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I hear few pharmacists that are PharmD refering to themselves as doctor in the clinical setting.
Also your optomology vs. trist comparison is skewed. I live in a city of 4 million with hundreds of optomologists and huge eye centers and still have to wait months to get a freaking routine eye exam by one. These guys are busy as hell and their is no freaking way their is enough of them to go around to fill the hundreds of thoussands of pts that optometrists see every year. Its an availability and a convienence issue. These guys can perform vision tests and fit my with contacts just fine. I have had one consult the ologist for a more serious eye issue I had and respected that.
Lets just face it there are able midlevels out their that can do many of the things a some MD's can do. Why? Because there are needs and they are safe. I dont want a optometrist operating on my eye but they can check my vision. No I dont want the CRNA putting me to sleep for my BIVAD insertion if they have little training doing so. I will go to the ologist that does VAD cases weekly.
CRNA's are in no way, shape or form driving down anesthesiologists salaries. In fact we are increasing them and have done so all along by increasing providers enabling larger contracts, more coverage, more cases, less time in the OR, more group productivity ect.
And again guys independence is not the issue here so please get it right. CRNA's can practice independent of an anesthesiologist in all states. The issue is medicare requirements saying CRNA practice must be overseen by a MD, DO ect. It does not have to be anesthesia, can be surery, chief of staff, someone not even in the OR ever that may review cases.
And you are wrong stating that the rural provider availabilty reasoning for a state opting out is a guise. Most urban areas are dominated by the anesthesia care team where both providers work as a team.
Really there are few CRNA's out there in urban areas working in these opted out states alone as independent contractors or as CRNA only anesthesia groups competing with MD groups. Now of course there is a ton of locum CRNA's working in cities but again thats all about supply and demand.
Yeah I cant wait for these studies to come out. Hopefully they are done by a non biased body. Thats all we need is another wasteful and totaly skewed study making claims about the other that can be countered by a study funded by the other.
And again it is hillarious how CRNA safety here is knocked yet in the same post AA's are promoted. Yes mister Senator limit the CRNA's practice b/c they have been around for 100 yrs and provide the majority of the anesthesia to the armed forces and because all of a sudden they are unsafe after 100yrs of no unsafe issues ever comming to the forefront. But at the same time increase AA providers which are better qualified than CRNA's b/c they took calc, physics and bio chem when they were 20 years old in undergrad and b/c they have only 4 education programs (got that # from AAAA), and b/c they can sit the AA qualifiying exam 6 months before they even graduate (tough test?), and because they are more cordial and b/c they will get down on their knees and open their mouths when ever we ask and b/c many have no back ground in hlth care what so ever. yet we will bill for our AA's the same that we would bill for CRNA's so it really wont save you any money, but will make us feel way more secure. Sounds like a weak lobbying agenda to me. Wheres the public benefit? Where the valid data prooving the allegations? Where are the AA's that are gonna replace the 30,000 CRNA's
lets all agree on one thing here. Face it, this is a control issue not a safety issue. One group wants to control the market and manipulate it as they please. In business we would call that a monopoloy. Listen anesthesiologists are essential and are greatly needed. CRNA's have alot to contribute as well and have been doing so without any reports of the majority of the profession being unsafe. Where are all the pt injuries are deaths if CRNA's are so unsafe. Seems like these statistics would be way higher if these allegations were true being that CRNA's are involved in a mojority of the care here. Lets see some real date to back these claims up.
And to who ever brought up the CRNA passing on hepatitis to pts by using the same syringe he was a dumba$$ and the lowest of the low in our profession and has recieved well deserved professional and judicial disciplinary consquences. Please dont turn this into a war of bringing up one of 2 individual cases of provider negligence. What about the thoussands of unethical cripiling ortho cases performed per year? These back and forth examples are pointless and get nothing done as one or 2 individuals is not at all representative of the either group as a whole.
Also your optomology vs. trist comparison is skewed. I live in a city of 4 million with hundreds of optomologists and huge eye centers and still have to wait months to get a freaking routine eye exam by one. These guys are busy as hell and their is no freaking way their is enough of them to go around to fill the hundreds of thoussands of pts that optometrists see every year. Its an availability and a convienence issue. These guys can perform vision tests and fit my with contacts just fine. I have had one consult the ologist for a more serious eye issue I had and respected that.
Lets just face it there are able midlevels out their that can do many of the things a some MD's can do. Why? Because there are needs and they are safe. I dont want a optometrist operating on my eye but they can check my vision. No I dont want the CRNA putting me to sleep for my BIVAD insertion if they have little training doing so. I will go to the ologist that does VAD cases weekly.
CRNA's are in no way, shape or form driving down anesthesiologists salaries. In fact we are increasing them and have done so all along by increasing providers enabling larger contracts, more coverage, more cases, less time in the OR, more group productivity ect.
And again guys independence is not the issue here so please get it right. CRNA's can practice independent of an anesthesiologist in all states. The issue is medicare requirements saying CRNA practice must be overseen by a MD, DO ect. It does not have to be anesthesia, can be surery, chief of staff, someone not even in the OR ever that may review cases.
And you are wrong stating that the rural provider availabilty reasoning for a state opting out is a guise. Most urban areas are dominated by the anesthesia care team where both providers work as a team.
Really there are few CRNA's out there in urban areas working in these opted out states alone as independent contractors or as CRNA only anesthesia groups competing with MD groups. Now of course there is a ton of locum CRNA's working in cities but again thats all about supply and demand.
Yeah I cant wait for these studies to come out. Hopefully they are done by a non biased body. Thats all we need is another wasteful and totaly skewed study making claims about the other that can be countered by a study funded by the other.
And again it is hillarious how CRNA safety here is knocked yet in the same post AA's are promoted. Yes mister Senator limit the CRNA's practice b/c they have been around for 100 yrs and provide the majority of the anesthesia to the armed forces and because all of a sudden they are unsafe after 100yrs of no unsafe issues ever comming to the forefront. But at the same time increase AA providers which are better qualified than CRNA's b/c they took calc, physics and bio chem when they were 20 years old in undergrad and b/c they have only 4 education programs (got that # from AAAA), and b/c they can sit the AA qualifiying exam 6 months before they even graduate (tough test?), and because they are more cordial and b/c they will get down on their knees and open their mouths when ever we ask and b/c many have no back ground in hlth care what so ever. yet we will bill for our AA's the same that we would bill for CRNA's so it really wont save you any money, but will make us feel way more secure. Sounds like a weak lobbying agenda to me. Wheres the public benefit? Where the valid data prooving the allegations? Where are the AA's that are gonna replace the 30,000 CRNA's
lets all agree on one thing here. Face it, this is a control issue not a safety issue. One group wants to control the market and manipulate it as they please. In business we would call that a monopoloy. Listen anesthesiologists are essential and are greatly needed. CRNA's have alot to contribute as well and have been doing so without any reports of the majority of the profession being unsafe. Where are all the pt injuries are deaths if CRNA's are so unsafe. Seems like these statistics would be way higher if these allegations were true being that CRNA's are involved in a mojority of the care here. Lets see some real date to back these claims up.
And to who ever brought up the CRNA passing on hepatitis to pts by using the same syringe he was a dumba$$ and the lowest of the low in our profession and has recieved well deserved professional and judicial disciplinary consquences. Please dont turn this into a war of bringing up one of 2 individual cases of provider negligence. What about the thoussands of unethical cripiling ortho cases performed per year? These back and forth examples are pointless and get nothing done as one or 2 individuals is not at all representative of the either group as a whole.
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It's the people's champ, I'm something like a ballersleepwithme said:
The candy paint dripping off of the old school Impala
I'm with that Big Bank Hank, that Poppi Joe and Box
Trunk bump like chicken pox, turn the bass up just a notch
You see them blades choppin', you see that trunk poppin'
Ho's that diss me in the club, the same ho's in the parking lot boppin'
They see me in the Jag, acting bad with T Ferris
Open mouth and showcase ice, and you gon' see about 20 karats
I'm what they do, you on 5-9 double O
In the Tahoe on 24's, I'm the truth, I got that glow
I'm out that Swisha House with Archie Lee and Couda Bang
Sittin' sideways on swang, the candy paint dripping off the frame
You see me acting bad, I'm showing out and pulling stunts
Say cheese and show my fronts, it's more carrots/karats than Bugs Bunny's lunch
It's Paul Wall baby, I got it made
I got a cup full of that oil, and I'm paid plus I'm sittin' sideways
Quote by nitecap:
"Lets just face it there are able midlevels out their that can do many of the things a some MD's can do. Why? Because there are needs and they are safe. I dont want a optometrist operating on my eye but they can check my vision."
Oh really? Why not? If you live in Oklahoma you have the luxury of being misled and having an optometrist perform surgery on your eye. After all, they can do many of the things those with formal surgical training can do.
Quote by nitecap:
"And you are wrong stating that the rural provider availabilty reasoning for a state opting out is a guise. Most urban areas are dominated by the anesthesia care team where both providers work as a team.
Really there are few CRNA's out there in urban areas working in these opted out states alone as independent contractors or as CRNA only anesthesia groups competing with MD groups. Now of course there is a ton of locum CRNA's working in cities but again thats all about supply and demand."
Sorry dude, you misunderstood my post. It is obvious to me and many that most CRNAs work in urban areas and under the team model. The reason they have had a strong push for opting out is secondary to underserved rural areas that cannot attract anesthesiologists. States have agreed to these changes for the hopes of increasing services to those in BFE with needs for providers. Unfortunately, as I feel the current studies will show, most CRNAs are practicing in urban areas.
Quote by nitecap:
"lets all agree on one thing here. Face it, this is a control issue not a safety issue. One group wants to control the market and manipulate it as they please. In business we would call that a monopoloy."
Yes, it is a control issue. A control for quality of care. Since the government is currently saying we as physicians can control the market then we should have complete and final say in the standard of care of patients. That is my point.
Quote by nitecap:
"What about the thoussands of unethical cripiling ortho cases performed per year?"
WTF are you talking about? I provide a real world case of a severe F(*& up by one of your associates, who by the way has no "real responsibility" other than having to live with themselves, and you bring up some unrelated crap.
I'm not saying CRNAs are useless *******es. Never have, never will. Bad things happen in medicine which is why we are held responsible despite risks and consents. These are the reasons CRNAs and others should always answer to us. If you don't like the sound of that and you want responsibility then go to med school.
One last thing. I don't and won't argue that we need to change out CRNAs for AAs. Especially if the argument is the one nitecap brought forth. In my opinion it just adds more of the same.
PS- nitecap I realize that you'll probably feel like I'm attacking you, but I'm not. I understand your agenda, as I'm sure you understand mine. I am sure if we met in person we'd get along fine and probably have a beer. I'm just using this as an open forum to discuss for all, and you often provide information that others can find useful.
As far as getting together studies, the AMA sends out a newsletter to physicians weekly/biweekly. In one of the recent ones there was a front page article addressing the issue of scope of practice with key legislation occurring this year in certain states. In the newsletter they discussed the studies that are underway assessing distributions of paraprofessionals, etc.
"Lets just face it there are able midlevels out their that can do many of the things a some MD's can do. Why? Because there are needs and they are safe. I dont want a optometrist operating on my eye but they can check my vision."
Oh really? Why not? If you live in Oklahoma you have the luxury of being misled and having an optometrist perform surgery on your eye. After all, they can do many of the things those with formal surgical training can do.
Quote by nitecap:
"And you are wrong stating that the rural provider availabilty reasoning for a state opting out is a guise. Most urban areas are dominated by the anesthesia care team where both providers work as a team.
Really there are few CRNA's out there in urban areas working in these opted out states alone as independent contractors or as CRNA only anesthesia groups competing with MD groups. Now of course there is a ton of locum CRNA's working in cities but again thats all about supply and demand."
Sorry dude, you misunderstood my post. It is obvious to me and many that most CRNAs work in urban areas and under the team model. The reason they have had a strong push for opting out is secondary to underserved rural areas that cannot attract anesthesiologists. States have agreed to these changes for the hopes of increasing services to those in BFE with needs for providers. Unfortunately, as I feel the current studies will show, most CRNAs are practicing in urban areas.
Quote by nitecap:
"lets all agree on one thing here. Face it, this is a control issue not a safety issue. One group wants to control the market and manipulate it as they please. In business we would call that a monopoloy."
Yes, it is a control issue. A control for quality of care. Since the government is currently saying we as physicians can control the market then we should have complete and final say in the standard of care of patients. That is my point.
Quote by nitecap:
"What about the thoussands of unethical cripiling ortho cases performed per year?"
WTF are you talking about? I provide a real world case of a severe F(*& up by one of your associates, who by the way has no "real responsibility" other than having to live with themselves, and you bring up some unrelated crap.
I'm not saying CRNAs are useless *******es. Never have, never will. Bad things happen in medicine which is why we are held responsible despite risks and consents. These are the reasons CRNAs and others should always answer to us. If you don't like the sound of that and you want responsibility then go to med school.
One last thing. I don't and won't argue that we need to change out CRNAs for AAs. Especially if the argument is the one nitecap brought forth. In my opinion it just adds more of the same.
PS- nitecap I realize that you'll probably feel like I'm attacking you, but I'm not. I understand your agenda, as I'm sure you understand mine. I am sure if we met in person we'd get along fine and probably have a beer. I'm just using this as an open forum to discuss for all, and you often provide information that others can find useful.
As far as getting together studies, the AMA sends out a newsletter to physicians weekly/biweekly. In one of the recent ones there was a front page article addressing the issue of scope of practice with key legislation occurring this year in certain states. In the newsletter they discussed the studies that are underway assessing distributions of paraprofessionals, etc.
ReefTiger said:
Dont worry not taking your post as an attack. I welcome an intelligent but mature response to anything I say. Any above the belt blows I can take.
Quote reeftiger:
Since the government is currently saying we as physicians can control the market then we should have complete and final say in the standard of care of patients
Since when is the government saying MD's can control the markey. Sorry havent seen this statement in any recent statutes or legislation.
That point is niave man, and the reason you guys have lost political ground.
Quote reeftiger:
Bad things happen in medicine which is why we are held responsible despite risks and consents.
Yes bad things can happen, thank you for aknowledging that. So how is answering to a MD gonna prevent these bad things that just happen despite risks and consents.
Quote reeftiger:
the AMA sends out a newsletter to physicians weekly/biweekly. In one of the recent ones there was a front page article addressing the issue of scope of practice with key legislation occurring this year in certain states. In the newsletter they discussed the studies that are underway assessing distributions of paraprofessionals, etc
Sorry man if the AMA is doing the study then it is biased from the get go. Of course most CRNA's work in urban areas where jobs are more plentiful and living more desirable to many. You are wrong about CRNA's not taking advantage of the opt out rules in those states and holding rural jobs. Many of these CRNA's already worked in podunct no where anyway, the opting out just makes it easier for both the hospital, CRNA and surgeon their since they dont have to claim oversite of the practice. But again in these opted out states you will find few if any CRNA groups taking jobs from and directly competing with MD groups in urban areas. Now rural may be a different story but urban is not the case. Check out gaswork yourself. The majority of positions in urban areas are either locums agencies or MD/CRNA ACT groups. IN more rural positions you will find locums, and independent contactor CRNA positions mostly. Again in my eyes since the study is conducted by the AMA it is already biased off the blocks and will be most likely easy for the AANA or ANA or AAPA to counter the claims with their own studies leading to even more wasted research money.
Quote reeftiger:
Yes, it is a control issue. A control for quality of care
What is the quality of anesthesia care presently poor or something? Really if you read the AANA standards of care it nearly resembels the standards of care set forth by the ASA when speaking of therapys or functions similar to both professions. These standards are used in court cases ect and hold high standards to CRNA's.
Here you go man. MD's screw up similarly. Guess this MD needed another MD to have control over him or "answere to us(MD)".
In December 2001, NYCDOH was informed of two elderly patients (aged >75 years) who had acute HBV infection diagnosed and who had visited the office of the same physician (physician A) during their incubation periods. A preliminary investigation by NYCDOH identified 19 additional cases of acute HBV infection.
On the basis of these results, NYCDOH offered testing for HBV, HCV, and HIV infection to 1,042 patients[B] of physician A; 38 patients, including the 19 previously identified, had acute HBV infection during February 2000[/B]--February 2002. HBV DNA genetic sequences of 24 patients with acute infection and four patients with chronic infection were identical in the 1,500--base-pair region examined. No evidence of HCV or HIV transmission was observed.
A retrospective cohort study was conducted among the 275 patients attending physician A's office during the 10 months preceding outbreak detection. Of 91 patients with serologic results and available medical records that were included in the cohort study, 18 were infected. Among 67 patients who received at least one injection, 18 (27%) had acute HBV infection, compared with none who received no injections (relative risk [RR] = 13.6; 95% confidence interval [CI] = 2.4--undefined). Patients with HBV infection received a median of 14 injections (range: 2--25), compared with susceptible patients, who received a median of two injections (range: 0--17) (p<0.001). Typically, injections included doses of atropine, dexamethasone, and vitamin B12 drawn from multiple-dose vials into one syringe. The same workspace was used to prepare, dismantle, and dispose of injection equipment.
In December 2001, NYCDOH ordered physician A to stop administering injections. In April 2002, physician A retired and closed his office permanently. In response to this outbreak and the outbreak described above, NYCDOH sent a letter (available at http://home.nyc.gov/html/doh/pdf/chi/ltr22002.pdf) to all city clinicians outlining the need for all staff to adhere to infection-control and bloodborne pathogen precautions, including single use of needles and syringes and appropriate use of multiple-dose vials to prevent cross contamination.
sleepwithme said:
I wasn't rapping. Ever heard of a movie called "Shaft"?
bullard said:
yeah, well, fellow crakka, the crakka-lyrics-section of this thread blows away the other B.S. Sorry. Not in a debating mood.
Actually, right here right now, would go as far as offerin' Nitecap/Mysterioso/Justin/Bullard/etc one of these iced-up Corona's I'm drinkin', since bull****t in' with homies is always more fun than turf/ego wars.
I prefer Murphy's.
Anesthesiologists as providers are actually more cost efffective to society :
Influence of the type of anesthesia provider on costs of labor analgesia to the Texas Medicaid program.
Abouleish AE, Prough DS, Vadhera RB.
Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555-0591, USA. [email protected]
BACKGROUND: The Texas Medicaid Program (Medicaid) defines billable time for labor analgesia as face-to-face time; therefore, anesthesia providers determine billed time. The authors' goal was to determine the influence of anesthesia providers on labor analgesia costs billed to Medicaid. METHODS: Under the Freedom of Information Act, Medicaid provided data on claims paid for 6 months in 2001 for labor analgesia administered during the course of a vaginal delivery. Claims were either time based (codes 00946 or 00955) or a flat fee (codes 26311 or 26319). Using modifiers, the authors grouped time-based claims as either anesthesiologist group or certified registered nurse anesthetist (CRNA) group. The cost to Medicaid was based on the 2001 fee schedule. The conversion factor was 18.21 USD per American Society of Anesthesiologists unit. The flat-fee reimbursement was 152.50 USD. CRNA services were paid at 85% of the fee schedule. Average time per time claim, percent of providers with more than 4 h of billed time, and cost per claim were determined for each group. Providers with more than 120 claims (> 20 claims/month) were considered high-volume. RESULTS: The database included 21,378 claims (anesthesiologist group: 12,698 claims from 219 providers; CRNA group: 8,680 claims from 117 providers). For time-based claims, the average time per case was significantly higher in the CRNA group (146 min) than in the anesthesiologist group (105 min). The CRNA group cost to Medicaid (225.11 USD) was 19% more per claim than the anesthesiologist group (189.26 USD). The difference in cost per claim was greater among high-volume providers--213.10 USD for the CRNA group versus 168.76 USD for the anesthesiologist group. If a flat-fee program were instituted using the average cost per claim for all groups (203.81 USD), the Texas Medicaid program would save more than 500,000 USD annually. CONCLUSIONS: The costs of labor analgesia billed to Texas Medicaid were 19% to 26% less per patient when provided by anesthesiologists than by CRNAs, despite lower per-unit reimbursement of CRNAs.
Influence of the type of anesthesia provider on costs of labor analgesia to the Texas Medicaid program.
Abouleish AE, Prough DS, Vadhera RB.
Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555-0591, USA. [email protected]
BACKGROUND: The Texas Medicaid Program (Medicaid) defines billable time for labor analgesia as face-to-face time; therefore, anesthesia providers determine billed time. The authors' goal was to determine the influence of anesthesia providers on labor analgesia costs billed to Medicaid. METHODS: Under the Freedom of Information Act, Medicaid provided data on claims paid for 6 months in 2001 for labor analgesia administered during the course of a vaginal delivery. Claims were either time based (codes 00946 or 00955) or a flat fee (codes 26311 or 26319). Using modifiers, the authors grouped time-based claims as either anesthesiologist group or certified registered nurse anesthetist (CRNA) group. The cost to Medicaid was based on the 2001 fee schedule. The conversion factor was 18.21 USD per American Society of Anesthesiologists unit. The flat-fee reimbursement was 152.50 USD. CRNA services were paid at 85% of the fee schedule. Average time per time claim, percent of providers with more than 4 h of billed time, and cost per claim were determined for each group. Providers with more than 120 claims (> 20 claims/month) were considered high-volume. RESULTS: The database included 21,378 claims (anesthesiologist group: 12,698 claims from 219 providers; CRNA group: 8,680 claims from 117 providers). For time-based claims, the average time per case was significantly higher in the CRNA group (146 min) than in the anesthesiologist group (105 min). The CRNA group cost to Medicaid (225.11 USD) was 19% more per claim than the anesthesiologist group (189.26 USD). The difference in cost per claim was greater among high-volume providers--213.10 USD for the CRNA group versus 168.76 USD for the anesthesiologist group. If a flat-fee program were instituted using the average cost per claim for all groups (203.81 USD), the Texas Medicaid program would save more than 500,000 USD annually. CONCLUSIONS: The costs of labor analgesia billed to Texas Medicaid were 19% to 26% less per patient when provided by anesthesiologists than by CRNAs, despite lower per-unit reimbursement of CRNAs.
ThinkFast007 said:
Yes I have seen the study and many questions have been raised about researcher bias in interpreting data as well as in the samples being off as far as the numbers not being even close to equal. There are claims the researchers left data out in the CRNA group selectively including longer times while leaving out shorter times.
As well when other groups reviewed the data they claimed that CRNA charting was much more extensive and had MD documentation been more extensive times would be longer.
I mean look where the study comes from, UTMB Dept of Anesthesiology. Of course the study is going be negative toward CRNA's. If not the study would be useless. Until a neutral group does a study with no outside monetary support or reward from either side then these studies are useless and easily refuted.
The whole issue is them wanting a fixed fee for spinals and epidurals and though both TANA and TSA are taking shots at each other both agreed from what I have heard to not fix the fee.
nitecap said:
Yes, it's actually from a reputable department....furthemore it's a study published in "Anesthesiology". True, there can be bias, but couldnt that be said about ANY study. So for every CRNA study which you come forward with I could do what you did and just say "there's bias".
I dont believe that " Anesthesiology" would publish just things they thought were fabricated. Of course, CRNAs will try to refute the study seeing as though, it makes them look inefficient and costly to society. But hey, that's what the DATA shows.
Nothing personal, but I think the general public and the academic world in general would be more akin to study from a MD program in an MD journal.
Yet again, nice try at refuting a point...but some of us simply arent buying into your ideology.
ThinkFast007 said:
First of all anesthesiology isnt the most reputable journal. Its is full of opinionated stances and you have to pick and choose the validity of many articles. anyone with any basic research knowledge should be able to pick this out.
And yes with any study conducted by the AANA you have the same basis as I to refute it. I feel the general public and the academic world will be able to take the study for what it is. A biased attempt to negatively impact the practice of CRNA's. I guess a pay back for the TSA fairing so poorly in this past years legislative session.
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Just post your questions in a new thread and pray the discussion doesn't go to sh it like it did here.
Soon2BENT said:
The earlier you start the more options you will find. I started around the late spring before my CA-3 year. You should go through your school's alumni foundation to find out if there are any ex grads practicing in the area you desire to practice in. Fellowship is necessary if you want to do comprehensive pain. Many places allow non-fellowship trained anesthesiologists to see pedi patients. Cardiac fellowship is useful if you are relatively inexperienced with it and may have to work a cardiac case, but not necessary to find a good job.
Start making contacts ASAP if you want to practice in an especially competitive area of the country. Call the local hospitals to find out what groups are practicing there, use the alumni connections, and look at the on line advertisements and in publications and society specific websites (SCA, etc.)
Don't jump on the first job offer you get unless you are 100% sure it is the perfect situation for you. Many groups do not make the decision to hire until the spring and the patient people that don't jump on the first offer are able to pick up offers from groups offering some aspect closer to the ideal situation for the applicant.
