Different Cloth

I've written about my stint as a surgical hospitalist. It so happens that I've been contacted about doing it again. Potential obstacles aside, I'm giving it serious consideration; I found it fun and satisfying. Other than the inability to establish in-depth relationships with my patients, it was -- free from much of the para-practice frustration -- surgery at its purest, in some ways at least.

The hospitalist concept is a window into the future, the perfect extrapolation from themes that are regularly discussed in the medblogosphere of late: the implications of the eighty-hour work week restrictions in training; the differing expectations and priorities -- and demands -- of the recently trained; what it says about the prospects for medicine in general, and the practice of surgery in particular. The person who called me was refreshingly candid.

My work in the last few years has been surgical assisting. The guys with whom I've been associated are both much younger men whom I'd (with concurrence of other partners) hired to join my clinic practice. After putting up with the rigors and frustrations and reimbursement cuts and ER calls for exceedingly fewer years than I (in the case of one, it was less than five), they bailed and opened an exclusively bariatric practice, which they run almost entirely in a non-hospital setting, free from the associated agonies and exempted from taking emergency calls from any but their own patients. And the young surgeon who called recently to inquire after my interest had given up his classical-style practice for that of a hospitalist, after completing the usual training plus a fellowship, and then less than four years in practice! In candor, he said, "Those of us coming out of training now are cut of a different cloth than your generation." So they are. And why shouldn't they be?

He joined my clinic a couple of years after I left, and was given an income guarantee, no matter how much production, higher than I'd made in any of my years, though I'd worked harder and harder and produced more and more in each of them. His call burden, while often busy during the nights he worked, occurred only once in seven or ten days. For most of my career, it was every three (when people were gone it was every two). Even with more money and less call, he found it not worth the struggle, the sacrifice of family, the placing of job far above anything else. After only a couple of weeks in his hospitalist job, he told me, "My young son said, 'Daddy, I like you better now.' That's when I knew I'd done the right thing." Who can argue?

In their graves, many of the old guard will turn over, prop on a gamy elbow, and say "Damn right I argue with that!" The current Bulletin of the American College of Surgeons has an article in which a surgeon (well, a former surgeon: she recently gave it up quite young to be a writer!) recalls how an old professor stood in the way of a fellow resident aiming to leave one evening. "Son," the old guy uttered most firmly, "Once you lay your hands on a patient, that patient is yours." That's how I was. Those days -- see it how you will -- are dead: most thoroughly, most Edselly, most sincerely dead. (Lest I be seen as hypocritical, since I gave it up too, let me point out that I hung in there for twenty-five years; I acknowledge that's less than many, but it's literally true that during the last many of my years I was doing at least twice as many operations as the national average, while earning at or below the average and seeing a thousand more patients per year than either of my partners. So, in my mind at least, I'm allowed my spouting.)

For physicians -- medical and surgical alike -- the hospitalist model is a clear WIN-WIN. For patients, it's more like win-win. The win-win for surgeons lies in the freedom from emergency cases and the ease of call whereby, presumably, one would only need to be available on the phone to one's own patients and could, if desired, let the hospitalists take care of middle-of-the-night need to hospitalize them. The ability to plans one's days and nights translates into a considerable lowering of stress. In the case of hospitalists, it means absolutely predictable work hours and the elimination of all calls when not at work. For patients, it's trickier. It's the future, though, without doubt.

First, let's clarify: if you have an elective (meaning non-emergency) operation, you'll see your surgeon in his/her office as usual, be operated by him/her, and he or she will care for you while you're hospitalized. The hospitalist is there for the person who shows up in a doc's office or the ER in need of urgent surgical care, or who is in the hospital under medical care and has need for surgical consult while there. Trading off for the fact that under those circumstances you likely wouldn't be able to see the surgeon who took out your gallbladder last year and whom you just love, is the fact that the surgical consult you get will be approximately immediate, and there'll be a surgeon in house every hour you're there. Not the same one, as it could change every twelve hours, but some one. For patients who present in emergency situations, that's worth something. Isn't it?

At the extremes of every bell-shaped curve there are outliers. I don't doubt there will always be surgeons and primary care docs willing to sacrifice their personal lives in the name of their practices. But the days of the iron men and women are over, and it's happened in the blink of an eye, in a quarter of a generation. I reject that it's because this is the first generation to value life outside of work, or that they're just selfish. The explanation, I think, lies in the changes that have gone before and around them. The profession is under stress in many areas. To maintain income -- at whatever level -- in the face of steadily decreasing reimbursement, docs must work ever harder. They're increasingly bogged down in paperwork and bureaucratic demands, many of which are predicated -- so it feels -- on the notion that a physician is an thoughtless, careless, and incompetent screwup. (Comments on some of my related posts would seem to confirm that apprehension.) Not a week goes by without a notice from the hospital, the insurers, the malpractice carriers announcing the latest requirements for form-filling, order-justification, chart-polishing. Why, the new generation is asking, knock yourself out in such an environment? "Calling" isn't a word you hear much any more. Other than calling for help.

I've said it before -- and I'll point out that it no longer affects me, as a provider at least, so the axe I'm grinding is not my own: the inevitable result of the trend to control healthcare costs only by cutting reimbursement, along with adding more and more onerous bureaucratic demands is to select for an entirely different sort of practitioner than we've had. People willing to work hard and to strive for excellence but who expect some sort of recognition of it will look elsewhere than in the field of medicine. Will look? Already are! And the ones that haven't heard, bolt like my compadres when they get the full taste of it.

Since it's less and less likely I'll have a surgeon like me if I need one (I don't live in Cleveland or South Africa), my plan is to remain healthy, and then drop dead.

More Solutions, Long Post

Free health care isn't free. The money has to come from somewhere; the question is how to get it into a bucket, and then how most effectively to get it back out, to where it's needed. People frame it in all sorts of ways, depending on their political persuasions. Andrew Sullivan says that in arguing for government to pay, liberals would have us all be permanent supplicants. Brilliant. And it fits nicely onto a bumper sticker. But it's fatuous. If the ultimate virtue is the taking of money out of one's own pocket and paying directly for one's health premiums, then probably less than 10% of Americans are virtuous. (No comment.) Premiums are paid by employers, by governments, but by only a few individuals themselves (I'm among them.) We're already supplicants. (Well, not me.) If there were universal coverage, taxes would go up somewhere, but premium expenses would go down. The money that goes into the bucket, in other words, would be mostly a wash. Left hand or right hand, it comes and goes. My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over. That would be good, by whatever method the money is taken from us, and by whichever agency it's given back in the form of health care. Package it with a name that makes you happy. Money comes from us one way or another, gets centralized somewhere, and returned in the form of plaster and penicillin. In what way does having insurers in the middle help that happen?

The always-thoughtful Eric worries: "The problem I have with single-payer systems is that I fear a serious erosion in innovation - what compels a single-payer to add coverage for a new-but-expensive lifesaving modality? If your choices are "take what you're given" or "pack sand and pay for it yourself", new technology won't be deployed to save people's lives nearly as quickly." He makes an important point, but, like my concern about monolithic control of reimbursement, it can be addressed (so says me, the non-politician, non-economist, non-systems-wonk) by having at the top panels of consumers and providers making reality-based (remember that bygone concept?) decisions. If such a structure were in place, given that we're now talking about a single entity instead of hundreds, it would be possible for providers and consumers actually to have control. This makes a strong argument for single-payor, as opposed to our current situation, wherein we're divided and conquered. How should such panels be constituted, by whom, with what feedback loop attached to the citizenry? I'm thinking, I'm thinking! But I'm guessing people much smarter than I could figure it out.

I haven't seen "Sicko" yet, but I've seen M. Moore's other movies, so I'm guessing that at its center, he has the problem right, and that in examples and solutions he's overplayed his hand with anecdotes and shot himself in the foot with hyperbole. Speaking of which, in a review of the film James Christopher of the London Times says, "What he hasn’t done is lie in a corridor all night at the Royal Free watching his severed toe disintegrate in a plastic cup of melted ice. I have." Interesting: in my opinion, universal health care has no business covering the re-implantation of toes. Fingers, yes (depending on which ones). Toes, unh-uh. If surgeons use big toes to replace thumbs, -- and they do, they do -- that they are otherwise dispensible, foot-wise, is spoken to. A thing to which it is spoken.

And that gets us to the nitty-gritty. The bucket isn't bottomless. We can decide how much it holds, but at some point we also have to decide for what kinds of care the contents will be doled out; unless we want to make it bottomless, which we could in theory, but won't and can't in fact. Keep the costs down, we all say, except (you know what's coming) when the care in question is for us or our loved ones. "Spend a little as possible on them, and as much as needed on me" is a plan, all right, but is hardly a workable one. (Less so in the minds of one political party than the other). But let me be clear (since I've given myself the soapbox): I'm OK with tiers in the system. Not tiers of joy, to be sure. But this is America; plus I've said in my previous post that I think payments to providers ought to reflect quality of work: if I'm asking for rewards for the quality of my work, I can't begrudge it elsewhere. It's not without moral unclarity (if health care is a right, it doesn't automatically follow that people should be barred from obtaining different levels thereof), but the idea that there might be a difference between basic coverage given to all, and that available to those willing and able to spend more is one I can accept. It's just the way it is: a system that is the same for everyone with no avenue for opting up won't fly, pragmatically, at this point in the US; but one that provided everything for everyone under all circumstances will bankrupt us, absolutely, eventually. Heck, we're heading there (bankruptcy) already, on more than one track.

It's either/or. Either we decide as a nation that we're happy spending whatever it takes on health care, or we address the issue of rationing (ok, let's call it "prioritizing.") Some countries do it openly: in England, on "the National" it was true at least at one time that, for example, a person of a certain age with a certain percentage of body burn got supportive care only: pain medication, comfort. Some do it de-facto and maybe even cynically: in Canada you have to wait a long time for certain procedures, which means some don't get them, even though it's not specifically proscribed. A few years back a British orthopedic surgeon responded to outcry over long waits for hip replacement by saying that the line wasn't as long as it looked, since some people die while waiting for the operation. Probably the hardest thing any health care worker does is deciding when further care is inappropriate. It goes on all the time; it's just not formalized. Somehow, sometime, on paper and in public, it needs to be. A comatose hundred-year-old in kidney failure doesn't get dialyzed. A ninety-five year old? Not him, either. Sixty? Sixty-five? OK, eighty-five? And if the idea is repulsive -- which it is -- and if it simply can't be addressed (certainly Congress never will), then let's just agree that the best we'll ever do is nibble at the edges. Which, to date, has pretty much meant nothing more than continually lowering reimbursement to doctors and hospitals. Turnip. Blood.

Outraged comments on posts such as this notwithstanding, people willing to work extremely hard under lots of stress to provide an excellent product have a natural inclination to expect some sort of commensurate reward. Certainly no doctor expects to get as much as a mid-level executive for Healthcom, or as much as a second-string second baseman. But something that reflects work and which doesn't continually drop would be nice. The price for the current approach has been, and will continue to be, burnout of the best, and the looking elsewhere than medicine by the sorts of people you'd like to see choosing it as a profession. The problem with us goddamn doctors is that we're also human beings. Tell me what you think a colon resection is worth, then stop lowering the amount every year. And if you won't let me charge more on my own because I do a better job (every other professional does), then show me a way you'll try to figure out if I'm better and slip me a little something. If not, don't expect everyone to keep striving. It doesn't work that way anywhere else; increasingly, it's not working that way in medicine, either. Which makes the next paragraph, probably, wishful thinking.

There's one thing to do before playing the rationing card. Doctors, as a group, have a hard time with it; but it's coming, and it needs to arrive. To the extent that it has arroven (yes, I know), so far it's pathetic. I refer to finding out what works, why some doctors get better results than others, why some can get the same results as others at half the cost. Determining, in other words, "best practices." Finding that out and putting in place methods to encourage the good and eliminate the bad. Care, that is. What we have so far, referred to by the much unloved acronym "P4P" -- which stands for "pay for performance" -- is, at best, silly; and at worst, counterproductive, because it's so stupid. An example of bureaucracy at its worst, the list of parameters seems to have been generated by a committee with little input from actual practitioners. Big surprise. I know medical quality is hard to quantify, to solidify into a checklist. But for surgeons, for example, the archetype is getting pre-op antibiotics into the patient no longer than an hour before surgery. Funny. In training, we were told to get it infused at least an hour ahead of time, so tissue levels could rise and equilibrate. Yeah, you can measure it and write it down. But what goes on much before that -- in terms of selecting and planning an operation -- and after that -- in terms of carrying it out and in providing post op care -- has volcanically more impact that the ticks of the antibiotic clock. Everyone knows that. Getting a handle on it is where the action is; but if it's possible at all, it'll take a hell of a lot of work. Thousands of records will need to be reviewed, outcomes compared, methods dissected. Necessarily, judgment will be called into question, egos will be threatened. Worse, errors in data collection and analysis will be made; conclusions may be wrong sometimes, or tainted. The various specialty societies and colleges will need to be at the helm, and it'll take time and will generate lots of heat (with good planning, maybe enough to reduce oil imports), but in my opinion it has to be done. All doctors and nurses know it: there are good ones, and better ones. And some bad ones. Crazy maybe, but I think most docs -- given the right incentives and handled in constructive ways -- will respond to information that allows them to do a better job, even if it means admitting that they may not have been in the past. Scream, yell, get pissed off, feel insulted. Then lie awake at night and think it over, look yourself in the mirror when you get up. And make some changes. Been there. Done that.

To the extent that people running for president are addressing health care at all, keeping the money-changers between consumers and providers seems to be a given, which strikes me as feckless and crazy. Why should a national health-plan include a layer which provides no care, is clearly dispensable, and which serves to suck huge amounts of money out of the system? It's like paying someone to put the key in your car before you start it.

So my thoughts distill to three things, needed in this order: a single-payor system that includes real and actual control at the top by providers and consumers; a no-holds-barred effort to find and encourage (enforce) best practices, which recognizes and rewards excellence; and, when all the money that's possible to save has been saved, the toughest of them all: prioritizing care; deciding which expenses make sense, and which don't -- rationing. (Alternative to number three: stop complaining about costs of health care.)

(I suppose it's not trivial that if the insurers were really to go away, there'd be lots of decent people without jobs. But that's hardly a reason to keep a useless system going. Maybe some of those displaced would be willing to do those jobs that, you know, Americans don't want to do. That way we could solve immigration, too.)

My Solution

Fourth of July. Birth of a nation. Childbirth. Health care. Seems a good day to step into the breech. As it were. Is our health care system salvageable? Does it have a pulse?



Several years ago, the clinic at which I worked signed an exclusive contract with a fairly large HMO; shock waved around the medical community, who felt we were trying to take over the town. A few years later, we threatened to fire the HMO, and that shock waved around the nation.

We'd come to the point at which the latest cut in reimbursement, announced via the usual one-way communique, was simply too much. Receiving the backside rather than the ear of the HMO, we sent letters to all our patients who were members (around twelve thousand, at the time) announcing the plan, along with toll-free numbers through which we'd help set them up in other plans. The HMO caved. It was, I'm told, written up in several health/finance magazines and hit the Wall Street Journal, as I recall. High fives.

For a while. Of course, it ended up only a holding action. We were able, on some occasions, to negotiate less onerous cuts; it's not as if we turned the tide. There is, however, a lesson. Our ability to get insurers to listen turned on two things: we were excellent, and we were big. Patients wanted to see us; lots of them. In that, I think, are some of the seeds of solution for the US health care crisis.

Let me say it up front: I favor some form of a single-payer system.* It's my view that the many problems with such a system can be overcome: it's not single payer per se, as I see it, to which people seem to object. It's some of the accouterments. Before getting to that, I'll state what I think is the obvious: having countless health insurance companies -- many of them for-profit -- sucks gazillions of dollars out of the health care realm, in form of profits to shareholders, salaries of executives, and tens of thousands of workers in cubicles. Both in the bowels of the insurers' buildings, and in hospitals and clinics and medical offices around the country, people input data, make calls, argue for and against payments, follow differing contractual rules within and between companies; in short, money that could be spent on care of the sick is diverted into pockets of those who provide no actual service to those in need of it. They are money handlers, nothing more. Medicare, for all its faults, has by far the lowest overhead of any payer in the country. By real far. The only way to get the most money going to actual health care is to be rid of the multiple middle men. And women. There are many other needs, as well. But to me, that's where it starts.

The biggest problems with Medicare are that it treats providers like shit, has stupid rules, and responds little, if at all, to input from those who know what's going on. It not only doesn't recognize, but actually deincentivizes excellence. No small things; but there's no reason a single payer has to be that way. What I'm saying, basically, is this: let's have a single payer, and let's make it smart and responsive. I think it's not categorically impossible. Faint hope, I realize. But if we take it out of the hands of politicians (after they approve it), eliminating the kind of politics-based governmental incompetence with which we've been regaled of late, there's at least a theoretical possibility of finding a workable approach.

Which brings us back to the preamble of this post: when the HMO relented, it was because we were big, and excellent. I'm aware it's also because they had competition, and that a monolith has none. But there's a point: when providers are able to have a say in the process, the system works. Better, anyway. The most destructive aspect of Medicare, from the point of view of a hard-working physician who has the ethic of excellence above all, there's nothing more demoralizing than being told, year after year, that that hard work doesn't matter; that there's another cut in reimbursement on the way. That the excellence of one is regarded no differently, in terms of payment, from the mediocrity of another. So: it's surpassingly important that this imaginary system has reimbursement guidelines that result from input from the people that do the work. Is there any other professional group about which it can be said that over the past twenty years the trend of reimbursement for service is steadily downward? It's really and truly perverse, and the effect is obvious.

I can hear the keyboards tapping away in fury: you doctors are a bunch of egomaniacal, money-grubbing assholes. Well, sure. Nor do I claim to know what's a fair level of pay for a doctor, compared to other occupations. But I do know that a system which generally lowers that level, and which disallows the ability to set or bargain for one's own pay, and which pays the same for a given widget whether the widget from one maker is a better product than that from another -- that system is headed for self-destruction. And it's already selecting against the sort of people we'd like to see join up.

The solution to the US health care problem, then, begins with this: a single payer system which is responsive to those who provide the care, both in terms of setting fees, and in recognizing those who do excellent work. Competition is a good thing. So is doing a good job. Let's build it in. Impossible? Maybe. Will it be imperfect? Of course. There's a need to recognize the special situation of training institutions. And there's always the doctors who (some with justification, and some not) claim their complications are higher because they get the toughest cases. Being excellent attracts challenges. But there are ways to deal with that. Make it like figure skating: toss out the high and the low scores. Borrow from the gassy world of anesthesia and the splashy world of diving: set up degrees of difficulty.

I'm no economist, so I can't say how much money will be saved by eliminating the profit-taking and the inefficiencies of the myriad insurers. But it's significant.

As hard as it would be to make it work, it's the easy part. Really to get a handle on health care cost requires a hard look at best practices, along with the staring right in the face of prioritizing care. I'll talk about it, like unto spitting into the wind, next...


* Need a definition, here. "Single-payer," to me, means something akin to Medicare, as opposed to the Canadian or British system of government-run hospitals and salaried physicians. I still believe in fee for service, because when you have doctors employed by governments on uncompetitive salaries, you have, as we see in England, to import them. And they become terrorists.

Thinking Out Loud....

(I'm hurriedly trying to change the subject from my sorry post below, so I'm rushing to print before fully fleshing out something I'd been working on. In retrospect, I wish I'd not posted my little fiction piece; but I've decided to leave it and move on. Quickly.)






This may sound self-indulgent and egotistical (what? from a surgeon??) but bear with me: I have a point.

I think I can honestly say my patients did well to have me as their surgeon, even as my wife may have gotten the short end, husbandly, and my son likewise, fatherly. By which I mean I spent my career, for whatever reasons, highly devoted to my patients and my practice, at the expense of my family and personal life. I simply had no choice in the matter: it's how I was trained, and what I believed. I was never entirely comfortable ceding surgical care to anyone else, even my closest partners. And for the first few years in practice, until I realized the folly, I even abhorred medical help: I felt obliged to manage even the intensive care of my patients. For a while, I was probably as good at it as the intensivists (of whom there weren't a lot, early on). As time went on, and I (happily) had only the occasional critically ill patient, I came to realize I wasn't the best one for the job. But surgically -- well, I never felt my partners would take as good care as I did. It might also be true that they felt likewise, in reverse. One would hope that all doctors felt that way. Or so I think. Thought. Wonder....

More than just imagining it, I lived it: I made hospital rounds no less than twice a day, and more commonly three. Except on the critically ill or unstable or as-yet undiagnosed: then it was four or more times. Six a.m. Between cases. Before heading to the office. At the end of the day. Go back in in the evening. I always took calls on my patients, whether I was the "on call" doc, or not. If a patient needed a re-operation, I'd usually do it -- on call or off. Although I think I may have overdone it, I'd say most surgeons of my era have similar commitment, if for no other reason than hearing the admonitions (to put it mildly) of our mentors in our heads. But it's more than that. To choose surgical training twenty or thirty (fifteen, ten) years ago was eye-openedly to enter into a contract; to agree that caring for patients was going to be the prime directive, and that it would be a never-ending commitment. That it was pounded in over and over for six or seven years of nearly twenty-four/seven training simply reinforced what was already implicit.

Considering my behavior mostly in hindsight, I have questions. How necessary was it? Did it really make a difference? Was it essential? Or delusional? An excuse for other shortcomings? In semi-retirement, it's clear my sense of irreplaceability was an illusion. But what of the rest? My younger partners never rounded as much as I. Unlike me, they took their full days off, and their allotted vacation days; weekends off were off. Their patients did well enough. Complications, for the most part, have their roots in the operating room. Data, when they were made public, confirmed my complications were fewer; but I think it had little to do with my post-op care. I do think those habits were part of why my over-all costs were less: in rounding frequently, I was able to expedite necessary testing and to get orders written sooner, discharge more efficiently. (Bureaucracy alert: the powers that be once decided to review afternoon discharges, intending to encourage doctors to make rounds in the morning to get patients out earlier. Afternoon discharges were to be some sort of black mark. Making rounds multiple times, I often discharged patients in the afternoon because some mornings they weren't ready but were later. I pointed this out to the medical director, asking if he'd rather I not make those afternoon rounds and wait till the next day, in order to avoid being dinged. The plan ended.) If my patients didn't have to get to know another surgeon during their hospital stay, if their hospital bills were lower, to whom did it really matter? No one mentioned it to me, much.

So what's my point? This: if any of this stuff actually did matter, I think it's moot. It's my sense that, as a generalization, things are changing fast. I'm not the first to blog about the recently restricted hours of trainees. In fact, nothing I'm saying is particularly original. I do, however, have several friends who are surgical professors in some high-level training programs, and I'd say it's unanimous among them that they are concerned about the surgeons of the future. "Shift-worker mentality" is a common theme in our conversations. The current crop of trainees, they say, aren't as committed as we were. They're happy to diddle around until the next shift arrives to solve a lingering problem. More importantly (but maybe a bit off the subject of this post), there's concern that the restricted hours lead to less experience, which works its way up the hierarchy: fewer hours means fewer operations. Senior residents are less likely to let the juniors do cases, which means those juniors, when senior, are less experienced. The need for formal mentoring after training is a concept being discussed seriously.

It's not entirely clear-cut: are patients better served by doctors less single-minded? The restrictions on hours resulted from a lawsuit over a death presumably due to mistakes by a fatigued resident. Avoiding fatigue, clearly, is desirable. But limiting experience? Selecting people less willing to make a full commitment? I imagine patients prefer a well-rested doctor. But one that plays the piano? Skis like a maniac? Coaches Little League? Not sure. Really. Not sure.

I burned out. After twenty-five years, chronically tired, dreading the phone-calls, missing family gatherings, I managed to wangle a temporary (I thought) leave of absence. It felt so good, I couldn't convince myself to go back to full practice. Had I been less crazily compulsive, maybe I'd have lasted longer; maybe I'd have, over a longer career, cared for more people (part of my problem was never saying "no." I did twice as much surgery as my partners, more or less.) So maybe it's better, from a cost-benefit sort of calculation, to have docs who want and have a life. And this: whatever else is true, the new crop aren't idiots. Surely they hear the cries; they know about decreasing reimbursement, malpractice, interference from all points of the compass. If there's much about the job that's become abhorrent, why give up your life for it? That's my point: is the current trend a bad thing, or a good one? Honestly, I don't know. Until a few years have passed, no one else will, either. And if it's true that the people choosing medicine now are different from those of a couple of decades ago, or have different expectations, I don't blame them. The essential rewards of being a physician, the privilege of caring for people, remain at the core: but the pleasures have become elusive, diluted by the myriad of impediments disguised as controls. It's illogical to expect docs to walk in the same way on ground that has fundamentally shifted under them.