Steven Reames has been the executive director of Ada County Medical Society since 2014. He has served in a variety of non-profit leadership roles in Boise since 2000. In his monthly blog for ACMS, he writes about personal reflections as he sees it from his chair in the Boise area medical community.
Last month, I hung out on the sides of a memorial service for Dr. James Valentine that was hosted by the St. Luke’s Medical Staff Office. Dr. Valentine passed away in a self-piloted helicopter crash in October near the Owyhees; his daughter who was riding with him survived. For those who do not know him, Dr. Valentine was a highly skilled bariatric surgeon who has been part of our medical community for 26 years. His surgical colleagues admitted that he was twice as productive as them because of his honed giftedness in the operating room.
There was, of course, a lot of grief and tears expressed, the quiet and solemn sense of loss, not just of a prominent surgeon in our community but also of a giant among human beings. On and off the field, he had a ravenous appetite for adventure and various hobbies. He taught one of his daughters how to fly a prop plan on a trip through Canada and the next week he turned around to go hiking in the Himalayas. He owned a Hummer, sports car, a dump truck and a smart car, the last of which apparently was especially fun to pull his six and-a-half foot frame out of. But beyond his technical skills, and maybe a little eccentricity, what was spoken about most was his genuine interest in every person that he encountered.
From the janitor to the nurses and M.A.s, physicians and patients, everybody shared how intensely interested Dr. Valentine was in their lives. In the middle of a fast-paced clinic, he would slow down to inquire with people how were things going. When finished with the patient’s health care needs, he would extend the appointment just to get to know them a little more, often asking patients, “What do you do for fun?” He loved making people laugh. As one doctor put it, “He was the only surgeon I’ve known to bring a fart machine into the operating room.”
And as I watched people laugh, cry, console and comfort each other, I believe that I witnessed a microcosm of the entire medical community we live in. The fact is that in healthcare, there is going to be pain. Sometimes it will revolve around patient care: bad outcomes, a malpractice suit, family that feels let down by our efforts. Other times, pain is initiated by the systems in which we work: bureaucratic hurdles to get good care to patients, credentialing issues, peer review, coding, and EMRs. We live in a world that no matter how hard we work at it to iron out all the kinks, there are always going to be kinks.
So, in this moment I felt honored to witness, I saw the true picture of how see our medical community operating under the most trying of times. It doesn’t matter the color of your scrubs, pedigree or degree, we can still connect with each other on the very basis of our society: human to human, heart to heart, people just being people.
Dr. Valentine’s friendship and warmth clearly inspired many people to live richer relational lives. At one point, Dr. Josh Barton, who provided one of the eulogies, said that he is done putting work ahead of everything else. “I’m not waiting any longer to build my friendships deeper. I’m starting now.”
That is something we can all take to heart.
Boise VA Medical Center’s Dr. William Weppner recently gave a presentation titled “How Innovation Takes Hold: The Structure of Medical Revolutions.” He described how scientific paradigm shifts occur when a theory that no longer adequately explains what we can observe is replaced by one that does.
This process, originally described in Thomas Kuhn’s seminal 1962 work, is usually initiated by those “very young or very new to the field whose paradigm they change.” Such new ideas are often initially rejected by insiders who defend existing models for a variety of reasons before eventual adoption. Case in point: when Ignaz Semmelweis’ proposed and demonstrated effectiveness in hand sanitation to prevent childbirth infections due to “cadaveric contamination,” his ideas were rejected by the medical community for many years.
Dr. Weppner finished by exploring game-changing medical revolutions that are already in process: gene editing, targeted immunotherapies, and of course artificial intelligence. This set me to wondering how A.I. might affect the way we educate medical students.
Let me back up and start by sharing how one local public charter school is openly asking some big questions about the way they teach. Administrators recently shared this video with parents and teachers which should leave educators everywhere scrambling to answer this question: If 40% of the jobs that our kids will fill in just 20 years do not yet even exist, what skills will we teach them to succeed? This is going to require completely different educational methods than the outdated 19th-century ones we currently use, such as standardized multiple-choice test-taking.
What is true in elementary school is certainly true in medical school. Even Dr. Weppner shared, to knowing chuckles and nodding heads in his audience, how medical school instructors will say that half of what is being taught is not accurate: they just didn’t know which half. The tongue-in-cheek admission is borne out by physician researchers Adam Cifu & Vinayak Prasad, authors of Ending Medical Reversals. They performed a study indicating that 40% of “practice changing” publications from a decade of a prominent medical journal articles were found to be either wrong, or actually harmful. A study by IBM in 2013 reported that clinical knowledge is doubling every 18 months.
If the acquisition of so much medical knowledge is so quickly outdated and A.I. is going to come alongside physicians to help make better medical decisions, this begs the question: how might medical education change to create better doctors for the future? Let’s look at some examples.
The exponential growth rate of the body of specialized biomedical knowledge is only going to continue to increase. And yet, medical schools continue to try to stuff all of this into the emotionally healthy brains of brilliant and uber competitive medical students in a short window of time. We know what this does to them based on research: just two years in, their mental health plummets below that of their non-medical peers. They simply can’t keep up without major mental distress.
Indeed, where I have seen the most distress in physicians is those who are unwilling or unable to roll with the punches that rapid industry change has brought over the past 15 years. I can cite local examples of physicians bow out of the game early because of ICD-10 or Epic adoption. I would submit that at a minimum, medical institutions need to continue to integrate “non-clinical” skills like stronger lifetime adaptive learning and team-based interpersonal abilities.
There are promising examples being proposed: AMA has just published The Master Adaptive Learner in their MedEd Innovation Series based on research led by William B Cutrer, MD, M.Ed. He describes the four critical personal characteristics that support this process are curiosity, motivation, growth mindset and resilience. In this model there is a learned balance between routine clinical expertise (where efficiency is high and innovation is low) and creative exploration (where the innovation and efficiency trade off is reversed.) The target of the “optimal adaptability corridor” is what they call “adaptive expertise,” where a wide range of conceptual understanding is applied and both innovation and efficiency are high.
This brings us full circle to Kuhn’s citation of Albert Einstein when he wrote about the wave-particle duality: “It seems as though we must use sometimes the one theory and sometimes the other, while at times we may use either.” Medical schools, health institutions and physicians who can hold this tension in balance will probably be the ones who can thrive in whatever the future brings. Teaching this skill might just help bring about another revolution in the practice of medicine.
This summer, the Ada County Medical Society (ACMS) Foundation provided suicide prevention training to more than 370 local medical students, physicians, advanced practice providers, and hospital administrators. So far, a grant from the St. Luke's Community Health Improvement Fund (CHIF) and partnership with The Speedy Foundation has made possible five different trainings.
Suicide rates for U.S. physicians are estimated to be up to 230% higher than the rate for the general population. Our goal is to equip our local medical professionals to help themselves, distressed colleagues, and their own families. We provided QPR training, an evidence-based suicide gate-keeper process with three steps: Question, Persuade and Refer. QPR is like CPR: both professionals and lay-people can be trained in it and should apply it immediately when they think someone they know might be suicidal.
I am glad to have received this training myself and have used it three times in the past year alone. For instance, I spoke with a physician this month who was struggling with something that most certainly would bring professional and personal shame. Not knowing her well, I took the risk of asking, "Has this made you consider harming yourself or taking your own life?" She answered, "Well, I think I've worked through those issues and have moved beyond them." My interpretation is that in her mind, that option was actually on the table.
The unique skillsets that help physicians make it through the rigor of medical school and residency, and make them good doc-tors – for example, being obsessive, autonomous, and able to turn their emotions off and just do their job – can be a recipe for suicidality when things go wrong.
And in medicine, things often go wrong.
St. Luke's Elmore and Treasure Valley medical staffs hosted two of the training sessions and we were very gratified when the Idaho College of Osteopathic Medicine (ICOM) opened its doors as well. We provided focused training to faculty and staff, as well as both first and second-year classes. Over time, I believe today's trainees have a strong role to play in reshaping the culture and systems of medicine, and helping bend the curve down toward zero physician suicides.
September was National Suicide Prevention Month and September 17th highlight-ed the second annual National Physician Suicide Awareness Day, organized by the Council of Residency Directors in Emergency Medicine. This day commemorates physician lives lost to suicide and strives to raise awareness about this issue.
I encourage you to program the Idaho Suicide Prevention hotline into your phone for calls or text: (208) 398-4357. You can also text 741741 or call 1-800-273-8255 for the national hotline. You do not have to wait until there is an imminent threat - you can use these lines to identify referral re-sources or get comfortable with asking the difficult question.
I just finished reading “Things Fall Apart” by Chinua Achebe. It is the 1958 archetypal modern African novel, one of the first to reach global critical acclaim and on many lists of the most influential novels of the 20th century. While it is a relatively simple read by length and content, it is not an easy read as a Westerner and left me squirming in my seat and thinking about its parallels to medicine.
The protagonist, Okonkwo, is a warrior tribesman in pre-colonial Nigeria. He is an overcomer against enemies, droughts and deluges, a champion wrestler, and strives to show no weakness. He judges other men to be “women” because of their inability to do hard things, whether it is work their own land or be willing to go to war. The novel follows his personal journey through ascendancy in his clan as well as a shameful temporary exile for a manslaughter accident.
His story climaxes as colonial and religious forces threaten to upend the way his people have lived for generations, leaving him bereft of his identity in a world that is evolving too quickly. SPOILER ALERT: The book is a tragedy. I won’t say just how it ends, but it concludes abruptly in the patronizing words of the British District Commissioner who is musing about the book he’ll write someday: “The Pacification of the Primitive Tribes of the Lower Niger.”
As I closed the book, my mind went quickly to the many physicians who I suspect may feel a bit like Okonkwo. In their own time, they were legendary, self-reliant warriors who did whatever was necessary for the tribe of medicine, revered heroes, maybe even a bit intimidating at times, holding influence over their clans as demi-gods.
In time, however, capital imperialists moved into their realm, offering assurances of salvation from everyday hassles and access to new markets. The younger warriors took the bait and the older ones suddenly found themselves trying to make sense of this new world order and where they fit in it. They moan about the “wussification” of medicine, don’t understand this whole burnout epidemic, and wonder what will become of their traditions. They ache for the days when their cultural identity and hard work provided them with influence, status, and security. Whether they like it or not, the world is coming to their front door and telling them how medicine is going to work (and how they’re going to work for medicine.)
In the end, will this warrior class of physicians become just a footnote in the annals of how medicine progressed towards some soulless ideal of care? Will they rise up against “The Man” and say, “you can go here, but only so far”? Will they remember the obstacles they overcame to get into medicine and use their fortitude to stay engaged in it? Or will they finish their careers or lives feeling the futility of fighting against a foe that views them as expendable widgets in the standardization of medicine?
It is too early to say if things will fall apart for physicians the same way they did for Okonkwo. There is still plenty of opportunity to fight for how medicine is delivered. The ideals that are worth “unsheathing machetes” for must revolve around what is best for the patient and what allows doctors to maintain their sense of purpose over the course of their career. This will require both resistance to and adoption of new ways. To have influence, doctors will have to learn the language and motivations of new administrations to keep them from destroying what is sacred in medicine.
Anything less than that will truly be a curse on the land.
Remember two, three, four years ago when all the construction along Myrtle Street was going on? The JUMP building was finally being finished, two new hotels were going up at Capitol Blvd, followed quickly by the Fowler Street apartments. And as soon as that was done, lanes were shut off on Front Street to host the new parking garage and hotel across from Simplot. It was like a vaso-construction of major arterials. Is it possible for a city to have a myocardial infarction in the heart of downtown?
By the end of 2017 it seemed that quality of life in Boise had been noticeably reduced for the first time in the 18 years I’d lived here. I had convinced myself that “someday we will get our lanes back that have been used for construction.” Perhaps I could recoup a third of my commute time that had been added. Eventually, I came to grips that there was probably never going to be any going backwards unless I wanted to move to Twin Falls, Pocatello or Moscow. This was the new normal.
I sometimes wonder if doctors feel the same way about their practice of medicine. Everyday it seems like there is more traffic added to your work: more boxes to check, more questions to ask, more paperwork to fill out. Suddenly, new lane restrictions arise that don’t allow you to use all the space or time or energy previously available to you when things seemed to flow so smoothly. Where there used to be a good “stopping distance” between patients, everything is crammed a little tighter now and patients expect more out of you in less time you’re provided to give it. Collisions between patient time blocks occur more frequently.
You tell yourself that someday EHRs, and AI, and ACOs you help you recoup your lost bandwidth and you’ll get your hands off the keyboards and onto patients during exams.
I have shifted my expectations and come to accept the reality that our streets will be as crowded as they are for a long time to come (or at least until artificial driving intelligence takes over and radically affects the number of cars on the road). In the meantime, here’s a few ways I’m responding that help me on my drive home:
Gratitude - First, my commute is only between 15 and 30 minutes, at worst. Compare this with our peers in Seattle or Portland or anywhere in urban California, let alone a third-world county. When I was driving a pastor from Kenya around Boise some time he said, “You have the most beautiful roads. I pray that someday my own people will have access to roads such as these.” Hearing that perspective made me appreciate all we do have.
Be Creative - it is too easy to always use the same proven paths over and over, and if you’re commuting from Boise to Meridian every day, you don’t have that many options. But there is something to be said about taking an entirely different way from time to time. It may be faster or slower or about the same, but seeing some different scenery can help a lot.
Travel as a Team - I have the privilege of carpooling with at least two of my kids during the school year. This summer, it’s been a real privilege to carpool with my college-age son, commenting about news stories with each other or just debriefing each others’ days.
Speak up when you see something wrong - over the years, I have provided DOZENS of suggestions to the very responsive Ada County Highway District, several of them being addressed and implemented. I am positive they roll their eyes every time they see another email. But they are responsive and I can take credit for the Federal Way speed limit south of Amity going up to 45 after they introduced five lanes there years ago. (My kids also credit me with the introduction of flashing yellow left-turn signals to the city, but it was probably coming anyway.)
I don’t know how my driving lessons might translate for you in regards to medical practice; that’s a journey for you to take on your own. I do know that by the time I get home I am ready to greet my family with a little more peace and understanding then if I bellyache the entire way.
I recently had the privilege of meeting over lunch with a handful of independent physicians to talk about fostering a trustworthy and supportive culture in their practice. Everybody was very friendly with each other, talking about plans to see the New Kids on the Block concert together, bragging about their latest mountain bike rides, and even one getting ready to begin a several week sabbatical.
I started my talk by posing the rhetorical question, “Have I ever shared my burnout story with any of you?” I knew the answer was “no” since I had not met most of them before and especially since I am not a physician (though I have played one on TV).
My own burnout story specifically involves being a director of a charitable, not-for-profit medical clinic, leading the organization through six or seven years of strong growth. As grants and other secure sources of income began to dry up, the organization began to take a financial nosedive. I had to start slowly letting staff go, picking up some of the slack, and became increasingly overwhelmed. I was coming home so vacant looking that my wife thought I was having an affair. I started questioning my own effectiveness out loud to the board of directors. After giving them three scenarios of restructuring and then disagreeing on which was the best, I was graciously relieved of duty. And I was relieved.
After I shared this, I turned the tables on the physicians and asked them to share their own burnout stories with each other. It started out a little quiet, but as they became comfortable with the process, I heard bits and snatches that made my heart ache for situations which many physicians find themselves in: “I lost three patients last year and started wondering if I was a good enough doctor anymore….” “My daughter told me I was a bad mommy because I always came home late….” Afterward, one doctor told me he learned things about people he had worked with for years he had not known and felt like it deepened everyone’s respect for each other.
Interactions like these in a safe environment allows people to thrive and grow together, in spite of their woes and distress. Unfortunately, many doctors are rightly afraid to share the messy middle of their stories for a multitude of reasons (see last month’s post). As a person who has also been involved in pastoral ministry, I completely understand this feeling: some people we serve or serve with want us to be flawless and many cannot handle it when we are not. In some congregations, those leaders that are honest about their failings are excised from the very communities of faith that would allow for a place of healing and restoration. Sound familiar?
To force somebody into emotional isolation like this is a wrong that cannot be endured anymore in the medical profession. As Brené Brown writes in her book Rising Strong, “The irony is that we attempt to disown our difficult stories to appear more whole or more acceptable, but our wholeness, even our wholeheartedness, actually depends on the integration of all our experiences, including the falls.” Unfortunately, to be wholehearted is not a value embedded in the medical culture yet.
I strongly contend that physicians must be allowed to be human beings at work, full of strength and weakness at the same time. When artificial intelligence is finally strong enough to take over most clinical decision making, the one thing that might prevent physicians from becoming just medical algorithm programmers is their humanity. Already, physicians are at risk of becoming automatons on a robotic assembly line of health care, dutifully playing their niche role to “practice at the top of their license.”
To create workplace cultures that are trustworthy and supportive, I suggest two definitions on this topic:
Leaders and workplace veterans must lead by example, willing to share their screw-ups and foibles, and to not always wait until perfect resolution to do so. We can gain more strength by sharing our stories while we are still in the middle of them rather than after gloriously overcoming obstacles. By modeling this and changing polices to support it, we empower people in the workplace to reach out to each other and build greater resilience in each other’s lives. Whether you serve in a non-profit healthcare setting or have shareholders, that is good for the mission and the bottom line.
Steven Reames, Executive Director
Related Previous Blog Articles
Suicide, Confidentiality and Getting Help (June 2019)
Reshaping Burnout River (July 2018)
Resolved: Physicians Should Be Free to Seek Help (July 2017)
Nobody really wants to have to talk about it because it is uncomfortable, but the facts remain: physicians kill themselves at higher rates than the average population. This has been proven through studies in the US that date back 4 decades and was even cited in the mid 1800’s in the UK. Many people recite the generally accepted estimate that about 300-400 physicians die by suicide each year – “an average medical school size” – but most do not know that the figure comes from a 1977 study published in JAMA.
Idaho is not immune to this, which is why ACMS Foundation applied for and received a grant from the St. Luke’s Community Health Improvement fund this year. With these funds, we will be able to train upwards of 400 local physicians, NPs, PAs, residents, administrators and medical students through a series of QPR trainings.
We are contracting with The Speedy Foundation to provide the Question, Persuade, Refer gatekeeper training. Like CPR, the material can be taught to anybody in a relatively short period of time to know how to look for warning signs of suicidality, ask the difficult question directly, offer hope, and where to refer people. The Speedy Foundation is named after Boise Olympic medalist Jeret Petersen, who battled depression and substance abuse and took his life in 2011 at the age of 29.
This month, ACMS brought the first training to St. Luke’s Elmore with about 14 in attendance, covering a huge swath of their medical staff. We plan to have at least four more sessions, with two already scheduled for first and second year classes of the Idaho College of Osteopathic Medicine. The training is useful for opening conversations with colleagues, patients, family members and friends. We are working to make at least one of these open to independent ACMS members.
As we have planned and implemented this training, some of the discussions I’ve been part of highlight the difficulty in asking this question of medical colleagues, knowing where to refer them appropriately, and some of the real reasons why physicians are reluctant seek help. Among many physicians, there is still some very deep skepticism and cynicism when it comes to looking for help. They still feel that their privacy, reputation, licensure, and means of making a living might be at stake should somebody find out the level of their pain.
These are tough issues to address, tender points among high performers who have seen some well-intentioned efforts go awry. But avoiding them doesn’t make them go away and our hope is that by talking about it more and more, we can foster a more trustworthy and supportive culture in medicine so that physicians can tend to the inherent emotional challenges of their work.
This sensitivity around confidentiality is part of the reason why ACMS chose, when starting its Physician Vitality Program (PVP), not to have any record or knowledge of the members who participate. We built the counseling program around maximum confidentiality whereby:
The only thing ACMS ever gets back is billing with demographic reporting (member type, career stage, gender, employment status, specialty, and types of challenges presented). If participants are concerned that the unique combination of these data points would identify them, they can say “other” to mask themselves. We're glad to have added a couple more contractors in Boise this month to our pool and intend to get one in Elmore County, which is part of our membership territory.
More information about Physician Vitality Program
If you are interested in hosting a QPR training at your practice or facility, please let me know.
The High Rate of Physician Suicide
Preventing Physician Suicide (1977)
Medscape's 2018 Article on Suicide
As we prepare to publish our membership directory, we have finalized our 2019 membership numbers and I felt it would be a good time to reflect on the trends.
Total ACMS membership climbed to just over 2000 for the first time in our history and this was due in large part to the addition of the first medical student class of the Idaho College of Osteopathic Medicine. ACMS represents 60% of the Idaho Medical Association’s total membership and 55% of its physician members.
Exactly half of the 1091 actively practicing member physicians (not retirees or residents) are connected to a hospital system as employer or clinic owner. This represents virtually no change from the prior year in real numbers or percentage.
In keeping with nationwide trends, the ranks of female physicians continue to grow, up a couple points over the prior year, and now representing 34% of member doctors.
The percent of ACMS’ actively practicing members in various specialties is closely representative of the 2017 AMA Master File. The only specialties locally that show more than a percentage point variance is Family Medicine (+6% in Boise), Emergency Medicine (+4%), Pediatrics (+3%) and Psychiatry (-2%).
As I reflect very briefly on these trends, my thoughts are:
Thank you for your membership this year and being part of a vibrant local medical society.
Whenever I have gotten the opportunity to eat a gourmet meal and the $35 dish is brought to me with only 50% of it covered in food, I start to feel ripped off. “Where is my $12, overloaded all-you-can-eat, Chuck-a-Rama filled-up plate?”
And then I taste what is artfully prepared and presented and remember the meaning of “less is more.”
I was sharing with a friend recently about the similar temptation to fill my life up to the brim, where I leave no margins for rest and replenishment. I cut out the white space of my schedule, always thinking that more is better and I want to have options, a little bit of this, a little bit of that. Invariably I get to the overfull, post-buffet feeling of, “I regret that I ate everything I put on my plate.”
Moreover, even though my job is entirely about serving our members, sometimes I feel like I am wasting time when I spend effort being relational rather than punching off tasks. I flashback to what my college pastor and mentor told me, “Steve, you are already efficient with tasks, but you need to become more effective with people.”
Ouch. It still hurts.
I know this is not just a personal problem. All too often, our very national culture of productivity and high-output becomes a gluttony for activity and turns towards an addiction to stimulation. Never is this truer than in medicine, where the trend is to try and squeeze every ounce of value out of increasing healthcare costs. But Princess Leia’s defiance certainly applies here: “The more you tighten your grip, the more star systems will sleep through your fingers.” We are becoming less effective with patients and struggle to remain efficient with tasks because there are just too many to hold on to.
Somehow, we must learn to build margins and rest both into our personal and corporate lives, even if it makes us feel guilty for being unproductive and inefficient. As they attempt to move towards “zero-harm,” healthcare employers and leaders must stop thinking about their organizations as 99.9999% uptime machines and start thinking of them as living systems built of human beings which cannot operate effectively OR efficiently 99% of the time.
I believe as we recover this flavor of our humanity, the quality of what and how we serve patients will leave them more satisfied and healthier than trying to offer everything imaginable.
For me, Winter Clinics is a mixture of extreme logistical output and a cathartic soaking up of gratitude. It is the culmination of many months of work, putting together speakers, travel arrangements, food choices, graphics and design work, securing sponsors and exhibitors, CME paperwork, videoconferencing arrangements, registering attendees…and making it all look like a well-oiled machine.
So as the event begins and wears on and there are inevitably things I want to fix or change, overall it is a weekend filled with various people being quite grateful. This is a moment that I purposefully slow down, listen to what is working and appreciated, and glow in the bask, sucking it in as potential energy for future event planning. When recognized amidst a crowd, I will sometimes even do a small bow, tipping my imaginary hat as if to say, "You're welcome. It has been my pleasure."
And it really is. For those of us gifted in hospitality and event planning, it turns our crank to put the gift of a conference, a dinner or a social all together and watch others unwrap it. I won't apologize for the satisfaction that comes from performing my job well.
And neither should you.
When Dr. Dike Drummond, author of thehappymd.com blog, spoke to us in Boise last May, he talked about moments like these in the exam room. He emphasized how important it is when a patient or their family members begins to thank you for your care that doctors need to stop, turn and give them your full attention, listen closely, and breathe the affirmation in deeply. It's like sitting in the warmth of the sun.
This is why you went to medical school, muddled half-awake through residency, and sometimes skip your kids' soccer games. It was to care for people and be a healing presence in their lives. If you aren't paying attention amidst everything you have to do, it is too easy to let those thank yous go to waste. In fact, some of us have the awful habit of blushing in self-deprecation and saying, "Oh, it was nothing (de nada)" when it really was something huge for them.
In fact, when we slow down, we might actually create more relational space to allow for more gratitude from others. My bad habit is wandering through a room of people with an "I'm too busy to engage with you" look on my face (and sometimes I am.) But when I slow down to prioritize relationships over tasks, it makes my job so much more meaningful than just punching things down. I know this is difficult when you still have to punch those things down, but it can make the extra time spent later so much more worth it.
Having interacted with many of you, I can see how much effort you put into your work so may I be the first (but not the last) to say, "Well done. Thank you for all you do."
Director: Steven Reames, email@example.com (208) 336-2930Membership Assistant: Jennifer Hawkins, firstname.lastname@example.org (208) 344-7888305 W Jefferson Street Ste 101, Boise ID 83702 FAX (208) 336-3294
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