Comfort Books

Tax season is always a stressful time around the Warnick house. With a professional musician in the family (my wife is a violist) tax time has always been, well…taxing…but, now that I have also joined the ranks of the self-employed, it can all be a bit overwhelming. For 2013 we had twenty W2′s and 1099′s. Twenty! Yes, we do have an accountant. A few years ago we spent an entire Sunday doing our taxes on our own with Turbo Tax. At the end, after we submitted them, we looked at each other and realized we had no clue if we had done them correctly. We’ve had an accountant ever since. Even so, it’s always a guessing game as to how much we’re going to owe this year.

In times of stress, while many people turn to “comfort food” to ease their troubled minds, I frequently find myself turning to “comfort books” (OK, yes, I turn to comfort food, too…) to help relax. For me, a comfort book is something for which the reading of it is a purely pleasurable experience. I want to be able to sit down, take a moment to read a chapter or two, and come out of it feeling more relaxed then when I started. This rules out much of my usual reading material. Whereas Connie Willis’s books on time-traveling historians in WWII era London or Henning Mankell’s Wallander series are really excellent reads, they are not the sort of books I turn to to soothe my soul. For that, I turn to baseball.

My go-to comfort books for the past few years have been memoirs and essays on America’s pastime. I love books about the history of the game and tend to gravitate towards authors who focus on the subtle nuances and pace of the game – writers not afraid to spend an entire chapter talking about sitting in the bleachers of a late July battle between two non-contenders on a hot and humid Texas night in 1982. They are masters at adapting their writing style to embrace the sights, sounds, and tastes of the game – less about telling a story; more about the slow rhythms and atmosphere that surrounds a night at the ballpark. David Halberstam’s Summer of ’49 and October 1964, Buzz Bissinger’s 3 Nights in August, and Dan Barry’s Bottom of the 33rd are all brilliant examples of this style of writing and my own personal comfort books. Summer of ’49 got me through my wife’s surgery to remove a meningioma. October 1964 was there when I came home late every night during my ACCME reaccreditation. 3 Nights in August traveled with me while going solo to a weekend conference in Spain.

Last week I attended the ACCME’s “CME as a Bridge to Quality” Accreditationangell Workshop and spent an evening wandering around After-Words New & Used Books — a must-stop for me whenever I’m lucky enough to have a little free time in Chicago. While browsing through the used books, I was thrilled to find a pristine hardback copy of Season Ticket by Roger Angell, one of my absolute favorite baseball writers (and one of my favorite writers, period, as exemplified by his recent New Yorker article on aging). What better way to get through the stress of another tax day than a series of essays on baseball in the 80′s — the decade that shaped and molded my childhood fandom – by our greatest living baseball writer? Just read these few sentences on escaping a crowded parking lot during a July 4th Mets game:

Actually, by the time we turned up at Shea the lot was full, with the gates and pay booths closed, and we had to make do with a narrow, muddy little junkyard off some street out beyond the center-field parking sectors, where a local entrepreneur took our seven bucks and then absolutely buried us in a welter of other late-comers. No hope, but when we found our way back there, hours later, beyond the motionless thousands of overheating cars and captive fans and patriots self-blocked in the main lot, someone in our group spotted a little alley at the back of our yard, and we took a chance and swung that way, against the flow of cars inching out, and found a miracle there: an empty street. I zipped through a couple of blocks, hung a right away from the honking tangle, extemporized a dazzling U-turn under the Whitestone Expressway, guessed and grabbed another right, spotted the good old boat basin off to my right, and laid a little left onto the Grand Central Parkway: home free, homeward bound, with the cheers of my fans in the car and cascades of Queens-side Roman candles on either hand celebrating our brilliant departure.

Sounds about perfect to me. If anyone needs me, I’ll be reading.

CMEpalooza Recap

It’s now one week post-palooza – seems like a good time for a recap. Let’s get right to it…

So, what was the point?
The point of CMEpalooza was three-fold:

  1. Provide a forum for individuals to present on any topic related to CE/CME. More specifically, I was particularly interested in folks who were uncomfortable presenting in traditional formats or who had something they wanted to share but had been unable to do so at the Alliance conference and elsewhere. I think CMEpalooza was successful in meeting this goal, judging from the variety of presenters and topics we had. I know for certain that several of the speakers did presentations for which they had abstracts turned down by the Alliance. I don’t know if any of the presenters chose to talk at CMEpalooza because they don’t like speaking at “normal” live meetings/conferences, but at least there were people presenting whom I’d never heard speak before.
  2. Show that doing an event of this scale was possible with freely available tools. In other words, if I was going to talk-the-talk, I wanted to walk-the-walk. I’ve done a number of blog posts and presentations on DIY CME and I’ve done some small scale projects, but I really wanted to show that the same tools I used for my smaller projects could be used just as easily for larger scale projects. Mission accomplished. We had a two day, 21 session event that over 200 people visited each day (more details below) and I spent absolutely no money on. Zero dollars. That includes software, hardware, marketing, AV, etc. All the tools I used were free for me and they’re free for you.
  3. Demonstrate that content is still king. From my perspective, the beauty of CMEpalooza was not that Google+ Hangouts is this incredibly unique learning format that keeps participants engaged purely through its own inherent awesomeness. Really, it’s just streaming video with slides and talking heads. Nothing so special about that. No, the beauty of CMEpalooza was the diversity of topics and excellent speakers — there was something for everyone. Participants visited CMEpalooza for the content, not the format. The tools are what enabled me to put it on, but if we had had lousy presenters or topics no one was interested in, no one would have watched regardless of how it was presented.

Was it a success?
Well, I had pretty low standards going in to it — as I stated many times, my goal for CMEpalooza was a consistent standard of “good enough” — so based on that, I’d say yes. We had a few technical glitches and delays, but nothing that stopped any sessions from happening and we never got too far off-schedule. All of the presenters and participants I heard from seemed to be happy and/or impressed with how it went (side note: I heard from a couple of folks afterwards who told me  they had their doubts about whether I could pull off an event of this scale with the tools I was using). I was happy with how it went. But, let’s look at the actual data.

Live sessions: most sessions averaged between 30 and 40 viewers, with a high of 50 and low of 10. The exact number of viewers per session is difficult to determine since I heard from multiple individuals who said they were watching sessions in a group setting, so the actual number of viewers is likely a bit higher than the number of views.

Archived sessions: The CMEpalooza archive was posted a week ago and since then, each session video has been viewed at least 33 times. Most of the March 20 videos (which were posted 3 days earlier than the March 21 videos) have at least 70 views with a high of over 100.

Website: On the first day of CMEpalooza, March 20, the CMEpalooza website had 243 unique visitors and 1932 views. On the second day of CMEpalooza, March 21, the website had 204 unique visitors and 2055 views. Since then, the website has averaged about 140 views per day.

Considering that when I first decided to do CMEpalooza, I didn’t know if anyone would watch, I can’t help but think that these numbers show that it was a rousing success.

If you had to do it over again, what lessons were learned for the next go-’round? (Question courtesy of Jacob Coverstone)
In all honesty, there’s not a lot that I would change. A few things that come to mind:

  • If I do it solo again, I’d design the schedule differently to give a little more time in between sessions. I’d like to have a little more time in the “green room” with the presenters before going live, to work out any last second glitches and not feel quite so rushed.
  • A second moderator would be ideal. As one session is going on, the other moderator could get the next one set-up and be ready to go as soon as the current session was over. They would also be able to help with questions. I was literally running slides with my left hand and responding to email, texts, etc with my right.
  • I wasn’t totally satisfied with the options for Q&A. The Google+ app worked exceedingly well, but too few people watching had a G+ account to use it. I’m not sure if the lack of questions was due to people not being able to ask them or just not having any.
  • It’s not a high priority, but having a nice set of headphones/microphones for all presenters would have been helpful. It’s something to consider if I do this again.

Are you going to do it again?
Many people have asked me this and…I don’t know. People seemed to enjoy and appreciate it, so I think I’d like to. I was in a unique position that allowed me to have the time to dedicate to a project like this (i.e. one that i made no money from) and I don’t know if that will be the case in the future. So for now I’m going to leave it that I’d like to, but we’ll see…

Overall, I was really pleased with how CMEpalooza went. If anyone has any questions or feedback, please feel free to comment below or shoot me an email. Thank you.

CMEpalooza: One Week To Go!

[a tumbleweed slowly rolls by, nearly taking out a semicolon on its way past...]

Things have been a might bit quiet around these parts, lately. A little too quiet, if you know what I mean…

Yes, the old Confessions of a Medical Educator blog has been gathering a bit of dust while I’ve been focusing my energies on CMEpalooza. Sad. But while we’re on the subject — Hey! CMEpalooza is only one week away! Wow!

If you haven’t been following the palooza blog (spellcheck tells me “palooza” isn’t a word. YOU’RE NOT THE BOSS OF ME SPELLCHECK!!!) here are a few quick updates on how the prep is going.

  • We’ve extended the palooza to a second day (I say “we” to make you think I have a staff of 20 working behind the scenes on stuff. There’s no staff. It’s just me. We’re very streamlined and efficient.). Here are the links for the March 20 and March 21 agendas.
  • For the past two weeks I have been holding quick Google+ Hangout training sessions with each CMEpalooza presenter and they have proven to be well worth the time and effort involved. If you’re ever [nuts] enough to try something like this on your own, I highly recommend doing something similar. It’s helped iron out a few glitches, both self-induced (sending my first two “trainees” the wrong link to access the Hangout) and presenter-induced (usually simple things like accidentally muting the laptop or forgetting to turn on headphones).
  • As I stated over on the CMEpalooza blog, I’m now 99% sure I can pull this off. Using Google+ Hangouts On Air is a good system, but not a perfect system. The audio and video quality fluctuates and isn’t always 100% in-synch. The picture can be a little jerky depending on the speed of the presenter’s internet service (I learned the hard way not to let my kids stream Netflix while I’m trying to do a Hangout. Good Luck, Charlie, indeed!). But overall, it’s pretty good and that’s my basic goal for this. I’ll be happy with “pretty good” and satisfied with “not bad”.
  • Lastly — and maybe most importantly — I created a page on the CMEpalooza website (http://cmepalooza.wordpress.com/live) where you can go to watch all the presentations as they stream live. You can read more specific instructions about watching the presentations here.

Another Snow Day

This is a close approximation to what my house in northwest Philadelphia currently looks like.

house-snow

 

 

 

 

 

We’ve had so much snow, I don’t think my kids even remember what school is anymore. It’s starting to turn into Lord of the Flies around here and I’m afraid I might be Piggy.

Anyhoo, all that is just a terrible segue for me to let you know that I’ve had a lot of time in front of the old MacBook Air, lately, and I’ve more or less finalized the CMEpalooza schedule. We’ve expanded the palooza to include an extra day (March 21), starting at 10 AM ET each day and ending somewhere after 3 PM. East coast bias? Yes, probably, but too bad, left-coasters. Wake up early, grab another Venti soy chai latte with extra foam and you’ll be fine (all this snow is making me unsympathetic as well as grouchy. Yikes.). You can see the March 20 schedule here and the March 21 schedule here.

Of Collaborations Loved and Lost

I thought we had something special,

You and I.

I thought we had a connection.
We communicated by email.
We talked on the phone.
We arranged to meet in person,
face-to-face.
We clicked.
It worked.

I thought we would do great things together,

You and I.

I thought you were the one.
You said, “Follow up.”
You said, “Get back to me next week.”
You were excited to work together.
So I did.
I emailed.

No response.

“That’s OK,” I thought to myself.
I was sure you were busy.
I’ll just wait a-while longer,
I told my laptop.
And I did.
I waited.
Another week.

No response.

“Hey,” I emailed to you,
“My email’s been on the fritz.
Wanted to make sure
you got my note.
Let me know,
if you did.
Thanks.”

No response.

Did I do something wrong?
I wondered,
Did I misspeak?
What wrong have I done to deserve
no response?
So, I picked up the phone
and I called you.

 *****

I’m glad we were able to chat,

You and I.

I’m glad we talked, again.
You said you’d been busy.
You said you’d been traveling.
You said you’ll get back to me.
I believe you.
I’ll wait
for

your response.

 

 

Last Week to Sign Up for CMEpalooza

The official deadline for submitting a presentation for CMEpalooza – February 1 – is fast approaching. We currently have nine presentations scheduled and if that’s what we have at the end, I’ll be 100% OK with that. Still, I’d love to see that number go up a little bit and be able to have a full morning and afternoon of educational presentations.

So, if you have any interest in doing a presentation, head on over to the CMEpalooza site right now and fill out the form. It will take you about 5 minutes. I’m telling you, doing a presentation won’t get any easier than this. You can do it from the comfort of your own home, wearing a T-shirt and slippers, with a cup of coffee in your hand (hmmm…I just described myself). I’ll control all the slides (if you have them) and ask the submitted questions (if there are any). All you have to do is look into your webcam and talk. I’ll even virtually hold your hand through a Google Hangout test run beforehand. It will be a low key, low stress environment.

After February 1, I’ll begin the process of contacting presenters and putting a schedule in place. There may still be room for any late additions, but first priority for time slot will go to those who already have submitted. If you have any questions about the process or your potential topic, please feel free to contact me.

#acehp14 Ignite Session: DIY CME

Below is my DIY CME Ignite session from last week’s Alliance conference. OK, no, it’s not the actual live session, but one I recorded beforehand using Screenr, one of the tools I talk about during the session (Yes, I used Screenr to talk about Screenr. How meta…). An Ignite session is 20 slides, 15 seconds per slide, auto-advancing. It’s not easy to put together and it’s easily the most time I’ve ever spent preparing for a 5-minute presentation.

I got two tips on putting together an Ignite session that I found to be very helpful: 1) Practice, practice, practice; and 2) Tell your story. I definitely did #1 and tried to do #2 the best I could. Unlike most presentations where I first make my slides and then talk about them during the presentation, for the Ignite session the first thing I did was write out an entire script. I edited and rewrote it until I had it down to 5 minutes and then I started breaking it into 15 second chunks. Once I had those 15 second chunks edited to make sense, then I made my slides. Since I only had 15 seconds per slide, I wanted the focus to be on what I was saying, not what was on the slides. That’s why I eschewed bullet points in favor of pictures and images, so the slides could just run in the background as reinforcement, without requiring the audience to try and speed read through them. That was my goal, anyway.

Below is the actual script I used and shows how I synched my text with the slides.

*****

SLIDE1
Good morning, everyone. My name is Derek Warnick and the man whose picture you see currently up on the screen is my father Don Warnick, one of the most stubborn individuals you will ever meet and a man who absolutely refused to let the words “I can’t” be used in his household.

 SLIDE2
He drove my sister and I crazy, but we understand why he did it. This is a man who grew up on a small farm in southern Delaware, where saying “I can’t” just wasn’t something you did.

SLIDE3
When one of the tractors broke down, you didn’t say I can’t. You fixed it yourself. When the electric in the old farmhouse needed to be rewired, you didn’t say I can’t. You rewired it yourself.

SLIDE4
When you get told at 8 years old that your aunt’s cornfield needs to be plowed and it’s not going to plow itself, you didn’t say I can’t. You hopped on the tractor and plowed it.

That do-it-yourself mentality has carried down to me, though sadly, not in the more practical areas of everyday life.

****(1:00)

SLIDE5
In all honesty, if I have to do much more than change a tire or light bulb, I’m at a bit of a loss. But, when we’re talking about CME and the use of technology – that’s when my DIY genes kick in.

SLIDE6
I have been fortunate in my career in CME to have worked for a few organizations where contracting out difficult or complicated tasks, especially those related to technology, wasn’t an option.

SLIDE7
This provided me with a great opportunity to learn how to do things on my own, without the assistance of an outside vendor or IT company.

It also helped me to realize not only just how expensive it is to put together a CME program but also that it doesn’t have to be that way, if you don’t want it to be.

SLIDE8
And that’s what I hope you take away from this and many of the other sessions in the Technology track: given all of the advancements in technology, you have fewer and fewer reasons to say “I can’t” when it comes to creating CE or other projects for your office, no matter how small your organization.

 **** (2:00)

SLIDE9
Here’s a quick example of what I’m talking about. I can remember spending hours putting together How-To demos using screenshots of my desktop and pasting them into Word with text descriptions. They did the job, but were both time and labor intensive.

SLIDE10
But now, I can use one of my favorite new tools, Screenr (which you just know must be cutting-edge by the way it’s spelled), to take a screen capture video of my desktop and create and even more effective How-To demo in a fraction of the time.

SLIDE11
Screenr is really simple to use and you can create up to a 5 minute screencast for the low-price of zero dollars.

Or, how about something a little more complex? How about a virtual conference where you can have a panel of speakers

SLIDE12
from across the globe and streaming video that allows anyone with an internet connection to watch and participate in Q&A?

And how about if that streaming video can then be automatically archived to create an enduring internet activity?

 ****(3:00)

SLIDE13
And to top it off, how about if the technology that allows you to do this is also completely free? That is the capability provided by Google Hangouts, specifically, the Hangouts On-Air feature, which, in my opinion, has been vastly underutilized as an educational too.

SLIDE14
Let’s take this idea one step farther and bring something like WordPress into the picture. Many of you probably know WordPress as just a blogging platform, but it can be utilized for so much more than just that.

SLIDE15
Say you’re a small organization that can’t afford the expense of your own Learning Management System. You can use WordPress to create your own mini-LMS.

You can take that Google Hangout video that is now archived in YouTube, embed it on your WordPress site

SLIDE16
and add one of the survey modules available to WordPress users that will allow you to create a post-test, evaluation, and customized certificate. You can create a full online CME activity with little to no coding experience.

****(4:00)

SLIDE17
I’ve done it. It’s not that hard. The cost of the WordPress site and survey module will set you back about a hundred bucks. No, it’s not free, but pretty darn cheap when you consider the alternatives.

SLIDE18
When I look at all the tools that are now available to us as educators, I truly believe that we are running out of excuses for saying I can’t. If there is something you want to do, there is most likely a tool out there

SLIDE19
that will help you do it, cheaply and effectively. In 5 minutes I have told you about 3 of them and you are going to hear about even more over the next few days through the sessions during the technology track.

SLIDE20
I encourage you to find a tool that fills a need for you, learn more about it, and give it a try. As my dad would say, never say I can’t. You can – you just need to figure out how.

Do State Accredited CME Providers Fall Under Sunshine Act Exemption Criteria?

Things were going pretty much as expected during the Shining a Light on the Sunshine Act session at the ACEhp 2014 Annual Conference last week, when the representative from CMS (whose name I failed to catch) dropped this little doozy out of the blue:

As you may recall, one of the exemption criterion for the reporting of transfers of value is that the program meet the accreditation/certification standards of the ACCME, AOA, AMA, AAFP, or ADA DERP. An individual in the audience asked that CMS clarify that state-accredited CME providers – who are accredited by their state medical society and not directly be the ACCME – do, in fact, meet that exemption criterion. Much to the surprise of everyone in the audience, her response was “no.”

The moderator, Jacob Coverstone (who did an excellent job parsing and clarify questions), attempted to rephrase the question differently, but the response was still “no.” An individual from the audience tried a different angle and stated that since an activity from a state-accredited provider is certified for AMA PRA Category 1 credit, it is meeting the AMA certification standards and should be exempt. Again, the response from CMS was “no.”

It seemed evident to me that the individual representing CMS was confused by and/or not familiar with some of the terminology that is second nature to many of us in the CME community (ACCME accreditation vs AMA certification, etc). In her defense, she was participating remotely via audio only, which comes with it’s own challenges. The session ended with an agreement that this was an issue that would need to be discussed in more detail and possibly result in an FAQ being submitted to CMS.

This is no small matter. According to the ACCME’s current list of CME providers, there is in excess of 1200 state-accredited providers, all of whom just discovered their CME activities aren’t exempt from Sunshine Act reporting requirements. Yikes.

Please keep in mind that I am paraphrasing and writing this post based on what I remember from the session. If you weren’t there, I encourage you to listen to the archived webinar (the specific Q&A on state-accredited providers comes near the end).

(UPDATE: There is a very thorough discussion of this issue over on the CME LinkedIn Group page. Well worth your time to read.)

As a side note, I did bring up the issue of individuals with dietary restrictions now being required to report their meals, which I blogged about a few weeks ago. My question to CMS was whether the CME provider had handled the issue correctly by informing the individual who requested a kosher meal that their meal would now need to be reported, when no other individuals meal was required to be reported. The response was “yes”, and then a lot of murmuring from the crowd. So there you have it. Good times all around.

20 Things I Believe

I believe that I’m a huge fan of the recent interviews Medical Meetings has done with Dr. Murray Kopelow.

I believe that we need more of this type of advocacy on behalf of the CME community.

I believe that Pete Rose, Barry Bonds, and Roger Clemens should all be in the Baseball Hall of Fame.

I believe that Dr. Wes’s blog post on The Slow Death of the Medical Blog-o-sphere is right on the money.

I believe that the situation is even worse when it comes to CME blogs.

I believe that this makes me kind of sad.

I believe that the Bacon Batter Bread I made last week was outrageously delicious and should probably be illegal.
IMG_1432

I believe I’m looking forward to going to the Alliance conference in Orlando next week.

I believe it’s been freaking cold in the Northeast these past two weeks.

I believe that might be the biggest reason I’m looking forward to going to the Alliance conference in Orlando next week.

I believe that the Flipped Classroom educational model might be a bit overrated.

I believe that I believe that because I believe most participants won’t do the initial work required for it to be successful.

I believe others will disagree with me and call me a Negative Nellie.

I believe they might be right.

I believe I’m looking forward to doing my Ignite Session on DIY CME next Thursday.

I believe I’m also a little nervous about it.

I believe that being an independent CME consultant can be a tough gig sometimes.

I believe that I still enjoy doing it.

I believe that the friends I have made in the CME community are incredibly supportive and I’m thankful to have them.

I believe that this “Sad Clown with the Golden Voice” cover of Lorde’s Royals is mesmerizing.

In Defense of Medical Education Companies

Yesterday, a “Brief Report” was published on the JAMA website titled Medical Communication Companies and Industry GrantsI have a few issues with the report and plan to write a more thorough response to the article with a few of my CME colleagues in the near future.

In addition, lead author Sheila M. Rothman, PhD did a brief interview with news@JAMA, which you can read here (no paywall). I would like to offer a quick response to one of the comments Dr. Rothman made on how “medical communications companies” work. Here is the question from news@JAMA and Dr. Rothman’s reply:

news@JAMA: How do medical communications companies work?

Dr Rothman: These organizations are fairly obscure and haven’t been studied. They essentially are groups that provide information they get from pharmaceutical companies and give it to consumers and physicians. They also take information from consumers and physicians and “give” it back to pharmaceutical companies.

A few points:

1) There is a difference between certified-CME and promotional education. Medical communication companies do promotional education programs. Medical education companies do certified-CME programs (the ACCME defines them as “publishing/education companies”). The companies listed in the JAMA report are ACCME-accredited medical education companies doing certified-CME programs. They do not do promotional education. They are not allowed to. This is an important distinction.

2) Just because you have never heard of something doesn’t mean it’s “obscure”. Medical education companies have been around for many years and are quite familiar to a lot of people. I never heard of Weibo until a few days ago. Half a billion registered users tells me it’s hardly obscure.

3) Medical education companies – and those that work there – do not “provide information they get from pharmaceutical companies and give it to consumers and physicians.” Developing certified-CME activities in this manner is a direct violation of the ACCME’s Standards for Commercial Support and would lead to a CME provider losing their accreditation status. There are strict regulations with regards to the communication between CME providers and pharmaceutical companies about the content of CME (to be specific: they can’t talk about it, period.) These are the same standards hospitals and academic medical centers and all other provider types are held to. I would even venture to say that since most medical education companies are aware they are highly scrutinized due to perception biases, they frequently hold themselves to an even higher standard. The content of certified-CME activities does not come from pharmaceutical companies. This may have been more of an issue 10-20 years ago, but it’s not how it works now.

4) Yes, medical education companies do “take information from consumers and physicians and ‘give’ it back to pharmaceutical companies,” but not the information implied by this article. The information given to pharmaceutical companies are outcomes reports based on evaluation and pre/posttest data from specific CME activities. These reports summarize various levels of participant outcomes for the specific activity, ranging from satisfaction with the quality of the activity to how they have used the information from the activity in their practice. Frequently, these reports include a summary of participant demographics: physicians vs non-physicians, areas of expertise, number of years in practice, etc. Personally identifiable participant information is not given to pharmaceutical companies. I cannot vouch for every single medical education company, but it is certainly not common practice. Ironically, this will unfortunately change due to the Sunshine Act. Reporting of personally identifiable information such as names, addresses, medical license number, etc, is now required for Certified-CME activities where a transfer of value, such as plated meals, is included. Don’t blame the medical education companies for this. Blame CMS.

These medical education companies have real people with real jobs working for them. It hurts me when I seem them being represented inaccurately. They deserve better.