On Facebook Friday I posted this picture of my wife Ginny, saying “There is an astounding story behind this photo. Details Monday.” Well, it’s Monday.
As you read this, bear in mind, your mileage may vary – everyone’s different, this wouldn’t be appropriate for everyone, and Ginny herself played a big part in it.
The astounding story:
In this photo we were out to dinner, nine days after Ginny had both knees replaced. She walked into the restaurant using only canes – no walker, no wheelchair. The surgeon is Howard Luks, the social media orthopedist (@HJLuks), whom I met on Twitter in 2009, and the surgical approach he used is called muscle-sparing (or “quad-sparing”) minimally invasive surgery, part of a larger package of methods he uses, described below. Bottom line:
- None of her muscles were cut
- She had no transfusions
- She has not needed to have any of her dressings changed
- She left the hospital on day 3, was discharged from rehab 8 days after surgery, and today on day 12 we’re returning to New Hampshire, to continue outpatient physical therapy from home.
Of course she’s still on pain meds, tapering down, and her endurance is of course limited. But she is basically functional and able to live on her own if she needed to, or rehab wouldn’t have discharged her.
Here’s a video of her walking around the hospital floor – 500’ – with a walker for balance (not leaning on it), less than 48 hours after leaving the O.R., and on the right, at rehab, walking with just canes, a week after the surgery:
She was discharged from rehab after demonstrating (among other things) that she can safely walk up and down a full flight of stairs … six days after the surgery. She can get herself into and out of bed, into and out of our Prius, etc. She’s not speedy at any of it but she’s functioning reliably.
(Of course I have Ginny’s permission to talk about all this. Also, I’m an e-tool geek and she’s not, so I’m the one using the tools discussed here.)
Again, everyone, please read this: your mileage may vary – everyone’s different, this wouldn’t be appropriate for everyone, and Ginny herself played a big part in it.
The part Ginny played, as an activated, engaged patient
In my speeches I talk a lot about “patient engagement” – the patient as an active partner in health and care – but usually I’m asking healthcare to listen to and welcome patient voices. The flip side is equally important: the patient stepping up and doing as much of the work as they can.
In joint replacements this is essential, because nobody but you (the patient) can do the physical work required to recover after the surgery, and it can be hard.
Howard (he insists on being called Howard) says that in his experience the biggest reason knee replacements fail is if the patient simply isn’t willing to do his or her part of the work. It hurts – he says “You know why mob guys hit you in the knees? Because knee injuries really hurt!“
Ginny was willing to do the work:
- An essential part was “prehab” (a play on “rehab”) – two weeks of physical therapy before surgery, to get in practice for what the muscles would need to do after.
- She also lost 20 pounds in the months leading up to the surgery, so her replaced knees would have less weight to lift and carry.
Another aspect is her choice of a surgeon who happened to be three hours from home. Ginny’s a retired veterinarian who’s done thousands of surgeries herself, and was on the New England Board of Veterinary Medical Examiners, where she was exposed over the years to many many doctors of varying degrees of excellence, so she has strong opinions about wanting someone good and decades of intuition about who that is. A few years ago she met Howard when we happened to be driving through his area, and when she decided surgery time had come, there was no question: “I want Howard to do it.”
Yes, my wife is an empowered, engaged, informed, activated patient. Imagine. (Unlike me, though, she doesn’t talk about it – she just does it.)
All of that happened before we learned about the new muscle-sparing approach. That turned out to be quite an unexpected bonus – we were prepared for the normal recovery that our friends and family had endured.
What it’s like to work with an “e-patient surgeon”
I’m best known for my relationship with my famous primary physician, Dr. Danny Sands. Nothing I say here about the very similar Howard Luks affects anyone else I’ve spoken of, including Dr. Sands, my oncologist David McDermott, my awesome urologist-surgeon Drew Wagner, my orthopedist Dr. Megan Anderson, my nurse practitioners Meeyoung Lee and Gretchen Chambers, all of whom are just tops, and fully encourage empowered patients. Yes, I remember their names and faces eight years later.
Howard Luks truly believes in making medicine more efficient. Like many docs I know, he’s suffering some from the changes in health policy and the sometimes obscene reimbursement rates he’s offered. (Know how much he gets paid by Medicaid for doing a knee replacement? $330! Can you believe that??) Installing their EMR and complying with Meaningful Use has cost his practice a big hit in productivity so far (appointment volume, and therefore income). But he sees the future and is pushing through into it, using whatever tools he can.
Cloud software tools
- He’s a big fan of Twistle, a secure (HIPAA-compliant) messaging system.
- This is a huge help if your doctor’s office(s) doesn’t / don’t have good, modern secure messaging; among other things, Twistle can include messages from multiple docs even if they work in different places. (It can integrate with EMR platforms, but most docs don’t consider that a necessity; Howard does, and he’s planning on doing it: “With machine learning and smart forms the platform can intelligently perform many useful functions.”)
- BUT, and it’s a big but, just remember that without such integration, Twistle messages aren’t visible in each doc’s “real” system where they work. (I’m starting to think “Who cares??” for most messages, but for seriously important information I’d want to be very careful about where the information lives.)
- He’s starting to use HealthLoop, which attempts to manage communicating each step in the plan to you before and after the surgery.
- [italic phrase added 7/7 per comment below] Personally I’m unimpressed with how HealthLoop has been implemented so far; the idea is great but it’s not ready for prime time: as with any other process automation tool, the whole team needs to be aligned with it, and the content and procedures need to be absolutely consistent, or it’s an automated mess. More than once HealthLoop disagreed with office staff, which in my view is worse than nothing.
- He’s happy to communicate by any medium – email or anything. My feeling is that anything we need to look up later needs to be in the secure message system, and of course anything confidential needs to be there. But for casual questions, he’ll use anything. (Just remember, if you don’t use an “official” communication tool with your providers, don’t expect a response in any particular timeframe. Providers have a life.)
Pre-visit communication
You could say Howard is nuts, because he’s so committed to sharing empowering information with everyone who needs it; he also knows how to do SEO optimization so his content can get found: his site gets 9,000 new visitors per day(!!!) and up to 20,000 pageviews/day from around the world. Let’s just say the vast majority of them are not his paying patients. :-)
Here’s an example of his approach: In my book Let Patients Help I said e-patients should ask “What’s your infection rate?” Howard not only welcomed the question (“average is 0.8%; mine is 0.6%”), he described the protocol he uses to minimize it. I asked “Is that on your website?? I didn’t notice it” and he said “It probably should be,” and now it is.
The evaluation appointment
- Prior to our first appointment I emailed him Ginny’s radiology images, so we didn’t need to take more images. (Howard gladly welcomed them, saving us time and saving everyone money.)
- Thanks to Beth Israel Deaconess, where our primary care is, for giving us a free CD of the images (at time of service) and for giving us free online access to the radiologist’s report!
Howard’s practice has flat-screen displays on the wall of each exam room (right), so we can look at images together and we can watch what he’s doing in the EMR, while he does it.
- He gave us a clipboard with a pad labeled “What We Discussed,” to take notes on.
Between visits, when questions come up
In my first book Laugh, Sing, and Eat Like a Pig (my cancer journal) I noted that my world-class oncologist Dr. David McDermott welcomes dialog, including in email: once when I apologized for what turned out to be a dumb question he replied “I am happy to field your questions.”
Howard is exactly the same. Ginny is less verbose (ahem), so with her permission I messaged Howard (sometimes several times a day), and every time he responded within a couple of hours. In short, he recognizes that when patient and family have questions, it’s a sign of engagement. Plus, he says, he understands “most people are too afraid to ask questions… so I offer platforms to communicate which are less imposing than sitting on a cold bench in my office with the clock ticking :-).”
There’s more to the package than this quad-sparing surgery
Personally, my mind is blown by this new surgical approach, but Howard quickly points out that Ginny’s extraordinary outcome is a result of a program that has many parts:
- Infection control (before, during and after surgery) (see his protocol, above)
- TXA (tranexamic acid) – The Mayo Clinic cites TXA’s use in emergency medicine (e.g. EMTs using it to stop blood loss in injuries), but Howard noted that cardiovascular surgeons have used it for decades, and now he is, in orthopedics. Result: “less blood loss, fewer transfusions, less blood received which leads to fewer infections.”
- TXA is also why she didn’t bleed enough to ever need her dressings changed, he says.
- An engaged patient who understands their role (their responsibility for doing the work)
- Includes doing the “prehab” as well as the rehab.
- A doc who understands the patient’s expectations. He will ask a patient what outcome they’re after, and won’t always recommend surgery, even if from the first description of symptoms that seems obvious.
- The surgical method (quad-sparing)
- Note: He says patients who get the usual surgical method do catch up eventually; the benefit is in faster recovery time. “People gain back their strength faster with a muscle sparing approach. Thus they can sustain a faster rehab.”
- Well, heck: I don’t know much about orthopedics, but I know people who’ve been out of week 12 weeks after having a single knee replacement, so being released from rehab in 8 days, functional, sure sounds like something worth knowing about as an option.
- Multi-modal pain management. Ginny received regional anesthesia during the surgery, and Howard injects the inside of the knee with a cocktail of meds to take advantage of pre-emptive analgesia. She’s now on four pain meds for different pain pathways.
- “Pain management is incredibly important in these cases,” he says, “because it affects how able the patient is to do the work and regain strength. But too often people overlook that not all pain is the same – you can’t treat it all with opiates.”
- Not to mention the horrid constipation that morphine, dilaudid etc can cause, sometimes bringing weeks of real suffering.
“All of that,” he says, “comes together to result in a better experience, fewer surprises and fewer complications.”
Astounding indeed. Every patient should know this option.
As I said: an astounding story, right?
Of course there are no guarantees, and problems do happen, and no two cases are identical … but wouldn’t you want to know about a new option that might have you functioning again five or six times sooner than the usual treatment, with a lot less pain?
I’m going to be blunt here about something I think is important: it’s not uncommon for a newer option like this to not be widely known, and thus not offered to patients. (Last month I spoke at a conference where someone mentioned this type of knee replacement, and said that it’s only used 18% of the time.)
I applaud the surgeons, like Howard, who have taken the steps to learn this surgical method (including the comprehensive package he uses). Honestly, it’s deeply moving to see my wife doing so well – she’s not out of the woods yet, but doing so well – and I want to help spread the word, so docs who offer this method can be rewarded by eager patients – and perhaps so surgeons who don’t know it yet will be inspired to learn.
Updates
| Day 14 – first day at PT, getting evaluated. (He said “Boy, your legs are strong!!”) | Day 19 (July 13) – third day of PT. |
Update day 17: mini-golf
Saturday, July 11: We’ve only been home from New York for five days, and she says “I want to play mini-golf.”
I said “Are you nuts??” and texted Dr. Luks. He replied “I side with Ginny!”
So off we go – nothing but a putter to serve as her “cane.” The Facebook post with more info and pix is here. (It’s a public post – no login required)
Update day 30: approved to drive
July 24: Surgery was 30 days ago. At today’s regularly scheduled physical therapy session she got approved as safe to drive. So, on the way back, off to the grocery story (no cane) (left), and she drove home (below).
The celebratory blog post is here, including these photos. Look Ma – no canes! No bandages! Just walkin’ an’ drivin’ unassisted!
Update day 48: stairs with no hands
Well. Last Tuesday (day 41) we visited Howard for the six week follow-up, and he said everything looked good and she’s doing great, and it’s time for her to start tapering off the dilaudid (opiate / pain med). Since then she’s had a total of two tablets, each before a PT session… none since last Friday (4.5 days)… and today she decided to try walking the basement stairs in a way she hasn’t been able to do for ten years.
(@MightyCasey, this was spontaneous and I forgot to turn the phone horizontal – sorry. I was excited. These replacement knees are lookin’ pretty darn healthy for seven weeks out.:-))
This is a great post and kudos to Dr Luks, you and your wife. I have known Dr Luks, virtually at least, over the past few years through Twistle. We both are early adopters of this technology and have served on its physician advisory board. I rely heavily on Twistle for post-op care and patient engagement. It has really helped me and my patients on many occasions. I use it primarily for for post-op wound checks, to answer patient questions, etc, though Twistle’s technology does for more than this.
Thanks for sharing and best of luck.
Dr Schoor
Congrats to Howard for a successful operation and to Ginny best wishes for quick recovery. Glad to hear that Ginny had this new type of operation and is doing well, it is also practised in Greece. A friend had hip replacement with this technique, one year ago with very good results, but had not seen yet a patient with knee replacement with this operation..
And yes, the patient commitment to do the physiotherapy and exercising needed is hard work but really rewarding…
Astounding indeed. I have had family members get the exact same surgery at renowned medical centers, and their recovery wasn’t nearly as fast or satisfying. The success of this surgery mostly has to do with a talented surgeon (Howard) and an activated and engaged patient (Ginny).
I am happy that Twistle could contribute. In addition to messaging, we are now working with health systems to engage with patients before and after procedures to enhance their recovery, and facilitating collaboration between the surgical team and the primary care team (which can be miles away from the surgery center). Our goals are to help patients get out of the hospital faster, avoid getting readmitted, effectively transition their care from one team to another, and to save the surgical team significant time by automating their routine communication.
And, Dave, you are right integration with the EHR is a must. While we integrate with all EHRs, it’s often an uphill battle to get IT support to make it happen, but we are are persistent and we get there. Our baseline integration is mostly about documenting the communication that happens on Twistle, but we are doing deeper integration with some EHRs like Centricity, where we can enter data into the appropriate fields and save the care team a ton of time. Its a fantastic experience, and the patient can document most of his record herself (with physician sign off, of course). You should see a demo of this because as a patient advocate you will appreciate what we think is the state-of-the-art.
Dave,
A great teaching post. I hope it gets the mileage it deserves. When I say teaching post I mean for both patients and health care professionals alike. Thank you to the 3 of you for making it possible.
We wish your wife a speedy and uncomplicated recovery. It’s wonderful to hear that the medical system was able to come together and provide such a positive experience for her. The time around having a knee replacement can be difficult enough with managing the surgical and recovery process. However, it’s great to have her physician be able to provide her with a comfortable and reassuring experience. Good luck!
Dr. Brian Hatten
Glad to hear the wife’s doing well. Pretty impressive to get both knees at once. Not sure if I’ve seen that.
We’ve used Twistle since starting my new practice. My patients are huge fans of it. The thing that’s different from EMR portals is that I actually send a copy of the records to the patient and the patient has direct access to me (most portals do it indirectly). They have also recently added something quite like HealthLoop, which does automatic follow-ups within Twistle. It’s harder to use in primary care, but we are thinking about ways to do it. We need independent patient engagement tools, not only for practices like mine, but to push the boundaries of access. Too many systems’ portals are far to tight when it comes to giving access to doctors and to the records.
Thanks for taking the time to write up and explain what you and Ginny are going through, I really learn a lot from this. I hope she recovers quickly with minimal discomfort.
My physician also uses Twistle, and I can only speak from a patients perspective – but Twistle really has empowered me as a patient.
1. I am able to communicate with the staff and doctor in an asynchronous manner. no more being placed on hold, no more wondering if they got my voicemail or not.
2. Allows me to have attachements. I can send in photos of a rash, a prescription, or a news article. They get it and can comment on it. i have had lab slips sent to me where i just print and carry. really has simplified my life.
3. Workflows. I know doctors can by busy – and with the demands placed upon them they cannot always follow up they way that they would in an ideal situation. The workflow feature is amazing. It has helped me in two ways. What it does is send a message to check on you post visit on things that could go bad and make sure things are going they way that they are supposed to.
In one instance, I was started on a new diabetic medicine : Victoza. I got a message after 3 days asking if i was having nausea from this. I said no – and then it just told me to continue to titrate the dose up. at about day 7, when I am supposed to move my dose up, it asked if I was having any nausea. This time I was – and it then directed me to not titrate up, but rather continue on the lower dose.
A week later it checked on me, and I was okay. It reminded me to then titrate up. It asked if I remember how to do it – and I didnt, so it then played a video for me showing how to do it. Amazing.
Another instance is where I had an infected pump site. 2 days after antibiotics where prescribed, it asked if I was having fever or spreading redness. I was. The doctor then got a message from twistle that something was wrong – I got a call that day and an antibiotic change and I improved. This could of been a serious complicaiton that pushed me into DKA. I was so thankful for this.
From a patients perspective – this cloud use of medicine communication with workflow and follow up – really engaged me more and I think helped avoid a hospitalization.
Hi Ananya – to help me understand your comment I went in and added a bunch of returns.
It sounds like Twistle is magic, and I imagine that it could be nearly magical(seeming) when properly configured it could be awesome – but to do that means EVERYthing has to be pre-programmed with every detail (e.g. what to do in situation X), and as I said about Healthloop, everyone needs to be on the same page about that. Because opinions do vary!
We might have the details a little bit off but the following is one example for us: Healthloop said to stop the patient’s regular ibuprofen 3 days before surgery, and the office staffer who contacted us separately said 5 days. This emphasizes that underlying it all must be some sort of protocol that’s been decided is The Right Way To Do It, and both the humans and the systems need to be aligned on that – which doesn’t happen automatically.
(AND note that this ain’t HealthLoop’s fault! Twistle or HealthLoop or anything else (including a human) can only do what it’s told to do. I’m going to go edit the post to make that clearer.)
Thoughts, everyone? How much work went into (a) agreeing on and (b) coding the protocol(s) that triggered Twistle to do what it did for Ananya?
To be clear, I love the idea, but from experience in other industries I know what happens when the worker-bee humans don’t know what The System is doing, or aren’t aligned with it.
What we had to do back then was teach people that The New Truth was now in the computer, and when in doubt the computer wins. And to do THAT, you better be darn sure that the computer is right, because if it’s not, everybody snorts and thinks the management is a bunch of idiots.
Dave
You make a valid point that for Twistle (or any similar platform) to work magically, every potential issue will have to be considered, and configured in a workflow. Not only is that not realistic, given the complexity of much of medicine, I am pretty sure this problem can’t be solved with hardwired rules. Products based on such attempts in healthcare (or any industry for that matter) have proven to be brittle. I am confident that machine learning/NLP approaches can and will solve these challenges, and many teams are working on this in healthcare.
Kulmeet
Terrific post, Dave, for so so many reasons, starting with getting to see a picture of St. Ginny! Moving right along to the clarity with which you explain the utmost importance (and value) of having an engaged, educated, empowered patient and working with Howard, a physician with a visible and documented commitment to working collaborative with patients. Howard, who has always understood the value of using online social networking tools to inform and educate, has also understood the value of sharing from his whole life — a reference to enjoying pictures of his backyard landscaping!
Well, it’s 14 days since the surgery, and Ginny just went to the physical therapist to be evaluated for the start of outpatient rehab.
I got 10 seconds of video of her walking down the hall – without canes or anything. I added it to the post, above. Click here to view it.
To be clear, she’s resting a lot at home, and still on medications. But the recovery is going just amazingly well.
Also, she was too quick for my camera but without saying anything she casually took the 6 stairs to and from the PT office normally – one footstep per stair – bearing all her weight on one leg at a time. For that she used the cane & railing, but each leg did all the lifting. (Her ability to do this is a direct result of the muscle-sparing method, and the related things noted above that helped her recover strength more quickly.)
Update for email subscribers –
It’s day 19 since surgery. We’ve been home for a week, and today was her third physical therapy session. She did REALLY well. Here’s a 40 second video
https://www.youtube.com/watch?v=MQgRC0EAIGw
I added it into the original post at https://www.epatientdave.com/2015/07/06/the-best-of-medicine-my-wife-gets-a-new-kind-of-knee-replacement#updates
Such a fun post to read … especially seeing her rapid progress! As I mentioned elsewhere … these results are seen when the patient and the surgeon are in sync, objectives and achievable milestones are realistic and the patient is engaged and “ready to go”. I routinely speak about taking 25% credit for a successful knee and offering the other 75% to the patient :-) This recovery takes a lot of effort on the patient’s part.
Ginny has been a pleasure to work with and assist through the process. Caring for engaged patients actually makes my job easier. I prefer to know more about your fears, expectations and goals. Some (physicians) may shy away from caring for the highly engaged patient … but they tend to be far more motivated and are thus great candidates for surgery — should it prove necessary.
An update for comment subscribers:
Today, 30 days after the surgery, the physical therapist approved Ginny as safe to drive. A-MAZ-ing.
There’s still work to be done – it’s not over yet – but she is strong enough and mobile enough to drive. The blog post is here: http://dave.pt/ginnywalkday30
Congratulations to Ginny! I too did research to find a great surgeon for minimally invasive bilateral knee replacement surgery. I asked my physical therapist who – what surgeon – had the best post-surgical results from his physical therapy perspective. He told me John Dearborn MD in Menlo Park, California (Institute for Joint Restoration).
I asked a number of other people, did internet searches, read books … interviewed and consulted with 6 surgeons, including Dr. Dearborn. I decided Andy, my physical therapist, was correct. I decided to have Dr. Dearborn do my surgery.
On June 1, 2015, I had bilateral knee replacement surgery. I am doing wonderfully well. Recovery has been smooth. It is almost 8 weeks since the surgery. I have received glowing reports from Dr. Dearborn, ex-rays, his staff and numerous physical therapists. I was walking in the hospital the day after surgery. I was only three days on the walker. I then used a cane for about three days. No aids since.
I am driving, off pain medications and am committed to physical therapy (2 – 3 times a week since the beginning). I have followed Dr. Dearborn and his staff’s instructions about recovery religiously and exercise every day to compliment the work of the surgeon … and get great range of motion and now build my strength. My recovery is amazingly fast.
It is a process however and hard work … and physical therapy / exercise is an on-going commitment that is life-affirming. There is much more to say but I will stop here.
Diane, I took the liberty of editing a bunch of paragraph breaks into your comments, to help (help me at least) absorb everything you shared here.
First, thank you for sharing it – I’m a firm believer in everyone knowing reality. Your second comment (below) went into how hard the recovery is turning out to be. (This is what we too were told is common. It kinda hurts to know this is what Ginny managed somehow to escape, and that you didn’t escape it.)
Did you change your mind, in your second comment, compared to saying in the first comment that recovery has been smooth? Or do you mean it’s been hard but is progressing smoothly?
(For those who don’t know, Diane is one of the most activated, motivated e-patients I’ve ever met. She’s s been the subject of a couple of posts over on the e-patients.net blog for her extraordinary work on behalf of her daughter. Start here. This is a highly engaged patient.)
Now for the patient’s view / experience of bilateral knee replacement surgery. Me …, and my internal experience of new knees.
My focus before surgery was on surgery, anesthesia, pain medication, control of nausea if I had trouble with narcotics, wanting epideral and not general anesthesia (granted and even preferred for most every patient at this center),hospitalization and preparing my home for post-op care, deciding whether I would watch the surgery while it was being done (I did – Kind of crazy). I also wondered about rehabilitation hospitals and whether I would need to … or want to go to one of those facilities (the Center prefers patients go home to avoid infections and so I did). It was as if all those issues over-shadowed any concern I might have about the actual recovery process.
I knew physical therapy was important and in my future big time. I was doing physical therapy already pre-op — at first trying to avoid knee replacement surgery then working to strengthen my body for the inevitable surgery.
I had no idea the recovery process would be so arduous. Strangely, I also had no idea that scar tissue would become so difficult and painful for me to work with. Physical therapy became my salvation because it felt / feels so good to stretch the tight bands … of what feels like scar tissue in my knees. Of course the new metal and plastic must settle into my knees and that is a process not an event too!
Tomorrow is my 8 week anniversary of the surgery. I have been told a lot of different things by a lot of different people (patients who have gone before me, PTs, my surgeon, staff at doctor’s office…) about recovery. I was told that it is 3 months post surgery before a patient is happy for having had new knees placed in their body. So far I agree.
Of course I am grateful for the best of modern medicine and getting new knees is certainly a kind of miracle. And, I am working very hard with my physical therapy exercises every day. And, I am so looking forward to the 3 month appreciation of the surgery I am told about. This process for me has been very difficult with a lot of discomfort in my knees and focus on recovery.
Sometimes I am patient with this process. Sometimes I am not. All in all — even I can tell it is all moving in the right direction. It helps having professionals support me and notice great range of motion and budding strength. My internal experience of this process is quite different than the glowing reports I get from professionals. At the end of the day I trust them and I trust the process and I keep finding my way.
Day 48: less than 7 weeks out, she’s off the post-surgical pain meds, and today she walked up & down stairs pretty much without hands. Video is in this update on the post above.
A tough and amazing woman!
Hey Dave. I am 15 weeks out from minimally invasive muscle-sparing bilateral (both knees) knee replacement surgery. I am doing fabulously, with range of motion = 140 plus (flexion) and zero plus (extension)! I have worked hard with physical therapy. With the expert surgical technique of Dr. Dearborn and guidance from his great staff, I am pleased, to say the least. I am back into my normal active life after a couple of challenging months of dedicated exercise and healthy healing time. I have some photos of extension if you would like to see them.