision, the USPTO did not suggest that the term “anesthesiologist” is reserved for physicians—and, in fact, it concurred that a “nurse anesthesiologist” is a specialized nurse that provides anesthesia services. (Id.)
 
2Fast2Des said:
Uneffingbelievable, these clowns will go to any end to justify themselves. Why do we fall all over ourselves to work with CRNAs again??
Click to expand...
Money, money, money. People will sit there and give you all kind of other reasons, but in the end, it’s all about Money.

That’s what runs this country.
 
chocomorsel said:
Money, money, money. People will sit there and give you all kind of other reasons, but in the end, it’s all about Money.

That’s what runs this country.
Click to expand...

Don’t you expect to be compensated for your skills and time at a level higher than a CRNA?
 
chocomorsel said:
Well yes. Yes I do. Are you saying that people who don’t work with CRNAs are making CRNA type of money?
Click to expand...

You decry that “everything is about money” also make some soft allusion to socialist beliefs, but you also expect to be compensated for your services commensurate with your investment in education. Sounds pretty capitalistic to me.
 
dr doze said:
You decry that “everything is about money” also make some soft allusion to socialist beliefs, but you also expect to be compensated for your services commensurate with your investment in education. Sounds pretty capitalistic to me.
Click to expand...

First of all, what? Socialism isn't the antithesis of capitalism. Plentyt of OECD countries are heavily socialist and they all value education.
 
dr doze said:
You decry that “everything is about money” also make some soft allusion to socialist beliefs, but you also expect to be compensated for your services commensurate with your investment in education. Sounds pretty capitalistic to me.
Click to expand...
I make enough money to not run around chasing CRNAs to make Even More money.

In this country, working with CRNAs is all about some damn money. No matter which way you try to rationalize it. Are anesthesiologists in Canada running after CRNAs?
Are they making pretty good money? Are they making CRNA money? Are they living in poverty?
 
Last edited:
While I disagree with the argument in general and thought the brief spent a ton of time merely talking about how great CRNAs are without addressing the issue, I do think they make a point about the term physician anesthesiologist.

They argue that the ASA realized that anesthesiologist was a generic term and so coined the term physician anesthesiologist (implying there are other kinds). I think this was a huge swing and a miss by the ASA, and while I wasn’t involved when the decision was made, I have to think they are in part responsible for this. No other field is out there saying “physician” before their specialty. Even radiology and pathology (where I would argue the public also doesn’t see them as doctors) don’t try to be physician radiologists or pathologists. Those are especially good comparisons because veterinary radiologists and pathologists exist like vet anesthesiologists, but again they don’t try to shoehorn physician into their specialty.

I would love to see the ASA drop this weird terminology, and instead focus on a campaign explaining that anesthesiologists are physicians.

“When seconds count, anesthesiologists saves lives,” sounds better to me than the current slogan.
 
chocomorsel said:
Money, money, money. People will sit there and give you all kind of other reasons, but in the end, it’s all about Money.

That’s what runs this country.
Click to expand...


Don't forget that many anesthesiologists who have been "supervising" CRNAs for decades on end probably couldn't deliver an anesthetic to safe their life, so they are reliant on CRNAs, though the MD is the supposed "expert"
 
Urzuz said:
Don't forget that many anesthesiologists who have been "supervising" CRNAs for decades on end probably couldn't deliver an anesthetic to safe their life, so they are reliant on CRNAs, though the MD is the supposed "expert"
Click to expand...

Those guys are clowns, and imo provide zero value because they are only there for medicolegal reasons only. There is no excuse that an anesthesiologist trains to become one and can't even do their own case, I mean Christ really, how can you be an anesthesiologist if you can't function without an anesthetist. Those guys need to retire and the ASA push health systems let those of us capable of delivering quality anesthetics ourselves reign.
 
Urzuz said:
Don't forget that many anesthesiologists who have been "supervising" CRNAs for decades on end probably couldn't deliver an anesthetic to safe their life, so they are reliant on CRNAs, though the MD is the supposed "expert"
Click to expand...

Yes - the super bad anesthesiologists are a combo of shamefully poor technically, and shamefully lazy (as noted by @Consigliere). They truly couldn't do a case to save their (or anyone's) life. Luckily most of these are dinosaurs and should be phased on soon enough - but many seem to linger on... This cohort I think was the impetus for our demise - lazy, shameless, and willing to exchange personal/professional integrity and good patient care for a buck or two. The quintessence of a sellout-itude.
 
kidthor said:
Yes - the super bad anesthesiologists are a combo of shamefully poor technically, and shamefully lazy (as noted by @Consigliere). They truly couldn't do a case to save their (or anyone's) life. Luckily most of these are dinosaurs and should be phased on soon enough - but many seem to linger on... This cohort I think was the impetus for our demise - lazy, shameless, and willing to exchange personal/professional integrity and good patient care for a buck or two. The quintessence of a sellout-itude.
Click to expand...

We will see what some you f@ckers are like after spending 20 years of only supervising.
 
dr doze said:
We will see what some you f@ckers are like after spending 20 years of only supervising.
Click to expand...
This is ridiculous. Step into an ACT model and you can actually see where the real complications of perioperative care are. I’ll give you a hint, it isn’t the operating room. I happen to personally provide anesthesia too and I can tell you I use my brain and skills much more while “supervising.” Some of my partners only supervise and they are top notch. Push comes to shove it’s a lot easier to sit on a stool IMO for 99% of surgeries, but I applaud others for however they wish to practice. I’ll also give you the same advice that other SDN members need to hear: quit bashing other physicians, it is getting you nowhere!
 
yossarian22 said:
This is ridiculous. Step into an ACT model and you can actually see where the real complications of perioperative care are. I’ll give you a hint, it isn’t the operating room. I happen to personally provide anesthesia too and I can tell you I use my brain and skills much more while “supervising.” Some of my partners only supervise and they are top notch. Push comes to shove it’s a lot easier to sit on a stool IMO for 99% of surgeries, but I applaud others for however they wish to practice. I’ll also give you the same advice that other SDN members need to hear: quit bashing other physicians, it is getting you nowhere!
Click to expand...
I do my own cases now but I personally found ACT much more difficult. When you have big ego, marginally competent CRNAs doing less than optimal anesthesia it really sucks. They don’t even know why they’re doing what they’re doing a lot of the time...too heavy handed with opioids...the list goes on. The headaches outside the OR that came along with them from the whining and entitlement is just icing on the cake.
I guess the anesthesiologists who no longer care and are just there to do the bare minimum would not find ACT more difficult, maybe I’m just too much of a control freak.
Who knows. That’s my take on it.
 
yossarian22 said:
This is ridiculous. Step into an ACT model and you can actually see where the real complications of perioperative care are. I’ll give you a hint, it isn’t the operating room. I happen to personally provide anesthesia too and I can tell you I use my brain and skills much more while “supervising.” Some of my partners only supervise and they are top notch. Push comes to shove it’s a lot easier to sit on a stool IMO for 99% of surgeries, but I applaud others for however they wish to practice. I’ll also give you the same advice that other SDN members need to hear: quit bashing other physicians, it is getting you nowhere!
Click to expand...

Man o War said:
I do my own cases now but I personally found ACT much more difficult. When you have big ego, marginally competent CRNAs doing less than optimal anesthesia it really sucks. They don’t even know why they’re doing what they’re doing a lot of the time...too heavy handed with opioids...the list goes on. The headaches outside the OR that came along with them from the whining and entitlement is just icing on the cake.
I guess the anesthesiologists who no longer care and are just there to do the bare minimum would not find ACT more difficult, maybe I’m just too much of a control freak.
Who knows. That’s my take on it.
Click to expand...

I posted this before, but I will post it again:

Supervising cases is more challenging for ALL THE WRONG REASONS. The anesthetic management isn’t more challenging, it’s that you have to worry about if your RN is appropriately fed and watered, if the patient isn’t coding next door and you haven’t gotten a phone call, biting your tongue when you know they chose a less-than-ideal anesthetic plan but you don’t want to hurt their feelings so you let them do it their way.

Yeah, if those elements are what make supervisory jobs more challenging, by means you all should pat yourselves on the backs for doing something that the average PP MD-only anesthesiologist can’t 👍
 
kidthor said:
Yes - the super bad anesthesiologists are a combo of shamefully poor technically, and shamefully lazy (as noted by @Consigliere). They truly couldn't do a case to save their (or anyone's) life. Luckily most of these are dinosaurs and should be phased on soon enough - but many seem to linger on... This cohort I think was the impetus for our demise - lazy, shameless, and willing to exchange personal/professional integrity and good patient care for a buck or two. The quintessence of a sellout-itude.
Click to expand...
To add to your point, those same "legacy docs" at the now-AMC's embody the very argument made by the militant CRNA's that docs are unnecessary. Most of this cohort slid into anesthesia during one of the periodic pullbacks in competitiveness and cashed out, knowing that they were as superfluous as tits on a bull. To add insult to injury, they honestly think they are somehow "slick", despite an inability to adopt new techniques LOL. Weak!
 
Urzuz said:
I posted this before, but I will post it again:

Supervising cases is more challenging for ALL THE WRONG REASONS. The anesthetic management isn’t more challenging, it’s that you have to worry about if your RN is appropriately fed and watered, if the patient isn’t coding next door and you haven’t gotten a phone call, biting your tongue when you know they chose a less-than-ideal anesthetic plan but you don’t want to hurt their feelings so you let them do it their way.

Yeah, if those elements are what make supervisory jobs more challenging, by means you all should pat yourselves on the backs for doing something that the average PP MD-only anesthesiologist can’t 👍
Click to expand...

You also have some folks who claim supervision is much more difficult cause they're running around doing so many more pre-ops, blocks, neuraxial, a-lines, central lines etc... It's great that the MD is doing all the procedures in these practices, but I can guarantee you that in these kind of practices that the nurses are not having their intraop records watched that closely or getting the kind of supervision of the vitals and med administration that I would like if it was me under the knife.
 
Man o War said:
I do my own cases now but I personally found ACT much more difficult. When you have big ego, marginally competent CRNAs doing less than optimal anesthesia it really sucks. They don’t even know why they’re doing what they’re doing a lot of the time...too heavy handed with opioids...the list goes on. The headaches outside the OR that came along with them from the whining and entitlement is just icing on the cake.
I guess the anesthesiologists who no longer care and are just there to do the bare minimum would not find ACT more difficult, maybe I’m just too much of a control freak.
Who knows. That’s my take on it.
Click to expand...
I’ve said it before and I’ll say it again. In the ACT model your main function is to exist for medicolegal reasons and as a liability sponge. You can be as involved as you want or just sign the chart so long as you are not signing more than 4:1 (in a direction model) you are good to go. Those of you who sweat the small stuff (CRNA gave too much opioid etc.) end up miserable. If the patient is alive and intact at the end of the case it goes in the win column....
 
dannyboy1 said:
I’ve said it before and I’ll say it again. In the ACT model your main function is to exist for medicolegal reasons and as a liability sponge. You can be as involved as you want or just sign the chart so long as you are not signing more than 4:1 (in a direction model) you are good to go. Those of you who sweat the small stuff (CRNA gave too much opioid etc.) end up miserable. If the patient is alive and intact at the end of the case it goes in the win column....
Click to expand...
It’s small stuff until you have to explain to the surgeon father who knows better why his healthy son undergoing a routine ortho procedure is taking forever to wake up because the idiot CRNA gave him multiples more intraop meds than I would’ve ever dreamed of sitting the stool myself.
Don’t miss that life at all.
 
Man o War said:
It’s small stuff until you have to explain to the surgeon father who knows better why his healthy son undergoing a routine ortho procedure is taking forever to wake up because the idiot CRNA gave him multiples more intraop meds than I would’ve ever dreamed of sitting the stool myself.
Don’t miss that life at all.
Click to expand...
This is easily solved by having control over your CRNAs, and by that I mean you can fire/discipline them on the spot. I feel sorry for those of you who don’t work in a practice like this (AMCs).
 
yossarian22 said:
This is easily solved by having control over your CRNAs, and by that I mean you can fire/discipline them on the spot. I feel sorry for those of you who don’t work in a practice like this (AMCs).
Click to expand...
Agreed, and one of the main reasons I left that practice (which was private but towards the end too many older partners who just didn’t want to deal with it and coast to retirement). I started seeing much more variability and clinically weaker CRNAs about 15- 20 years ago. They were much more predictable before that, skills wise. They also in general had less ego which is interesting because they were much better than the newer/younger ones I worked with.
 
Man o War said:
Agreed, and one of the main reasons I left that practice (which was private but towards the end too many older partners who just didn’t want to deal with it and coast to retirement). I started seeing much more variability and clinically weaker CRNAs about 15- 20 years ago. They were much more predictable before that, skills wise. They also in general had less ego which is interesting because they were much better than the newer/younger ones I worked with.
Click to expand...
Man o War said:
It’s small stuff until you have to explain to the surgeon father who knows better why his healthy son undergoing a routine ortho procedure is taking forever to wake up because the idiot CRNA gave him multiples more intraop meds than I would’ve ever dreamed of sitting the stool myself.
Don’t miss that life at all.
Click to expand...
Still small stuff. Uncomfortable, yes, but in the end amounts to not much. I’ve lost count of how many patients told me that “I take really long to wake up”. Don’t think I’ve seen a single lawsuit come of it.
 


oral arguments in this case.


 
Last edited by a moderator:
dr doze said:


oral arguments in this case.


Click to expand...

Holy moly the ignorance of these judges, the physician neurologist/nurse neurologist guy... does he even have any idea what is going on?? The other judge thinking physician is MD or OD? I mean christ, the law has no idea what medicine is or entails. I can see how AANA is able to push so hard and successfully because they can convince those in power/politics who clearly are lacking any sense. What was the ruling in this case again?
 
2Fast2Des said:
Holy moly the ignorance of these judges, the physician neurologist/nurse neurologist guy... does he even have any idea what is going on?? The other judge thinking physician is MD or OD? I mean christ, the law has no idea what medicine is or entails. I can see how AANA is able to push so hard and successfully because they can convince those in power/politics who clearly are lacking any sense. What was the ruling in this case again?
Click to expand...
It’s absurd, seems clear cut that the bird of medicine can restrict the term.

how would they feel if their paralegals called themselves paralegal lawyers, how is that not confusing to the public?
 
dipriMAN said:
It’s absurd, seems clear cut that the bird of medicine can restrict the term.

how would they feel if their paralegals called themselves paralegal lawyers, how is that not confusing to the public?
Click to expand...

The defense should have used the paralegal lawyer\judge as a comparison. Or mentioned janitor\judge since they are clearly not even caring
 
dr doze said:
We won this one.

www.asahq.org

ASA Applauds New Hampshire Supreme Court's Decision to Ban Nurses' Use of Physician Term, Anesthesiologist

The American Society of Anesthesiologists (ASA) today applauds the New Hampshire Supreme Court for upholding the New Hampshire Medical Board’s decision that health care professionals using the term “anesthesiologist” must be licensed physicians and meet all of the requirements to practice...
www.asahq.org www.asahq.org
Click to expand...
All states should do the same...
 
The bad news is that the justices voted 2-2. The decision went to us because the Appellate Court ruling was in our favor.

www.unionleader.com

Doctors win title fight, but judges' cards not announced

CONCORD — New Hampshire doctors have won a battle with nurses who want to be called anesthesiologists, in an anonymous decision by the state Supreme Court.
www.unionleader.com www.unionleader.com
 
dr doze said:
We won this one.

www.asahq.org

ASA Applauds New Hampshire Supreme Court's Decision to Ban Nurses' Use of Physician Term, Anesthesiologist

The American Society of Anesthesiologists (ASA) today applauds the New Hampshire Supreme Court for upholding the New Hampshire Medical Board’s decision that health care professionals using the term “anesthesiologist” must be licensed physicians and meet all of the requirements to practice...
www.asahq.org www.asahq.org
Click to expand...

Is it a win when you're fighting something that should be a given?
 
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