Shows
On Becoming a HealerEmboldened Bullies Come for Medical Education In an April 23rd executive order (EO), the president of the United States alleges that the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) are requiring medical schools and residency programs to pursue unlawful discrimination through DEI policies. The EO calls for the US Department of Education to “assess whether to suspend or terminate” them, and to “streamline the process” for recognizing new accreditors to replace them. In addition, medical journals, including the New England Journal of Medicine, are getting letters from a US Attorney, calling them “partisans in various scientific...2025-05-0153 min
On Becoming a HealerPhysicians and Authoritarians: Are We Too Obedient?The record of physicians standing up for their values as healers under authoritarian regimes is not good, whether it’s Nazi Germany, the former Soviet Union, or Iraq, with behaviors ranging from assisting in torture, to psychiatric hospitalization for political reasons. And sadly, it’s often without any coercion. More subtly, physicians may go along with authoritarian regimes' demands, thinking they can just "stay above the fray." But is that possible? Already, other professional institutions, including academia and law, have struck deals in the hope they they can move on, rather than defend academic freedom or long-standing legal p...2025-04-0847 min
On Becoming a HealerCaring for Patients or Policing Them? Prescription Drug Monitoring, Doctors and OpioidsPrescription Drug Monitoring Programs (PDMPs) were originally designed for law enforcement to monitor patients and physicians for criminal behavior before it became available to health care professionals. Physicians and pharmacists often find PDMPs helpful because they can verify what a patient tells them and will often decide not to prescribe or dispense opioids if they discover their patient has been going to multiple providers and pharmacies. But is that health care or policing? Who benefits and who is harmed? Those are questions we consider with our guest, Elizabeth Chiarello, PhD, sociology professor and author of Policing Patients: Treatment and...2025-03-181h 08
On Becoming a HealerWhat can we learn from all those "Why I quit medicine" videos on YouTube?There are a lot of videos on YouTube that feature typically young physicians explaining why they decided to leave the profession after years of dedication and hard work. For some it appears that they were so successful at building a social media presence and related businesses, that they quit medicine. Others seem to just want to share their experience in the hope it might help others. They describe how a sense of exhaustion, dreading work each day and discovering that it wasn’t what they imagined when they dreamed of becoming a doctor drove them away. What they have to s...2025-02-1849 min
On Becoming a HealerThe New Medical School Graduation Competencies and Why One of the Them Stands OutIn December 2024, the three organizations that oversee medical school (MD and DO) and residency education released a set of “Foundational Competencies for Undergraduate Medical Education,” that represent a consensus on the observable abilities medical students should exhibit as they begin practicing medicine under supervision. Not surprisingly they include taking a relevant patient history, performing a relevant physical exam, and creating and prioritizing a differential diagnosis. But a new one – and it’s the first one under Patient Care -- entails integrating patient context and preferences into patient care. Stefan interviews co-host Saul Weiner who has documented a strong cor...2025-01-2151 min
On Becoming a HealerA Conversation with Pediatric Surgeon John Lawrence MD, Past Board President of Doctors Without Borders, USAAt a moment of increasing isolationism and xenophobia and -- for physicians – burnout, in a highly bureaucratic and profit driven health system, service in low resource high needs settings can be an antidote for what ails America and American medicine, at least for the individual clinician. John Lawrence has spent decades serving all over the globe as a pediatric surgeon, most recently in war torn Gaza and South Sudan. He explains how he headed to college with plans to become a mathematician and then got diverted from that career trajectory while teaching math to Native American youth in Montana and...2024-12-1756 min
On Becoming a HealerAddressing Social Drivers of Health: What is the role of the clinician? In can be confusing and even demoralizing for a medical student or resident to understand what’s expected of them when caring for patients with social needs. They already feel overwhelmed. Are they supposed to now also screen for housing insecurity? Is it their job to intervene to address social needs? And if someone else is doing the screening, what’s their role? And are they also supposed to be advocating for changes to social policies? Finally, what’s special about social needs as opposed to all the other reasons that, for instance, a patient can’t control their diabetes...2024-11-1952 min
On Becoming a Healer“Simonisms”: Revisiting the uncommon wisdom of a physician and educator who shaped us deeplyTo commemorate the start of our fifth season, we revisit a conversation we had almost two years ago about the wisdom of Simon Auster, MD. Simon was a family physician and psychiatrist who inspired the conversations we’ve been having with each other and with guests on every episode. “Simonisms” embody Simon’s insights: pithy observations about the practice of medicine that are never cliché, challenge commonly held assumptions and offer fresh perspectives. We share -- and reflect on -- these pearls because we believe they can help many doctors, those in training, and those...2024-10-1534 min
On Becoming a HealerDo the doctors who sold Matthew Perry ketamine indicate something rotten in mainstream medicine?The two doctors charged for their roles in the events leading up to actor Matthew Perry’s death were both involved in a “side hustle”: selling ketamine at a big mark-up to make extra money, above what they earned through legitimate practice. One was an internist-pediatrician and the other an emergency medicine physician. Their cynicism was starkly evident in a text one sent the other about jacking up the price: “I wonder how much this moron will pay. Let’s find out.” It’s easy to write off these doctors as just bad apples; regrettable examples of how difficult i...2024-09-1757 min
On Becoming a HealerSome Pitfalls of Narrative Medicine and How to Avoid ThemThe term “Narrative Medicine” (NM) refers to a range of activities, including close reading and reflective writing about literature, designed to improve the clinician-patient relationship. What could go wrong? Our returning guest, English professor Laura Greene, lays out the case for narrative medicine, while co-host Saul Weiner highlights his concern that the challenges and rewards of interacting therapeutically with patients are categorically different from those of a physician interacting with a text. Unless proponents of narrative medicine articulate these differences explicitly, they risk creating unrealistic expectations about what NM can achieve, particularly in regard to actual healing interactions in the ex...2024-08-2055 min
Hope Illuminated PodcastPain, Opioids, Addiction, and Suicide – It’s Complicated with Dr. Stefan Kertesz | 129In this illuminating episode of Hope Illuminated, I sit down with Dr. Stefan Kertesz, a seasoned researcher from the University of Alabama, Birmingham, to unravel the complexities surrounding pain, opioids, addiction, and suicide.Stefan shares his profound insights into the intricate relationship between these factors, drawing from his extensive experience in caring for vulnerable populations. We delve into the repercussions of removing individuals from opioid medications while they grapple with unmanageable, intractable pain, shedding light on the multifaceted challenges faced by both patients and healthcare professionals.From personal anecdotes to evidence-based research, Stefan navigates the nuances of this pressing...2024-07-3043 min
On Becoming a HealerThe chasm between how doctors are taught to communicate and what they actually sound likeThere is an idealized version of physician-patient communication that is taught in medical schools, reinforced with acronyms like PEARLS, SPIKES, and LEARN, but what resemblance does it bear to how doctors actually sound in the exam room? Co-host Saul Weiner leads a research team that has audio recorded and analyzed thousands of medical encounters. In this episode, he and Stefan read a transcript from a typical visit, portraying patient and doctor, respectively, breaking out of role periodically to reflect on what’s just happened. Throughout, the physician interacts with the computer, peppering their patient with questions while conducting data ent...2024-07-2346 min
On Becoming a HealerWhat do we lose and what do we gain by calling addiction a disease?The National Institute on Drug Abuse defines addiction as a “chronic disease” occurring in the brain – Many believe this definition can help to reduce stigma. But, is it helpful in the care of individual patients? In this episode we discuss what we gain and what we lose when we speak of people with addiction as having “diseased brains.” The view of addiction as a chronic disease has traction, supported first by mid 20th-century alcoholism research, and then by a flood of brain imaging and neurophysiologic studies. Functional MRIs highlight changes in the brain, whether the addiction is to a subst...2024-06-1850 min
On Becoming a HealerCan we learn and practice medicine well in a system that is so ill?In his book, The Present Illness, American Health Care and Its Afflictions, physician and historian Martin Shapiro, MD, PhD, MPH presents a scathing critique of a profession suffused with status, money, and power. At the same time, he also describes many deeply caring and rewarding patient care experiences, his own and those of colleagues. But these relationships are only possible when the clinician has a clear understanding of the pernicious corrupting forces in medicine and consciously rejects them. This is a moral act that must be renewed continuously. They also require a capacity to confront one's own insecurities -- Dr...2024-05-2151 min
On Becoming a Healer“Tough Love” is Not the Answer: A critique of NEJM reporting on student/trainee grievances and educator discontent A recent NEJM article and accompanying podcast episode (“Tough Love”) authored and hosted by the Journal’s national correspondent sound the alarm that a culture of grievance among medical students and trainees about the discomforts of medical training is threatening to undermine both their medical education and patient care. She also describes widespread anxiety among medical educators who feel fearful of speaking because of concerns of retaliation on social media. Absent from the discussion, however, are the voices of students and trainees who, in the podcast, are referred to as “our children.” Medical Students and trainees we spoke with did not fee...2024-04-1659 min
On Becoming a HealerWhat a James Baldwin story can teach doctors and patients about care amidst suffering“Sonny’s Blues” is a 1956 story by the author, James Baldwin, about a “sensible” and pragmatic algebra teacher and his younger musically gifted younger brother (“Sonny”), who struggles with heroin addiction. Both of them, raised in Harlem, are deeply affected by anti-Black racism. Although the older brother, who narrates the story, feels responsible for Sonny, he struggles to relate to him. With the help of an English professor, Laura Greene at Augustana College, we reflect on some of the lessons of this story for the physician-patient relationship, especially when caring for individuals with substance use disorder. We explore the cost both to pa...2024-03-191h 02
On Becoming a HealerHow confronting racist ideas I didn’t realize I had is shaping me as a physician and a personIn a 2021 episode that we reran last month, “About me being racist: a conversation that follows an apology,” Saul talked with a former Black colleague after apologizing to her for something racist he had done twenty years earlier that hurt her for a long time. Since then, Saul has been thinking about how he got exposed to racist ideas and notions of power as a white male growing up in the United States (in his case in a liberal, highly educated community) and suggested that he and Stefan talk about it, taking to heart Toni Morrison’s admoniti...2024-02-2055 min
The Doctor Patient ForumThe Suicide Study - Dr. Stefan Kertesz - Episode 43Dr. Stefan Kertesz' Bio:
Stefan Kertesz is a physician at the Birmingham Veterans Affairs Medical Center, and Professor at the University of Alabama at Birmingham. Since 1996, Dr. Kertesz has focused his work on helping populations at high risk of receiving poor care, including people with pain whose care has changed a great deal in the wake of the US opioid crisis. He's certified in internal medicine and addiction medicine. Dr. Kertesz leads the only federally funded study that seeks to examine suicides occurring after prescription opioids are reduced in people with long-term pain. His team does this...2024-02-151h 05
Daily RemedyDiscussing patient suicides following forced tapering with the investigators of CSI: OPIOIDsCSI:OPIOIDs (Clinical Context of Suicide Following Opioid
Transitions) is a scientific research study to closely examine suicides that have occurred after prescription opioid dose reductions in patients with long-term pain. The team will look at 110-120 suicides, split between those individuals who were Veterans of the US armed forces and people who were not Veterans.
The CSI:OPIOIDs team will:
Compile a registry of people who have died by suicide following a reduction or stoppage in their opioid medication.
Perform in-depth, one on one interviews with survivors of individuals who have died...2024-01-1949 min
On Becoming a HealerAbout me being racist: A conversation that follows an apologyWe are re-running this episode from 2021 because we’re releasing a sequel next month in which Saul reflects on his journey confronting racist ideas he’d absorbed and that became impossible to ignore after he’d acknowledged his role in the incident described here. We are also re-running the episode because it exemplifies our commitment to facing things -- about ourselves and our profession – to enhance our wellbeing, and our relationships with colleagues and patients. Rather than disheartening, we find such conversations and the changes they bring rewarding and healing.2024-01-1642 min
VHA Homeless Programs – Ending Veteran HomelessnessS1EP21: What’s the Big Deal with Housing First?This month, we are joined by Dr. Keith Harris, senior executive homelessness agent for Greater Los Angeles with the Office of the Secretary, and Dr. Stefan Kertesz, a physician with the VA Birmingham Healthcare System, to learn more about Housing First.Our guests talk about what Housing First is, how VA has used it to cut Veteran homelessness by more than half, and why it’s become a controversial topic among policymakers and housing providers.Veterans who are homeless or at imminent risk of homelessness are strongly encouraged to contact the National Call Center for Homeless Veterans at...2024-01-0846 min
On Becoming a HealerHow effects of racism were mistaken for “race” in clinical algorithms: What clinicians should knowFor years, when physicians order tests to assess lung function, or blood work to determine kidney function, or look up guidelines for managing high blood pressure the results have been adjusted for race. This practice has been based on studies that seemed to indicate that the same result means different things if the patient is Black vs white. So, for instance, an “uncorrected’ creatinine of 1.6 was thought to be less concerning in a Black than white patient as Blacks were thought to have greater muscle mass (not true). These correction factors masked underlying environmental and social stressors disproportionately affecting Blac...2023-12-191h 03
On Becoming a HealerDrug testing at time of birth: How physicians are co-opted into harming families while thinking they are doing the right thingThe practice of urine drug testing during pregnancy and then often reporting positive results to Child Protective Services triggers a cascade that can result in separation of mother and newborn, with devastating consequence for both. These practices are more common when patients come from marginalized communities even when baseline substance use rates are the same. As our guest -- obstetrician/gynecologist and addiction medicine expert Mishka Terplan MD, MPH -- points out, illicit substances are not teratogens in comparison to, say, alcohol, tobacco or lead exposure. So why do we order these tests? He also discusses how talking with...2023-11-211h 02
Expert Guidance for Effective Management and Appropriate Monitoring of Patients With PainPatient and Provider Perspectives on Opioid Pain Treatment PlansListen as Stefan Kertesz, MD, MSc, and Kate M. Nicholson, JD, provide unique healthcare professional and patient perspectives on opioid tapering in the setting of chronic pain management. Their conversation includes commentary on the impact of the 2016 and 2022 CDC guidelines for prescribing opioids for pain, the importance of informed consent, and the ongoing research regarding risks and consequences of opioid tapers.Select links to resources related to the content of this podcast episode include:Assessing Reasons for Decreased Primary Care Access for Individuals on Prescribed Opioids: An Audit Study journals.lww.com/pain/Citation/2021/05000/Assessing_reasons...2023-10-2531 min
On Becoming a HealerDirectly and Covertly Observing Care: How it Can Transform Medical Education and Improve Clinical PracticeDirect, covert observation of health care is a novel and underutilized tool to assess health care trainees and clinicians. In this episode we talk with experts about two such approaches: the unannounced standardized patient and patient-collected audio. In the former, actors are sent incognito into practice settings, and in the latter real patients volunteer to record their visits on behalf of a quality improvement team. Both approaches address the question, “How are our learners and experienced clinicians performing in the real world?” They also identify those who may do well on simulations but underperform in the clinical setti...2023-10-1850 min
On Becoming a Healer"Dire Consequences": When students do not receive appropriate accommodations on the USMLE examinationsIn the prior episode we learned that there is no evidence that time-limited testing improves test validity and that, in fact, there is ample research showing that it makes tests less valid and less equitable. In this episode we discuss how, despite the data, the NBME denies accommodations on the USMLE exams to over half of medical students who have a documented learning disability and are approved for accommodations at their medical school (e.g., extra time). We talk with a leading medical educator about a national survey she and her colleagues conducted to assess the scope and impact...2023-09-1943 min
On Becoming a HealerWhy it's time to remove time limits on tests, like the USMLE examsThere is a widely held perception that being able to complete a test quickly is an indication of mastery when compared with those who need more time. As a result, it is often difficult to obtain accommodations on high stakes examinations, including the USMLE exams. Many students who request extra time because of a disability are denied accommodations and many other students who need it aren't eligible (e.g., English is a second language) or are inhibited from applying (e.g., Veterans, students from certain cultural backgrounds). But what does the evidence show? In this episode we interview an e...2023-08-2239 min
On Becoming a HealerRunning the Gauntlet: My Journey into Medicine with a Learning DisabilityStefan interviews co-host Saul about his experiences becoming a doctor with a learning disability. This episode, first run in 2020, sets the stage for two that will follow – in August and September, with experts on the science of student learning assessment and its implications for the USMLE examinations. These will address questions such as: Does struggling with multiple-choice tests under time pressure predict anything about future performance in the clinical setting? Do time limits make tests more or less valid and reliable? What are implications of denying so many students accommodations on the USMLE examinations? And, most importantly, what...2023-07-2520 min
Expert Guidance for Effective Management and Appropriate Monitoring of Patients With PainPatient and Provider Perspectives on Opioid Pain Treatment PlansListen as Stefan Kertesz, MD, MSc, and Kate M. Nicholson, JD, provide unique healthcare professional and patient perspectives on opioid tapering in the setting of chronic pain management. Their conversation includes commentary on the impact of the 2016 and 2022 CDC guidelines for prescribing opioids for pain, the importance of informed consent, and the ongoing research regarding risks and consequences of opioid tapers.Select links to resources related to the content of this podcast episode include:• Assessing Reasons for Decreased Primary Care Access for Individuals on Prescribed Opioids: An Audit Studyjournals.lww.com/pain/Citation/2021/05000/As...2023-07-1031 min
On Becoming a HealerWhy are doctors turning to ChatGPT for help relating to patients?A recent New York Times article, titled "When Doctors Use a Chatbot to Improve Their Bedside Manner," should raise questions about why physicians are turning to artificial intelligence for help talking with other humans. While GPTChat can generate things to say, what comes out of AI is impersonal, as it knows nothing about the individuality of the doctor asking them, or of their patient, or of the relationship between the two. Much of the joy of being a physician is forming personal, healing connections with patients. Are physicians unprepared to cultivate them? US Medical schools now teach...2023-06-2733 min
The Curbsiders Internal Medicine Podcast#401 Updates in Addiction Medicine - SGIM 2023We are far too classy for a “Rocky Mountain High” joke.
Live from SGIM 2023 in Aurora, Colorado! We talk to a panel of Addiction Medicine specialists who recap their outstanding talk on all of the exciting developments in treating addiction. We review major policy changes, trends in drug overdose, outpatient screening for alcohol use, and all of the ways we might be using psychedelics to treat addiction. We are joined by Stefan Kertesz, MD @StefanKertesz (University of Alabama at Birmingham), Ximena Levander, MD, MCR, FACP @XimenaLevander (OHSU), Kenneth L. Morford MD, FASAM (Yale), and Katherine Mullins, MD, AAHIV @_kmullin...2023-06-261h 02The Curbsiders Internal Medicine Podcast#401 Updates in Addiction Medicine - SGIM 2023We are far too classy for a “Rocky Mountain High” joke.
Live from SGIM 2023 in Aurora, Colorado! We talk to a panel of Addiction Medicine specialists who recap their outstanding talk on all of the exciting developments in treating addiction. We review major policy changes, trends in drug overdose, outpatient screening for alcohol use, and all of the ways we might be using psychedelics to treat addiction. We are joined by Stefan Kertesz, MD @StefanKertesz (University of Alabama at Birmingham), Ximena Levander, MD, MCR, FACP @XimenaLevander (OHSU), Kenneth L. Morford MD, FASAM (Yale), and Katherine Mullins, MD, AAHIV @_kmullin...2023-06-261h 02
On Becoming a HealerPrescription Opioid Reductions and Suicide: What Should Caring Physicians Do in the Face of Uncertainty? The narrative that getting patients with chronic pain off opioids makes them safer was reinforced by a recent paper that got substantial media attention showing an association with reduced suicide rates at the population level -- But other data, at the patient level, shows an increased rate of suicide. Which is closer to the truth? And, if there's an answer, how does it apply to the individual patient? Is it ever okay to taper a patient when it’s not a shared decision? How do you talk about it, and does the power dynamic between doct...2023-05-2336 minDaily RemedyA conversation with Dr. Stefan Kertesz, PI of CSI: OPIOIDSDr. Stefan Kertesz is the principal investigator of CSI:OPIOIDs (Clinical Context of Suicide Following Opioid Transitions), a scientific research study that examines suicides after prescription opioid dose reductions in patients with long-term pain.
Beginning as a pilot study supported by UAB Heersink School of Medicine’s Department of Medicine, today it’s supported by a Veterans Administration grant under the title “CSI:OPIOIDs-V“.
The study’s purpose is to increase knowledge of the demographic, societal, and clinical factors that have led and may lead patients with pain to die by sui...2023-05-0747 min
On Becoming a HealerMy patient’s in shackles: Can we take these off?We might assume that a patient who is chained to their hospital bed must be restrained for good reason, but our guest challenges that assumption in a published account of a man in shackles who is intubated, sedated, and paralyzed in the ICU. He and his co-author write that "Over-policing and mass incarceration have led to Black prisoners being disproportionately represented in jails and prisons. Those of us in positions of power may disregard the shackle, or not question its purpose, or even propose that it is justified." But how often do incarcerated patients actually try to escape while re...2023-04-1839 min
On Becoming a HealerFrom medical student mistreatment to burnout: How can we change the culture?In this second of a two-episode series on medical student mistreatment, we discuss its impact on burnout with a colleague who is working to change the culture of medical education and practice through research and leadership.2023-03-2240 min
On Becoming a HealerMedical Student Mistreatment: A Wicked ProblemHow is it that a healing profession -- medicine -- has such a deeply ingrained culture of harming its own? And what can we do about it? In this first of two back-to-back episodes on medical student mistreatment we consider the scope of the problem and attempts to confront it. We hear from one medical school that, with external funding, developed a program with online resources available to any school that are designed to foster discussion and self-reflection among all stakeholders: attendings, residents, students, and other health care professionals in the ecosystem. We share here links to re...2023-02-2143 min
On Becoming a HealerUncommon wisdom from a family physician and medical educatorSimon Auster, MD, was a family physician, psychiatrist, and medical educator who had extraordinary insight about practicing medicine but absolutely zero interest in drawing attention to himself. His students and patients had the good fortune of having him as their teacher or doctor but far too few have benefited from his wisdom. Today we discuss some of Simon's saying's -- "Simonisms" -- that are remarkable because they are not the usual cliches one hears. Some challenge us to reconsider our assumptions. We share and discuss them because we believe they can help many doctors, those in training, and those...2023-01-1933 min
On Becoming a HealerChallenging Questions to Help Physicians Reflect, Grow, and Find More Joy Practicing MedicineMedical training and practice habituates physicians to a culture that narrows the possibilities we see for finding joy and meaning in our work. We often become efficient task completers, stuck in routines, and prone to burnout. Saul and Stefan discuss a set of questions that challenge physicians to look at their work and themselves in fresh ways, can be used for mentoring or teaching purposes, as prompts for reflective writing exercises, or to engage thoughtful colleagues (perhaps over a beer). 10 Questions (selected from On Becoming a Healer: The Journey from Patient Care to Caring about Your Patients) ...2022-12-1543 min
The Roy Green ShowDec 4: Prof/Dr. Stefan Kertesz, Story from One of Millions of Canadian and American Chronic Pain PatientsMillions of Canadians and Americans are chronic pain (agony) patients. A disturbing story from Georgia about Danny and Gretchen Elliott. Danny, A 61 year old chronic pain patient (was electrocuted while standing in water) and his 59 year old stage 4 breast cancer wife committed suicide together a few weeks ago. Reason: Danny, because of the electrocution suffered from constant chronic agony which was controlled somewhat by long prescribed opioid pain medication. This medication was denied after the U.S. DEA forced his pain physician out of practice. Danny could find no other doctor to provide the pain meds he needed to...2022-12-0416 min
On Becoming a HealerOrganic Chemistry and the Questionable Ways We Select and Train PhysiciansIn October, the New York Times published the first of several articles about an eminent professor at NYU who was dismissed after his students complained that his organic chemistry class, essential to medical school admission, was too hard. Thousands of comments were unsympathetic saying, essentially, that students who couldn't hack it shouldn't be doctors. But is that really true? Saul and Stefan debate not only whether organic chemistry should be a gateway into medicine, but what else is questionable in how we train physicians -- and why it matters. Are medical students spending massive amounts of time jumping through...2022-11-1630 min
On Becoming a HealerContextualizing Care in a Nutshell (and a New Study)Today, Stefan talks with Saul about his favorite topic (and life's work), contextualizing care. We're re-releasing this conversation (from January of last year) because Saul's research team has just published a new study -- an RCT, titled "Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial," which is open access, so you can read it by clicking on the link. This episode provides a brief "one-stop-shop" for anyone who wants to understand what it means to contextualize care and why it matters. 2022-10-2427 min
Addiction Medicine PodcastS2 Episode 3: Lessons from Our Prescription Opioid StoryEpisode 3 addresses some of the unintended consequences of the 2016 CDC Opioid Guidelines which were widely misinterpreted and implemented.After the guidelines were published, Dr. Stefan Kertesz, a Professor of Medicine at the University of Alabama at Birmingham and attending physician at the Birmingham VA Health Care System, began researching and writing about the unintended consequences, especially for stable patients with severe chronic pain who were subject to prescription opioid reductions or who lost access to the medications altogether.This is his talk from the 2022 Addiction Medicine Conference titled, Irrational Exuberance, Incautious Stoppage: Lessons from Our...2022-10-0346 min
On Becoming a HealerMedical Gaslighting: Why Are We A--holes?Recent articles in mainstream media about "medical gaslighting" have struck a nerve with thousands of comments on social media platforms. People are complaining about how their doctors are treating them, with women and underrepresented minorities disproportionately telling some of the worst stories. Meanwhile physicians are responding, mostly on the defensive. They're saying their jobs are too tough and patients are unreasonable. We explore what's going on. 2022-09-1935 min
On Becoming a HealerUrine Drug Screening: How it can traumatize patients and undermine the physician-patient relationship without helping anyoneUrine drug screening (UDS) is used in the care of patients with opioid use disorder, and for patients receiving opioids for chronic pain. There's no strong evidence that testing helps patients, however, and no consensus on what to do with the results anyway. These tests, often mandated, may cause serious harm when physicians don't realize how often there are false positives or react punitively by cutting off treatment. Testing can resemble a criminal justice encounter, where failing could result in jail time. In a conversation with an expert, we reflect on how urine tests can be helpful, but only if we understa...2022-08-1138 min
On Becoming a HealerPursuing a Medical Career While Black: What it Takes and Why it MattersMaking it into and through medical school is tough even for those who have all the advantages: excellent schools starting at a young age, well-educated parents who may be doctors themselves, lots of role models and…white skin. In this episode we hear from two pre-meds and one newly minted physician, all Black, about their journeys with few of these advantages. Despite their remarkable optimism, their burdens are evident, and many do seem tied to race, as it is understood in the US. The extreme underrepresentation of Blacks in medicine should be a source of deep...2022-07-1455 min
On Becoming a HealerRescuing medical professionalism: Could “cup-of-coffee conversations” do more good than committees and letters-to-the-file?Medical students may be subject to professionalism review by committees, most commonly for “unreliability” such as not responding to emails, falling behind on compliance requirements, showing up late for assignments and so on. Then they hit the wards, and frequently experience mistreatment by residents and attendings (many of whom also don’t answer their emails etc…), most commonly in the form of public humiliation. This seems like a recipe for cynicism and burnout, rather than growth as a professional. In this episode we talk with our guests, experts in a more nurturing approach, about alternatives. We hear about “cup-of-coffee conversations” and other re...2022-05-2642 min
The Curbsiders Internal Medicine Podcast#336 Updates in Addiction Medicine: Live from SGIMLearn from an expert panel in addiction medicine about a potpourri of fascinating topics, with updated data to guide clinical decision-making. We picked the brains of physicians Stefan Kertesz, Ximena Levander, Kenny Morford, and Katherine Mullins to learn about the latest updates in opioid tapering (don’t do it if there isn’t a good reason!), how to define recovery in alcohol use disorder, different options to treat methamphetamine use disorder, and Hepatitis C treatment in patients with active IV drug use. And there’s so much more, that we’re following this with a whole series in Addiction Medicine, set to come...2022-05-2348 minThe Curbsiders Internal Medicine Podcast#336 Updates in Addiction Medicine: Live from SGIMLearn from an expert panel in addiction medicine about a potpourri of fascinating topics, with updated data to guide clinical decision-making. We picked the brains of physicians Stefan Kertesz, Ximena Levander, Kenny Morford, and Katherine Mullins to learn about the latest updates in opioid tapering (don’t do it if there isn’t a good reason!), how to define recovery in alcohol use disorder, different options to treat methamphetamine use disorder, and Hepatitis C treatment in patients with active IV drug use. And there’s so much more, that we’re following this with a whole series in Addiction Medicine, set to come...2022-05-2348 min
Annals On Call PodcastEvidence-Based Care of Substance Use DisordersDr. Centor discusses current thinking about the appropriate treatment of patients with substance use disorder with Dr. Stefan Kertesz.2022-05-1626 minOn Becoming a HealerWhy Residents UnionizeMany residents are not doing well, psychologically, and sometimes physically -- and with good reason. High levels of mistreatment and harassment, patient care that some experience as moral injury, and a lack of voice in the workplace, contribute to burnout and can adversely affect the kind of physicians people become. A growing path to empowerment is unionization. What are resident and fellow unions doing to create healthier training environments? Today we hear from a recent residency program graduate who served as president of a resident union at a large academic medical center. 2022-04-2136 minOn Becoming a HealerOpioids and the physician-patient relationship: What are we getting wrong?The opioid crisis was precipitated by physicians overprescribing opioid pain medication, egged on by the pharmaceutical industry, contributing to suffering and death from addiction and overdose. Now, many physicians are forcibly cutting patients off of opioids and refusing to prescribe in the setting of a backlash, contributing to suffering from pain, and death from suicide. Saul and Stefan consider some of the striking similarities in how we -- the medical profession -- are getting it wrong on both sides of the crisis, why, and what we can do about it. 2022-03-1541 minOn Becoming a HealerFalse Positives Traumatize Patients...If Clinicians Aren't CarefulOn January 1st, the New York Times ran a story about prenatal genetic tests that are "usually wrong" -- but they got it wrong. These are actually just tests to tell if someone is high risk. The real story is that clinicians are not communicating with patients about what these tests mean, causing confusion and trauma. This happens across medicine and we discuss how to avoid it.2022-01-1930 minOn Becoming a HealerHealing Interactions: What are they made of?There are two qualities we may experience in others who comfort and ground us when we feel vulnerable and lost. First that they engage with us, meaning that they are fully present with a sense of shared humanity. Second, that they respect our personal boundaries and know their own. Such boundary clarity makes them a safe sounding board. In this episode, first aired last May, we explore the interdependence of engagement and boundary clarity and their essential role in healing interactions.2021-12-2627 minOn Becoming a HealerKind People on AirplanesLately we've been hearing about bad behavior on airplanes. Here we discuss an incident in which a passenger unselfconsiously stepped up at an inconvenient time to assist a group of passengers in a tough spot. Saul and Stefan reflect on the qualities of people who go through life making the world a better place in small ways. As millions travel during Thanksgiving, we thought this episode (originally released last year) might inspire those flying the not-always friendly skies. 2021-11-2419 minOn Becoming a HealerWhen an attending yells at a residentOur guest, a physician a few years out of residency, describes an experience from her training when an attending yelled at her and hung up the phone when they were discussing a patient. We talk about resident abuse, its impact on patient care, and what can be done about it. 2021-10-2825 minOn Becoming a HealerWhen your patient has a Swastika tattooOur guest, a resident physician, describes her reaction and what followed, when she discovered a symbol of hate tattooed on her hospitalized patient's leg. Most of us appreciate that as physicians we don't get to choose who are patients are, and that all deserve good care. But is there more to it than that? Can one grow as a physician and person, and even feel privileged when caring for patients who one might otherwise shun? 2021-09-0938 minOn Becoming a HealerAbout me being racist: A conversation that follows an apologySaul reached out to a former colleague whom he worked with closely so that he could apologize for something he did many years ago that he now sees as racist. Saul is a white man and his former colleague, a subordinate at the time, is a black woman. Because of his apology, along with their longstanding relationship, they are able to have an open and honest conversation about how it affected her life, why it happened and how to prevent and respond to racist behavior in the workplace. Stefan moderates the conversation. Guest: Chanel Brown2021-07-2942 minOn Becoming a HealerThe Dartmouth Debacle: Why the culture of medical education needs to changeIn a widely reported incident, Dartmouth Geisel School of Medicine accused, suspended and expelled medical students for cheating based on faulty data -- and then retracted the decision amidst a large public backlash. During the episode students were allegedly given only 2 minutes to defend themselves and were encouraged to plead guilty. When they complained about the administration online, the school passed a policy on social media that would ban some forms of communication. In this episode, Saul (@SaulWeiner) and Stefan (@StefanKertesz) discuss whether what happened at Dartmouth was an anomaly or emblematic of a dysfunctional and even toxic culture w...2021-06-2143 minOn Becoming a HealerVaccine Hesitancy and the Doctor-Patient RelationshipA primary care doctor in solo practice in a small mid-west city who is deeply trusted by his patients talks about talking about vaccine hesitancy. 2021-05-1723 minOn Becoming a HealerEngagement and Boundary Clarity: The two essential characteristics of healing interactionsWe feel safe and can open up in conversations when there is full and open engagement combined with a clear, respectful sense of personal boundaries. Why are such exchanges so rare and yet so important to medical practice and to the good life? 2021-05-1027 minOn Becoming a HealerJudgementalismPhysicians are neither judges nor God, and yet we seem prone to judge our patients...and ourselves. Saul and Stefan discuss. 2021-03-2225 minOn Becoming a HealerContextualizing Care: What it means and why it mattersSaul and his research team have listened to and analyzed thousands of audio recordings of medical encounters for clinician attention to the life context of each patient when planning their care. Here is what they've learned. 2021-01-1927 minOn Becoming a HealerPart 2: International Medicine: "My purpose for being there is not for me."In Part 2 of our interview with Dr. Bhalla, hear what makes for a good fit for a long term career practicing medicine and leading projects in international settings2021-01-0325 minOn Becoming a HealerPart 1. International Medicine: "Putting myself outside my comfort zone"A physician describes what attracted her to international medicine where she’s worked for Doctors Without Borders in many challenging places. Guest: Naina Bhalla MD, MPH Intro and Outro are Prelude by J.S Bach, arranged by Sophocles Papas, with permission from Carl Fischer. Also, Largo from Four Seasons by Vivaldi, arranged Per-Olov Kindgren. Guitar played by Saul Weiner.2021-01-0340 minOn Becoming a HealerMy Learning DisabilityStefan interviews Saul about his experiences becoming a doctor with a learning disability, leading to questions such as: Does struggling with multiple choice tests mean you won't be a good doctor? How do grades shape our self image and the culture of medicine? 2020-11-2921 minOn Becoming a HealerAsking patients "Why?"What should a doctor do when a patient behaves in a way that doesn't seem to make sense? Saul and Stefan discuss a case. 2020-11-1016 minOn Becoming a HealerPart 2: “This is what I trained for.”In Part 2 of our interview with Dr. John Scala, hear how an experienced primary care physician in solo practice responds to the pandemic, particularly as he thinks about the physician-patient relationship, the well being of his staff, and personal risk. 2020-10-3128 minOn Becoming a HealerPart 1: Meaning and Joy in Solo PracticeA primary care physician describes why he's loved being a solo doctor, mostly avoiding corporate medicine. His patients love him too. Learn how and why this kind of practice is still possible. 2020-10-3155 minOn Becoming a HealerPart 2: Hope and Healing for Those Who FollowDr. Conway responds to violence and hopelessness in her community, traumatized by systemic racism, by establishing the I Am Abel Foundation as a haven and resource for young people aspiring to careers in medicine. 2020-10-1936 minOn Becoming a HealerPart 1: Pursuing a Dream and a CallingDr. LaMenta Conway shares what she experienced and learned growing up in an economically and socially marginalized community in Chicago, pursuing a dream to become a physician. 2020-10-1943 minOn Becoming a HealerForced Opioid Taper: First, Do No HarmA middle aged man had been on a high but stable dose of opioids for years for chronic pain. His provider decides to wean him. He says "I'm not sure I can handle it," but they keep going. Is this what a caring or evidence-based physician would do? 2020-09-1116 minOn Becoming a HealerAirplane GuyWhat's a better way to pick a student for medical school: High MCAT scores or seeing them help a vulnerable stranger when it's inconvenient and they think no one's watching? Reflections on healing as an organizing principle.2020-09-1119 minOn Becoming a HealerPatient AbuseA very bright physician scares a patient from a marginalized community out of the ER with a nasty prank -- and "I laughed too." How does this happen? Saul Weiner reflects on a moment from residency.2020-09-1116 minOn Becoming a HealerThe "Difficult" PatientA patient got labelled as "difficult" who really wasn't so difficult, and it cost him his life. Where did things go wrong? Details changed to assure patient confidentiality.2020-09-1124 min
On Becoming a HealerIntroducing: On Becoming a HealerIntroducing a new podcast that takes a critical look at medical training and the culture of medicine. Explores how interpersonal boundary clarity and the capacity to fully engage are essential to effective medical practice, mentoring, medical education, and a nourishing career. Designed to challenge you, help you grow, and prevent burnout, The podcast features Prelude by J.S. Bach, arranged for classical guitar by Sophocles Papas, and played by podcast host Saul J. Weiner. Used with written permission from Carl Fischer.2020-09-0703 min
The Curbsiders Internal Medicine Podcast#216 Homeless Healthcare with Stefan Kertesz MDLearn the nuances of caring for and building relationships with patients experiencing homelessness from expert internal medicine and addiction physician Stefan Kertesz, return guest from Episode 74 on Opioids and Health Policy (highly recommend a re-listen, y’all!). Topics: the challenge of creating a welcoming and useful space for individuals experiencing homelessness, how to meet patients where they’re at--both physically and mentally--the challenge of managing diuretics for those without stable access to a bathroom (avoid, if possible), and how absolutely essential the foot exam is.
Show Notes | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!2020-05-281h 06The Curbsiders Internal Medicine Podcast#216 Homeless Healthcare with Stefan Kertesz MDLearn the nuances of caring for and building relationships with patients experiencing homelessness from expert internal medicine and addiction physician Stefan Kertesz, return guest from Episode 74 on Opioids and Health Policy (highly recommend a re-listen, y’all!). Topics: the challenge of creating a welcoming and useful space for individuals experiencing homelessness, how to meet patients where they’re at--both physically and mentally--the challenge of managing diuretics for those without stable access to a bathroom (avoid, if possible), and how absolutely essential the foot exam is.
Show Notes | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!2020-05-281h 06
VA HSR&D PodcastsAllyson Varley, PhD, MPH, and Stefan Kertesz, MD, talk about their work surveying and understanding the clinical experiences of vulnerable Veterans.2020-05-1900 min
Conversaciones en la CentralGuerra y lenguaje: y las palabras producen efectosConversaciones en La Central 16, celebrada 19 de abril de 2012.
Adan Kovacsics y Juan Carlos Monedero conversan sobre... Guerra y lenguaje: y las palabras producen efectos.
Adan Kovacsics es traductor del húngaro y del alemán. Nacido en Santiago de Chile, es hijo de inmigrantes húngaros. Premiado en numerosas ocasiones por el Ministerio de Educación y Cultura de Austria - por las traducciones de Karl Kraus- Los últimos días de la humanidad (1992), Hans Lebert: La piel del lobo (1994), Heimito von Doderer: Un asesinato que todos cometemos, Hans Lebert: El círculo de fuego (1996), Peter Altenberg: Páginas escogidas (1998), Joseph R...2020-05-081h 33
The Social ExchangeEpisode 16: Where The Story Meets Pain (Volume 3: "Pain Patients")Where The Story Meets Pain Volume 3: "Pain Patients" Series Episodes: 1. Addiction 2. Drug Deaths 3. Doctors and Pain Patients __________________________________________ Despite our best efforts, we’ve yet to slow the rate of death related to drugs in our country… In the year 2016, there were 64,000 total drug-related deaths. Something is not working, and that truth is getting increasingly difficult to stomach. Host, Zach Rhoads spent the last two years challenging the standard story about the opioid crisis. He spoke to relevant experts...2018-07-1958 min
The Social ExchangeEpisode 15: Where The Story Meets Pain (Volume 2: "Drug Deaths")Where The Story Meets Pain Volume 2: "Drug Deaths" Series Episodes: 1. Addiction 2. Drug Deaths 3. Doctors and Pain Patients __________________________________________ Despite our best efforts, we’ve yet to slow the rate of death related to drugs in our country… In the year 2016, there were 64,000 total drug-related deaths. Something is not working, and that truth is getting increasingly difficult to stomach. Host, Zach Rhoads, has responded; he spent the last two years challenging the standard story about the opioid crisis. He asked spoke t...2018-07-0842 min
The Social ExchangeEpisode 14: Where The Story Meets Pain (Volume 1: Addiction)Where The Story Meets Pain "Addiction" volume 1 (of 3) Series Episodes: 1. Addiction 2. Drug Death 3. Doctors and Pain Patients __________________________________________ Despite our best efforts, we’ve yet to slow the rate of death related to drugs in our country… In the year 2016, there were 64,000 total drug-related deaths. Something is not working, and that truth is getting increasingly difficult to stomach. Host, Zach Rhoads, has responded; he spent the last two years challenging the standard story about the opioid crisis. He asked...2018-06-2631 min
The Social ExchangeEpisode 11: Stefan Kertesz: When Hyper-Regulation Goes WrongZach Rhoads sits down with Dr. Stefan Kertesz to talk about the unintended harms of putting strict limits on pain pills. While he is here in Vermont, he will speak at the Howard Center alongside Dr. Sally Satel (American Enterprise Institute), Dr. Carl Hart (Columbia), and Dr. John Brooklyn (Howard Center) to talk about what is commonly called "The Opioid Crisis." 2018-05-2214 min
Conservative Review with Daniel HorowitzHow politics, not data, is driving policy on painkillers — and hurting patients Ep. 219Today, we are joined by Dr. Stefan Kertesz, a professor in the division of preventive medicine at the University of Alabama at Birmingham School of Medicine. Dr. Kertesz joins us to discuss his concerns about government's totally unscientific approach to cutting off pain medicine.
In a wide-ranging conversation, we delve deep into the drug overdose crisis, what really causes it, the most recent trends, and how the lack of proper science and data is driving the government to make things worse. In fact, most of the problems with overdoses have nothing to do with pain patients and doctors who write...2018-04-271h 18
Addiction Medicine: Beyond the AbstractThe Unexpected Urine Test: A Matter Far From SimpleIn episode two of Addiction Medicine: Beyond the Abstract, we are joined by Dr. Stefan Kertesz of the University of Alabama Birmingham and the Birmingham VA Medical Center. In his recent piece from the Journal, Dr. Kertesz discusses the challenge of treating patients who obtain benzodiazepines from another provider in addition to known prescribed opiates. He addresses this issue in the context of the results from a recent study by McClure, et al. in the same issue of the Journal which analyzes patterns of urine drug test results from a national laboratory.
Read more here.
...2018-01-0314 minAddiction Medicine: Beyond the AbstractThe Unexpected Urine Test: A Matter Far From SimpleIn episode two of Addiction Medicine: Beyond the Abstract, we are joined by Dr. Stefan Kertesz of the University of Alabama Birmingham and the Birmingham VA Medical Center. In his recent piece from the Journal, Dr. Kertesz discusses the challenge of treating patients who obtain benzodiazepines from another provider in addition to known prescribed opiates. He addresses this issue in the context of the results from a recent study by McClure, et al. in the same issue of the Journal which analyzes patterns of urine drug test results from a national laboratory.
Read more here.
...2018-01-0314 min
Journal of Addiction MedicineThe Unexpected Urine Test: A Matter Far From SimpleIn episode two of Addiction Medicine: Beyond the Abstract, we are joined by Dr. Stefan Kertesz of the University of Alabama Birmingham and the Birmingham VA Medical Center. In his recent piece from the Journal, Dr. Kertesz discusses the challenge of treating patients who obtain benzodiazepines from another provider in addition to known prescribed opiates. He addresses this issue in the context of the results from a recent study by McClure, et al. in the same issue of the Journal which analyzes patterns of urine drug test results from a national laboratory.2017-12-2814 min
The Curbsiders Internal Medicine Podcast#74 Opioid use disorder, pain, detox, tapers, health policy, and more!Combat opioid use disorder and the opioid epidemic as we review common clinical scenarios with addiction medicine specialists, Dr. Stefan Kertesz, University of Alabama at Birmingham School of Medicine and Dr. Ajay Manhapra from the VA Hampton Medical Center in Hampton,Virginia. We need all hands on deck, and that means you! Learn the basics of opioid use disorder treatment as Dr. Manhapra gives us the scoop on “bup, bup, bup” (buphrenophine), and Dr. Kertesz primes us on opioid related health care policy and reminds us that “We can all do something about the opioid crisis”. Plus, Stuart and Paul express s...2017-12-221h 15The Curbsiders Internal Medicine Podcast#74 Opioid use disorder, pain, detox, tapers, health policy, and more!Combat opioid use disorder and the opioid epidemic as we review common clinical scenarios with addiction medicine specialists, Dr. Stefan Kertesz, University of Alabama at Birmingham School of Medicine and Dr. Ajay Manhapra from the VA Hampton Medical Center in Hampton,Virginia. We need all hands on deck, and that means you! Learn the basics of opioid use disorder treatment as Dr. Manhapra gives us the scoop on “bup, bup, bup” (buphrenophine), and Dr. Kertesz primes us on opioid related health care policy and reminds us that “We can all do something about the opioid crisis”. Plus, Stuart and Paul express s...2017-12-221h 15
The Curbsiders Internal Medicine Podcast#73: Opioid Addiction, Chronic Pain, and AbstinenceTake the pain out of pain management with clinical pearls from addiction medicine specialists Dr. Stefan Kertesz at the University of Alabama at Birmingham School of Medicine and Dr. Ajay Manhapra from the VA Hampton Medical Center in Hampton, Virginia. They walk us through an approach to pain management in persons with a history of opioid use disorder (OUD), discuss treatment options for OUD, plus hot tips on how to interpret guidelines surrounding opioids, and more! What are you waiting for? Hit the play button! Special thanks to Elena Gibson, MD and Carolyn Chan, MD
Episodes | Subscribe | Spotify | Swag...2017-12-1854 minThe Curbsiders Internal Medicine Podcast#73: Opioid Addiction, Chronic Pain, and AbstinenceTake the pain out of pain management with clinical pearls from addiction medicine specialists Dr. Stefan Kertesz at the University of Alabama at Birmingham School of Medicine and Dr. Ajay Manhapra from the VA Hampton Medical Center in Hampton, Virginia. They walk us through an approach to pain management in persons with a history of opioid use disorder (OUD), discuss treatment options for OUD, plus hot tips on how to interpret guidelines surrounding opioids, and more! What are you waiting for? Hit the play button! Special thanks to Elena Gibson, MD and Carolyn Chan, MD
Episodes | Subscribe | Spotify | Swag...2017-12-1854 min
Voices of VA Research PodcastSeverely limiting opioid prescriptions may harm pain patientsErica Sprey of VA Research Communications speaks with Dr. Stefan Kertesz, an internal medicine physician who works primarily with Veterans experiencing homelessness and substance use disorder. He runs the patient-aligned care team for homelessness at the Birmingham VA Medical Center in Alabama, and serves on its opioid safety initiative committee. In addition to conducting research on interventions for homelessness and substance use disorder, Kertesz has written extensively on the problem of opioid addiction and the movement to severely restrict opioid prescriptions.
Read More: 'Will strict limits on opioid prescription duration prevent addiction?'2017-08-2909 min
Voices of VA Research PodcastSeverely limiting opioid prescriptions may harm pain patientsErica Sprey of VA Research Communications speaks with Dr. Stefan Kertesz, an internal medicine physician who works primarily with Veterans experiencing homelessness and substance use disorder. He runs the patient-aligned care team for homelessness at the Birmingham VA Medical Center in Alabama, and serves on its opioid safety initiative committee. In addition to conducting research on interventions for homelessness and substance use disorder, Kertesz has written extensively on the problem of opioid addiction and the movement to severely restrict opioid prescriptions.
Read More: 'Will strict limits on opioid prescription duration prevent addiction?'2017-08-2900 min
NEJM InterviewsNEJM Interview: Dr. Stefan Kertesz on the success and evaluation of programs providing permanent supportive housing to homeless people.Dr. Stefan Kertesz is an associate professor at the University of Alabama at Birmingham School of Medicine and a physician at the Birmingham VA Medical Center. Stephen Morrissey, the interviewer, is the Managing Editor of the Journal. S.G. Kertesz and Others. Permanent Supportive Housing for Homeless People - Reframing the Debate. N Engl J Med 2016;375:2115-7.2016-11-3010 min
JAMA Author InterviewsAssociation Between Marijuana Exposure and Pulmonary Function Over 20 YearsInterview with Stefan Kertesz, MD, author of Association Between Marijuana Exposure and Pulmonary Function Over 20 Years2012-01-0306 minJAMA Author InterviewsAssociation Between Marijuana Exposure and Pulmonary Function Over 20 YearsInterview with Stefan Kertesz, MD, author of Association Between Marijuana Exposure and Pulmonary Function Over 20 Years2012-01-0306 min