Category: Healthcare

“That is not a drug, it’s a leaf.”
– Arnold Schwarzenegger

In the next few years, two of the many areas that could be interesting areas of medical research and therapy may be the the fields of cancer immunotherapy and the medical use of cannabinoids. Yes, cannabinoids – those extracts from cannabis aka marijuana aka weed!

No other plant is as controversial as Cannabis. In spite of an almost 5000 year-old history of use around the world, it has been a banned substance in most countries in the last 100 years or so.

It’s ill-repute stems from it’s psychoactive effects which can be significant.
Some of the chemicals inherent in the most common species of this plant, Cannabis sativa, have been isolated and they are called cannabinoids. There are about 85 of them. The two most researched are:

– Delta-9 Tetrahydrocannabinol (THC) and
– Cannabinol (CBD)

Whereas THC is responsible for most of the psychoactive effects (the high), CBD has none of the high effect. Both cannabinoids have some very significant therapeutic effects.

THC – analgesic, anti-spasmodic, anti-tremor, anti-inflammatory, appetite stimulant and anti-emetic
CBD – anti-inflammatory, anti-convulsant, anti-psychotic, anti-oxidant, neuroprotective and immunomodulatory effects

Even more interesting is that the human body has cannabinoid receptors. This has been an area of research for the last 20 years or so. Two types of cannabinoid receptors have been found so far – CB1 and CB2. CB1 receptors are present in the brain and spinal cord and in certain peripheral tissues. CB2 receptors are expressed primarily in immune tissues.
Now if the body has cannabinoid receptors, then humans must produce natural cannabinoids. At least 3 have been isolated so far – arachidonoyl-ethanolamide (anandamide), 2-arachidonoyl glycerol (2-AG) and arachidonyl glyceryl ether (noladin ether).

These endocannabinoids are involved in areas of the brain responsible for:
– movement and postural control, pain and sensory perception, memory, cognition, emotion,
control and reward centers in the brain (limbic system and hypothalamus)
– cytokine release from immune cells and immune cell migration

So when one uses marijuana, do the cannabinoids from the weed react with the natural receptors? That is the thought and that is how they exert their action.

The push is then for strains of Cannabis high in CBD to capture the medicinal sans psychoactive effects. This is achieved by altering the genome of the cannabis plant to get strains that contain mostly CBD. An example of a strain with high levels of CBD is Charlotte’s Web.

In the forefront for drugs made out of CBD is GW Pharma, a company out of the London, UK. They have a drug out named Epidiolex for Dravet Syndrom. This a condition marked by intractable seizures in kids. These kids can have over 20 seizure a month. It reduced the incidence of seizures in a study of 120 children by close to 40%. FDA approval is pending.

CBD-based drugs are also being studied for Multiple Sclerosis. It reduces the incidence and severity of muscle and bladder spasms as well as the intensity of neuropathic pain.
CBD has been shown to reduce the incidence of psychosis in Schizophrenics and may modulate symptoms of fear in patients with PTSD.
CBD has been shown to be very effective in the treatment of chronic pain with a much safer safety profile than opioids.
There are a few studies out showing the cytotoxic effects of CBD on breast cancer cells.

All these examples are but a few of the therapeutic possibilities being researched actively.

CBD however still remains a Schedule I substance and thus viewed as illicit when used without a prescription or in a state where the use of marijuana is not legal.

Maybe Bob Marley was right after all:
“Herb is the healing of a nation, alcohol is the destruction.”

“Half of us are blind, few of us feel, and we are all deaf.”
– Sir William Osler

This incident occured in my third or fourth year of medical School in Leipzig (outside the US, most medical schools are 6-year programs). We were on a medical-surgical (med-surg) floor one afternoon with one of our instructors for a session on the Physical Exam. Before we went off to terrorize our patients, he warned us to pay attention and observe. He asked us not to be too distracted by what the patients said – to listen but also to watch. To use all five senses.
I marched off to my patient – a 60-something year old woman who was in the hospital with an unknown-to-me cardiac condition. My job was to talk to her, examine her and figure out her condition and the cause. The patients are usually asked by the instructors beforehand not to divulge their diagnoses.
Well, my patient was as garrulous as they come. She thought I was the cutest thing she ever saw and I allowed her to pinch me cheek and pull my hair (I had a ‘fro then!). Soon she told me what her ailment was – Atrial Fibrillation (a condition where the heart beats iregularly) – and all the medicines she was on. Well, who was I to complain? I had my diagnosis and treatment. I stepped out, feeling like the second coming of Hippocrates. I had totally forgotten why I was in the room in the first place.
Well, I presented my patient to my instructor who promptly asked me what the cause of her Atrial Fibrillation (A-fib) was. Having neglected to examine her, I promptly responded that it was idiopathic, a fancy term for ‘I don’t know’. He asked me to list the causes of A-fib, which I did. He asked me if the lady could have Hyperthyroidism (an overactive thyroid gland and a cause of A-fib). I said no.
At this point, most of the other students were back. He introduced my case to the group and asked me to lead the group to my patient’s room. The instructor was a tall man and he was right behind me when I opened the door to the patient’s room. From the door, one saw the patient resting in bed and she turned her head to look at us as we entered. From about 12 feet away, one could see the goiter (a large swollen thyroid gland) bobbing in her neck. I wanted to vanish!

It’s a lesson I’ve never forgotten – to observe, to watch, to feel, to smell and listen. Do I do it well or all the time? Of course not but I try.
The power of observation is as important to the practice of medicine as the power of taste is to a chef. A doctor needs to be able to notice that jaundiced skin, that throbbing mass in the abdomen, those engorged veins in the neck, those blue lips, the child who is alwsys squatting instead of playing, those trembling fingers, that deviated tongue, that strange gait.
We need to listen to the patients’ answers but above all know what to ask. We need to examine patients and really listen to those breath sounds and make out those murmurs. We need to be able to smell those almonds on a patient’s breath.

The practice of observing the patient has been dealt a serious blow by the use of technology in medicine. In this age of CT-Scans and MRIs, why even bother? What not let technology do all the work? An echo will soon tell you if the patient has valvular disease so why does one need to know what aortic stenosis sounds like?
First, it makes one a better doctor then it forces a one to be interested in that human in front of him or her. You have to be truly interested in another person to observe them closely.
It also does save time and money. It cuts down the amount of useless tests. Sure, we do a lot of tests to cover our butts (Defensive Medicine), but there are also cases where a good physical exam does make a huge difference.
Further, it gives one a better picture of the patient. One may pick up other ailments that the patient may not even know about.
Our colleagues who practice in developing countries will tell you most times, all you have are your five senses.
(At this point, a shout out to all the doctors in Ghana and to two esteemed colleagues – one who spends half his time working in Haiti and the other who volunteers with Doctors Without Borders).
Recently, the practice of observation has been dealt another blow. Since electronic medical record-keeping became mandatory in most medical practices and hospitals, I often take time to observe other colleagues and nurses working. It is a sad sight. One sees extremely well-trained and dedicated professionals observing not the patient, but a screen. A culture that already suffered from the lack of observing the patient has been worsened by the need to chart electronically.
Then is the notion that the practice of medicine is nothing but a series on protocols and best practices and that the best results are obtained when everyone sticks to these protocols and best practices. Well, the jury is still out on the wisdom and effectiveness of that. As most practitioners will tell you, no two patients or two cases are ever the same.
Lastly, just the volume of patients one has to deal with plus production pressure make it sometimes really challenging to really observe well.

I look on in despair and wonder what William Osler would say if he was alive today. He aptly once wrote:
“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.”
We have all become experts but are we in the process forgetting how to see, hear, feel and smell? If we do forget, what kind of experts do we become then? I wonder, I really do…

Like life, the practice of medicine is filled with the highs and lows, the moments of heartbreak and euphoria of success, times of hair-pulling (if one has any) frustration and uplifting encouragement.
Loosing a patient unexpectedly is very traumatic. It happens to every doctor and it is a pipe dream to think it would never happen to you. It is a fact that some specialties are less prone to experience it than others. However, when it does happen, most physicians have no one to talk to.
Fellow physicians are the worst group of people to seek solace from. The majority have their own professional and personal issues. Then is the judgmental bit – “If you had done A instead of B, maybe…” Which leaves our significant others, the majority of whom have already been overburdened with medical talk to the point where they are insensitive and frankly do not care anymore. And then is the small issue of “..anything you say can be used against you when the family sues you!’
Would it not be great it there was a ‘listening ear’ for physicians in those times? I am thinking a 1-800 number one could call and be able to unload the disappointment and pain. Say 1-800-i-LISTEN.
A physician could call and talk anonymously to a listening ear about the death one had in the operating room (or emergency room or cardiac cath lab or floor).
About the fact that the team did all it could? About the fact that the patient had undiagnosed SAM or carcinoid or an unknown tight left main? About the fact that you were in the operating room for 15 hours? About the fact that you bonded with the patient and his wife gave you a hug and his kids shook your hand? About the fact that the malignancy was inoperable? About all those things we are supposed to keep inside because we are supermen but really aren’t?
What if you could just open up without fear of judgement or medico-legal action?
What if…?

“The Scream” by Edvard Munch, 1910

Then are those times where one out of pure frustration wishes to yell or scream or throw something. My surgical colleagues, can I get an Amen? Yet you cannot yell or swear or throw anything. It is unprofessional and creates a hostile work environment. It is absolutely disrespectful to the team busting their chops to make it happen. You may have done it in the good old days but we are in 2016 and that kind of behavior will get you in trouble quickly. However, every doctor has had a day where frustration rolled down like waters and impediments like a mighty stream. Where that surgeon didn’t understand that blocks sometimes don’t work, where that anesthesiologist cancelled that case even though the best cardiologist in town “cleared the patient”, where that cardiologist wants you to do that CABG today and not on Monday, where you are stuck in the OR because the PACU is full, where you find out that some administrator decided to pull your favorite suture or antibiotic because it’s too expensive, wherw you have to work with the scrub tech you cannot stand….. the list goes on.

You want to scream and yell and call someone names that would make Tony Montana wince, don’t you? You want to do that because long before you became a doctor, you were a human with emotions and long after you cannot practice anymore, you will still be that human!… And humans get frustrated and sometimes, just sometimes, want to yell and scream and hop up and down on one leg and then the other.
So won’t it be great if there was a Scream Room?
“Scream Room?”, you wonder. “What is a Scream Room?”
The Scream Room would be a soundproof room somewhere in the hospital where one could go and scream and throw things of one’s choice for as long as one wanted to let out pent-up frustration. One could use as many four-letter words as one wanted and jump up and down like Rumpelstiltskin if one wished to.
The room would also have a 100-lb punching bag hanging from the ceiling. There would be boxing gloves available. One only has to pin a picture of the cause of one’s ire on the bag, don appropriate size boxing gloves and punch away.
What if there was such a room?
What if…?
Like I wrote earlier, before we become doctors, we were humans. Humans are strong but can also be weak. They can be wise but sometimes folly reigns supreme. They can be patient and understanding but occasionally brash and irritable. It’s only in accepting our strengths and weaknesses that we become whole. Whole humans. Whole doctors.

The FDA regulates food safety, tobacco products drugs vaccines and medical devices among other things. The agency as we know it today came to be due largely to 3 health crises in the 20th century – the Diphtheria Antitoxin crisis of 1901, the Elixir Sulfanilamide crisis of 1937 and the Thalidomide crisis of 1961.

Prior to 1901, the only federal body that looked out for food and drug safety in the US was the Department of Agriculture’s (USDA) Bureau of Chemistry ran by Harvey Wiley. Wiley’s advocacy was aided by a crisis in 1901. At the beginning of the 20th century, there was no cure for diphtheria. In the US, there were about 200,000 cases per year with a death toll of about 15 000. With the introduction of the diphtheria antitoxin, attempts were made to vaccinate all children. On October 26 , 1901, a five-year-old girl died in St Louis, MO after receiving the vaccine. The cause of death was tetanus. Over the next weeks, other children died after receiving the antitoxin, which came from the St Louis City Health Department.

Now the antitoxin was made by injecting horses with the diphtheria bacterium and collecting the horse serum. Investigations after these deaths revealed that a horse named Jim, which had been used to produce the serum, had tetanus. It also revealed several other shortcomings at the City Health Department including mislabeled bottles, no testing of sera and continued use of the horse Jim even though the officials knew that it had contracted tetanus. In all 13 children died. Around the same time, a similar tragedy was occurring in New Jersey. Almost 100 cases of post-vaccination tetanus was recorded after administration of the small pox vaccine. In all 9 children died.
The public outrage after these events lead o the passing of the Biologics Act in 1902. In 1906, the Food and drug Act was passed.The Act prohibited, under penalty of seizure of goods, the interstate transport of food that had been “adulterated”. Wiley’s Bureau of Chemistry became the enforcer of this law. In 1927, his Bureau was renamed the Food, Drug, and Insecticide organization and shortened to the Food and Drug Administration (FDA) a few years later.

In the mid-1930s the antibiotic sulfanilamide came to the US market form Europe. It soon became the first line of treatment for streptococcal infections. It came in tablet and powder forms. Due to it’s taste, consumers, especially in the South, wanted a liquid version which would be easier to administer to children. In 1937, Harold Cole Watkins, the chief chemist at S.E. Massengill Company of Bristol, TN introduced the drug in it’s liquid form. Mr Watkins realized that sulfanilamide was soluble in diethylene glycol. The solvent that gave the mixture a sweet raspberry-like taste. He added extra raspberry flavor and coloring. Though he tested the mixture for taste, appearance and fragrance, he never bothered to test it for toxicity in humans or animals. Diethylene glycol, otherwise known as antifreeze, is rather poisonous.
In September 1937, the Massengill Co shipped 600 cases (about 268 gallons) all over the country. It was named the Elixir Sulfanilamide-Massengill.
On October 11, 1937, AMA officials in Chicago were informed of 6 deaths form a liquid sulfanilamide formulation in Tulsa, OK.There were also reports of deaths form Kansas City. On Oct 14, a NY physician tipped off the FDA about deaths from the Elixir Sulfanilamide. Meanwhile the deaths mounted. By Oct 17, it was apparent to the Masengill Co, the AMA as well as the FDA that the Sulfanilamide Elixir was causing deaths and that they had a crisis on their hands. Massengill Co, having been notified of the deaths was trying to recall the drug. The FDA urged the Massengill Company to send a follow-up telegram containing the caution “Product may be dangerous to life” to it’s salesmen.
Realizing the catastrophe at hand, the FDA dispatched all it’s 238 agents to round up all the bottles of the elixir on the market. The tales of how most of the bottles were rounded up in an era of relatively low level of mass communication can be the plot of a major Hollywood blockbuster.
Of the 268 gallons shipped, 267 gallons are confiscated. A gallon of the elixir was consumed in various parts of the country leading to 105 dead, including 34 children.
FDA and AMA had in the interim asked Dr Geiling, Head of the Department of Pharmacology at the University of Chicago to examine the elixir. Working on this project was one Frances Oldham Kersey, who almost 30 years later played a key role in the thalidomide crisis. The Geiling team analyzed the ingredients of the Elixir and found it to contain sulfanilamide, diethylene glycol, color and flavoring. They synthesized an elixir according to the same proportions and using rats, administered one of four solutions – the Massengil Elixir, their synthetic elixir, just sulfanilamide or just water. The rats who received the elixirs,as noted by Frances Kelsey Oldham, “shriveled up and died.”
It is worth noting how these victims died:
Victims of Elixir Sulfanilamide poisoning–many of them children being treated for sore throats–were ill about 7 to 21 days. All exhibited similar symptoms, characteristic of kidney failure: stoppage of urine, severe abdominal pain, nausea, vomiting, stupor, and convulsions. They suffered intense and unrelenting pain. At the time there was no known antidote or treatment for diethylene glycol poisoning, no dialysis machines or the ability to do renal transplants.
At the end, S.E. Massengill ended up paying over $500,000 (about $8.45 million today) in wrongful death suits. The company’s owner was also fined $26000 (today about $430,00) for mislabeling and misbranding; by technical definition, an elixir contains alcohol. The chemist, Harold Cole Watkins sadly committed suicide.
Most importantly, Congress passed the Federal Food, Drug and Cosmetic Act of 1938, a law that expanded federal regulatory oversight over drugs and mandated drug safety testing before marketing.

Dr Frances Kelsey Oldham started working at the FDA in August of 1960. She was responsible for the approval of new drugs coming to the market. Back then, the approval process was rather routine. The drug maker had to show that a few patients had take the drug without any ill effects. In September of 1960, the application for the approval of a new drug came across her desk. The drug, thalidomide, was being marketed under the name Kevadon by William S Merrell Co of Cincinnati. It was already on the market since 1957 in Europe, Britain, Canada and the Middle East, where it was used to treat nausea in pregnant women as well as a sedative.
Dr Oldham, working with a chemist, Lee Geismar, and a pharmacologist, Oyam Jiro, initially rejected the application for being incomplete. Early in 1961 came case reports about painful neuropathy in patients on Thalidomide in the British Journal of Medicine. She asked Merrell for more information. Merrell in the interim was mounting it’s own counter offensive, labeling Oldham as an obstructive petty bureaucrat and complaining to the higher-ups in the FDA. Dr Oldham however held her ground.
Dr Oldham had during the WWII also worked on new anti-malarial therapies. At that time, she became aware of the ability of certain drugs to cross the placenta into a fetus with negative consequences. With this in mind, she also asked Merrell to furnish her with any data on fetal effects of the drug. After all, it was being administered to pregnant women. This was in May of 1961. In November 1961, reports began to emerge in Germany and the United Kingdom that mothers who had taken thalidomide during pregnancy were now having babies with severe birth defects – phocomelia. The occurrence of this malformation in an individual results in various abnormalities to the face, limbs, ears, nose, vessels and many other underdevelopments. Although operations can be done to fix the abnormality it is difficult due to the lack of nerves, bones, and other related structures. In all about 4000 babies were affected worldwide. Thalidomide samples given to American doctors were traced, but not all were recovered. Seventeen births of babies with phocomelia were reported in the US.
Merrell pulled it’s application in face of all this evidence.
The efforts of Dr Oldham would have gone unnoticed were it not for coverage in the Washington Post of all her efforts to keep thalidomide off the US market. In August 1962, President John F. Kennedy awarded Frances Kelsey the highest honor given to a civilian in the United States, the President’s Award for Distinguished Federal Civilian Service. Also, Congress passed the Kefauver Harris Amendment or “Drug Efficacy Amendment” in 1962 amendment to the Federal Food, Drug & Cosmetic Act. This amendment required drug manufacturers to provide proof of the effectiveness and safety of their drugs before approval. It provided a proof of efficacy requirement that was not there before. It also required them to provide information of side effects when advertising and stopped cheap generic drugs being marketed as expensive drugs under new trade names as new “breakthrough” medications. It effectively gave us the FDA we have today.

The issue of MJ’s death bothers me not because I was a huge fan. No! I loved his earlier work but I recently realized I don’t have any of his albums! ….and believe me, I collect! It bothers me because it shows physicians behaving badly.

MJ was using several aliases to get narcotics and propofol, and no one noticed or tried an intervention! My only explanation is that, the money all the physicians were getting, bought their silence and compliance! How sad!
Another issue that bothers me is the fact that MJ was using propofol like water! But then there are lots of non-anesthesiologists who demand to use the drug and will probably not appreciate it’s effects.
The practice of anesthesia is a not something one dabbles in. There are peoples’ lives at stake. I know there is a perception out there that “we just put the patient to sleep”! Well, someone just put MJ to sleep, this time eternally!
We as a profession may also have contributed to this perception. True, there is a lot of downtime during certain cases but the probability for loss of life is ever present. Less if you are dealing with healthy, young adults having elective surgery but much higher with the old and very sick.
So we as a profession always stay vigilant. We understand the medications we use, know their effects and appreciate the possible complications. We get to know our patients as well as a physician should and tailor the anesthetic to their needs, the surgical procedure and their general health status. Most important of all, we try TO DO NO HARM! We will not provide an anesthetic for a patient if the anesthetic will endanger his life and the surgery is not life-saving. We will not provide anesthesia at places where we feel the we will not be able to support the patient’s if he needs cardiopulmonary resuscitation.
Of course there are exceptions. If one works in developing countries, one makes do with what they have in equipment and supplies. Then also, there are anesthesia providers who may not be conscientious, but that is the minority.

So it bothers me to see how easily our practice was mimicked to someone’s detriment. We don’t know the details yet but a non-anesthesia provider thought administering propofol in someone’s home without the necessary support and know-how was a piece of cake.
Whoever you are I have news for you – IT AIN’T EASY!

The country is in the grip of a healthcare debate that is split unfortunately along party lines. No matter what changes are made, there are certain attitudinal changes that the population has to make or we’ll be worse off than before.

Before all that, there is one question for which I cannot find a good answer.

Is healthcare a privilege or a right?

There is nothing in the constitution about that. Now in the Declaration of Independence, we read:

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

That is the closest we come to healthcare being a right. Now prisoners have it good – they receive free healthcare because it is seen as an obligation of the state to them!

If the constitution does not guarantee it, then any argument for or against is just that – an argument!

Congress must then decide whether to pass this as a law or not. If healthcare is a right, all efforts must be made by the government and businesses to ensure that all have adequate access to healthcare. If it is a privilege, that totally changes the stakes. Then, anything the government or businesses want to do is subject to good will and policy.

My feeling is whereas a majority of liberals see healthcare as a right, many conservatives and libertarians see it as a privilege!

As I said earlier, regardless of what happens, the population needs a huge attitudinal change to make any form of healthcare policy work.

1. Prevention is better than cure.

This is an old saying and it has stood the test of time. Yearly checkups, mammograms, staying active, eating healthy are little things that go a long way to keep one healthy and prevent that severe illness and fat bill from the surgeon! It seems to be an anathema these days. It’s get sick, then rush to the ER! Even people with good health insurance are guilty of this. Whatever type of policy is decided on, it should mandate yearly visits to a physician and quarterly visits to a dentist! Europeans tend to be healthier for several reasons – one is the fact that they have very good preventive healthcare.

2. Each is responsible for his/her health.

Just as I am responsible for my car’s upkeep, so am I responsible for my body, mind and soul. If my car’s engine burns out  because I forgot to fill it with oil, I cannot blame my mechanic if he can’t fix it. The repair is usually so expensive, most people don’t consider replacing the engine. On the other hand, if one eats uncontrollably, drinks and smokes and ends up in the hospital with heart failure, the expectation is that the doctors should fix him to be as good as new! Consider a scenario where each citizen controlled his/her own healthcare dollars. You paid for every procedure, visit, test etc or you bought the insurance to pay for these services. It would make people  more cognizant of the cost of not taking good care of themselves. I believe there should be an added cost for being obese, for smoking  and/or drinking and for not getting yearly checkups. If a young man decides to go riding his motorcycle even though his blood alcohol level is in the stratosphere, any care he subsequently receives after he wrecks his bike should come out of his pocket. In short, be responsible for your health.

3. Don’t forget the baseline.

We live in the age of Viagra, where sex is possible for the older generation. Age does not seem to be much of a hindrance anymore. In 2007 a 60-year-old woman delivered twins in New Jersey. Last year, a 59-year-old delivered triplets in France! We keep pushing the limit. It is no surprise that patients expect nothing short of miracles when they show up in the hospital. Expectations are so high that, it is not uncommon that both doctors and patients seem to forget the baseline. A diabetic who has  uncontrolled blood glucose for years is not going escape unscathed. If he/she shows up with a gangrenous foot, that limb has to be amputated and their mobility is going to be compromised. This reduces physical activity and increases the already high chances for morbidity. Don’t forget the baseline!  It is sad to loose patients to cancer but terminal cancer is in most cases, well, terminal. Heroics just lead to even greater disappointment and pain. Don’t forget the baseline!

4. Let there be Dignity in Death.

Maybe it’s cultural, maybe it’s the wish not to loose a loved one but millions of dollars are spent every year in the care of patients who should have been left alone to die in dignity. It may be that the patient is too old and frail to survive a surgical procedure or that a particular test won’t add anything to the attempts to save a loved one. Time and time again, family members insist on having everything done. They are not alone in this. Physicians are apt to give them false hope. There is the need among some doctors,  to look like the knight in shinning armor who swooped in and saved the day. Then is the small matter of litigation attorneys who circle like buzzards. It is much more dignified to let a death occur with family members (after the requisite goodbyes) than alone in some hospital room with the body flayed open and expectations crushed! I agree, death can strike anytime but if one has the chance to prepare for it, isn’t that a bonus for the family and loved ones? Lets accept death when it’s inevitable  – we’ll afford family members and patients dying in dignity and save countless healthcare dollars.

Healthcare resources are not infinite. Lets use what we have wisely!