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The Future of Anesthesiology: Should the Perioperative Surgical Home Redefine Us?

Prielipp, Richard C. MD, MBA, FCCM*; Morell, Robert C. MD; Coursin, Douglas B. MD, FCCP; Brull, Sorin J. MD, FCARCSI (Hon)§; Barker, Steven J. PhD, MD; Rice, Mark J. MD; Vender, Jeffery S. MD, FCCM, FCCP, MBA#**; Cohen, Neal H. MD, MS††

doi: 10.1213/ANE.0000000000000711
The Open Mind: The Open Mind

From the *Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota; Department of Anesthesiology, Twin Cities Hospital of Niceville, Niceville, Florida; Departments of Anesthesiology and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; §Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida; Department of Anesthesiology, University of Arizona, Tucson, Arizona; Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida; #Department of Anesthesia/Critical Care Services, NorthShore HealthSystem, Chicago, Illinois; **University of Chicago Pritzker School of Medicine, Chicago, Illinois; and ††Department of Anesthesia and Perioperative Care and Medicine, UCSF School of Medicine, San Francisco, California.

Accepted for publication January 29, 2015.

Funding: None.

Conflict of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Richard C. Prielipp, MD, MBA, FCCM, Department of Anesthesiology, University of Minnesota School of Medicine, B515 Mayo Medical Bldg., MMC 294, 420 Delaware St.-S.E., Minneapolis, MN 55455. Address e-mail to prielipp@umn.edu.

“You’ve got to be very careful if you don’t know where you are going because you might not get there.”—Yogi Berra

Anesthesiology is at a crossroads. The “Burning Platform” allegory highlights the dilemma facing clinical care and anesthesiology today. We are the workers trapped 150 feet above a stormy, cold ocean on a burning oil platform.a Balanced on that burning stage, our options are limited. None are attractive. For the oil rig worker, death is certain if he stays, and almost certain if he jumps.

This metaphor emphasizes that in the face of uncertainty about the future, radical action is required of all of us. This analogy is particularly relevant to the practice of medicine in an unsustainable and rapidly evolving health care environment. Survival instincts (e.g., jumping 150 feet into icy water) trumps one’s instinct to hesitate and hope the current situation fades.

For years, the flames of change have been nipping at the heels of the medical practice of anesthesiology. Some think we are “crying wolf.” But most health care experts and even the lay public acknowledge that we must change how we approach our patients and practice. We must adapt to new models of care. We must address some of the most vexing problems that compromise the patient-provider relationship and its impact on quality, safety, and health outcomes. As Dr. Karen Domino opined in her 2014 American Society of Anesthesiologists (ASA) Rovenstine Lecture, “This is no time for business as usual. The forces driving change are enormous, but they can be guided. The clock is ticking. The time to act is now.”

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EVOLVING ROLES

We acknowledge that the traditional practice of anesthesiology has been undergoing change for many years, expanding some of the opportunities outside of the traditional operating room (OR) environment to include perioperative care. At the same time, even these expansions of our roles and responsibilities may not be sufficient to sustain our specialty. The future options for anesthesia practice are less clear as we confront challenges at many levels. We need to assess our current practice, build on successful initiatives, and most importantly address deficiencies in current practice and the relationship of these items to quality, safety, and costs of care to address the needs of our patients and the overall health care system.

A number of changes in our scope of practice have been demonstrated to address some of these challenges. None of these changes should be undervalued nor the implications ignored. Subspecialization has created new opportunities for some of our colleagues to focus their clinical skills and practice on a subset of what has been the focus of anesthesia practice for decades. These include the specialty disciplines of obstetrical anesthesia, pediatric anesthesia, and cardiothoracic anesthesia. In addition, we have expanded our scope of practice to include critical care medicine, pain medicine, palliative care, and, for a modicum of clinicians, sleep medicine. However, in each of these areas, other medical specialists and other providers are competing for the same roles and responsibilities. Many have been formidable competitors with or without data to support their positions. Perhaps, most importantly for our specialty, anesthesiologists have taken on new administrative and clinical roles in perioperative care. We have demonstrated our ability to effectively manage patients preoperatively rather than simply assess them and provide improved care in the postanesthesia care unit and during their hospitalization.

Our expanded perioperative role has occurred in parallel with the changes in the roles and expectations for surgical specialties. Surgeons are rewarded and incented to operate. As a result, our surgical colleagues have requested assistance in the management of some aspects of perioperative care. This assistance is often provided by hospitalists, nurse practitioners, and physician assistants. Finally, we have been encouraged to take a broader view of each patient’s clinical experience and to provide for the continuum of care into and out of the surgical suite. This has been promoted by the introduction of value-based purchasing, with the need to reduce hospital lengths of stay, prevent nosocomial complications of care, and reduce hospital readmissions. Although costs are a primary motivator for these changes, quality and safety are the ultimate goals.

In response to these changes both within and outside of health care, we have been encouraged to reassess our roles, to identify new models of care, and to take an even broader perspective of patient care throughout the perioperative period and beyond. Most recently, the ASA as well as other groups have proposed that anesthesiologists become the integrators for what has been termed the perioperative surgical home (PSH). The PSH is a strategic response to the challenge laid out by Dr. Berwick and the Institute for Healthcare Improvement to derive better value for the resources invested by providing improved coordination and management across the continuum of clinical needs for each patient. This approach is designed to fulfill the conditions of the frequently articulated “Triple Aims” of health care:

  • Improved health of a defined population;
  • Enhanced patient care experience, including quality, access, and reliability; and
  • Reduction in the per capita costs of care.1

What is incorporated into this new paradigm for perioperative care? What does it mean for the future of anesthesiology? In its simplest definition, the PSH is a broad-based approach for surgical patients that covers the full continuum of the preoperative period, the surgical procedure itself, the immediate postoperative care, and extends care into the postdischarge period. With this perspective, it is very important to address whether this model makes sense for patients, providers, and the health care system. It is also critical to address whether anesthesiologists who are provided the opportunity to take on this role have the skills and interest to do so, along with the ramifications for all other aspects of anesthesia practice. Will this integrated approach increase value, patient-centeredness, and provide better treatment for our patients? Most notably, we need to ask several core questions: are anesthesiologists (now or in the foreseeable future) the best educated, best trained, and best suited to accomplish this effort in the most cost-effective manner? Is it expected that all anesthesiologists will adapt their practices to this model? If so, what are the implications for all other aspects of anesthesia care? Will other providers and health systems allow anesthesiologists to take on this role or will there be competition from surgeons, hospitalists, nurse practitioners, and others? If so, do we create new antagonistic relationships with colleagues who have previously been supportive and collegial? Will we continue practicing in the best interests of our patients? Finally, and perhaps most critical to this proposed model, how do we get compensated, or at least financially supported, for creating, piloting, managing, and sustaining a PSH?2 To our knowledge, no published studies compare anesthesiologists to other providers in fulfilling the tenets of the PSH. There is no published economic analysis of how adequate revenue will be generated by these efforts (whether by anesthesiologists or others) to ensure financial viability.

The innovative PSH model is predicated on global perioperative care (“door-to-door” service) of the surgical patient, with the laudable goal of reduced cost coupled with improved outcomes. The proof of concept is particularly timely and important, as similar primary care–based attempts have shown limited efficacy in attaining the desired goals. In one of the earliest, largest, and longest running medical home pilot demonstration projects that sought to measure the changes in quality, usage, and costs of care resulting from participation of primary care practices in medical homes, performance was improved in only 1 of 11 quality measures.3 Unfortunately, this pilot project failed to reduce usage of hospital facilities or total cost of care over 3 years.

The PSH model is currently being evaluated with the support of the ASA Collaborative.2–4 There are several innovative and robust pilot programs in progress in which anesthesiologists are managing care for orthopedic, colorectal, and urology patients.5,6 These pilot projects will provide important lessons to allow us to determine how the PSH model fits within the overall specialty of anesthesiology. They will also identify the implications for the work force, including recruitment and education of anesthesia residents. The ASA Collaborative and the pilot projects will help the specialty address some of these specific concerns associated with evolution of the PSH.

At the same time, there has been little engagement by others who have an interest in the success or failure of this model. Although some surgeons and some hospital administrators recognize that anesthesiologists are well positioned to take on the role of manager of the PSH, in most cases, it will only succeed if the specific model in each institution takes into account the roles and responsibilities of all stakeholders involved in the care of the surgical patients.2,4–6 In other words, these models will succeed not because of fundamental economic principles but rather because they are compatible with local environments and leverage relationships established during a long period of time. We are therefore encouraging more open dialogue and debate about what the PSH entails, the various models that might be evaluated, and the metrics that will be used to define success for these experiments within the ASA Collaborative and beyond.

The stakes are huge. The implications of this proposed change in the roles and responsibilities of anesthesiologists are significant. Although the PSH incorporates some important aspects of the new model of anesthesia care, it alone, or its current iterations, may not be sufficiently responsive to our patients, our colleagues, or the payers. Even now some graduating anesthesiology residents struggle to identify optimal practice opportunities because of the consolidation of practices into regional or national multispecialty groups.7 They also may find themselves competing with nurse anesthetists who have already gained independent practice in many states.

The final challenge associated with the implementation of the PSH in any clinical environment is the financial implication each model imposes. How will anesthesiologists and other providers be compensated, or at least supported, under this model? Will funds be distributed to physicians based on relative value units from a bundled payment to a health system? Will anesthesiologists be incentivized to reduce costs? If so, how will their role in the cost savings be defined? What other metrics will be used to compensate anesthesiologists or other physician specialists to participate in the PSH?

The PSH group at the University of Alabama at Birmingham highlights that the health care organization must be willing to “purchase” the increased “value” achieved by the PSH process.2,4 To that end, 3 conditions must be met:

  1. Strong institutional desire to meet the Triple Aims,1
  2. A robust informatics system to capture the impact of the PSH, including local expertise to collate, manage, and analyze the global data, and
  3. An anesthesia practice that is financially aligned with the institution.2

This third element requires that the anesthesia practice becomes fully employed by the institution (while simultaneously remaining distinct corporate entities), that the institution develop an integrated funds flow model to achieve collective objectives, and that the institution and anesthesia practice develop comanaged contracts.2 Obviously, these contracts must balance the needs of both partners across value-based purchasing programs and bundled payments methodology. We believe it is incumbent upon the ASA and leading pilot organizations to delineate a financial pro forma as well as demonstrate positive balance sheets from mature PSH programs. In addition, the future of the independent anesthesia practitioner or private practice group within this context should be addressed transparently.

We have described many of the challenges associated with the implementation of the PSH. Our intent is not to view these challenges as irreconcilable barriers to adoption. Rather, this is a call to consider how this model is integrated into current practices and to identify ways to evaluate it in a scholarly manner. Our view is that while the PSH incorporates some important aspects of a future model of anesthesia care, it or its current iterations may not be sufficiently robust and responsive to market demands. Whether the PSH model will apply to all patients, subsets of surgical patients, or selected clinical service lines, the transition from the current fragmented model of care represents a major change in focus, required skill set, and, most importantly, a commitment to define how to implement this type of practice. Anesthesiologists are already fragmented into clinical anesthesia, preoperative assessment, pain management, and intensive care unit care. Will we welcome further fragmentation into PSH managers?

We acknowledge that the current anesthesia care model may not be either sufficient to meet our patients’ needs or sustainable, at least for many practices and traditional clinical situations. Anesthesiology is at risk of becoming, or perhaps in some cases has already become, a hospital “commodity.” The recent consolidation of practices into regional or national multispecialty groups7 has changed the professional environment and options for graduating residents and may or may not support any role by anesthesiologists in the PSH. For example, some of the national multispecialty organizations use hospitalists or nurse practitioners to manage patients through the continuum of care. Is there a role for the anesthesiologist as well, or is the anesthesiologist best suited to either provide or supervise care in the OR and non-OR procedural areas? What are the implications of the recent decisions to grant independent practice status for advance practice nurses?

It is important to encourage a robust dialogue with our colleagues about these questions as we continue the experiments under the ASA Collaborative and beyond. Table 1 summarizes the issues that we believe require further consideration.

Table 1

Table 1

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Our View of a Different Future

Others can best summarize the history and development of the PSH.2,4,8–10 The pursuit of the PSH has involved efforts during the past 14 years and has currently yielded a number of pilot programs in part supported by substantive funding of the ASA Collaborative. Even in a mature PSH future, Warner and Apfelbaum10 predict “most groups would recruit 1 or a few partners who have specific training in this subspecialty.” Will that model be sufficient for the future health of our specialty?

The forces driving change in anesthesia practice and health care in general are enormous, as acknowledged in a number of recent Rovenstine lectures (Miller, 2008; Domino, 2014). It is critical to be reminded that these changes may not be stopped, but they can be managed. It is our responsibility to our patients and colleagues to do so. The current instability in health care provides us with the opportunity to reengage in the debate about the future of our specialty, the roles we might play in the changing health care environment, and the implications for future work force development.1,4

Web accept that the PSH pilot programs are likely to be beneficial in some situations. We accept that the PSH might evolve into a significant opportunity for some anesthesiologists to redefine or expand their role. We also anticipate that some of the key constructs of the PSH will be incorporated into anesthesia care of the future. At the same time, the challenges faced by all health care providers, health systems, and patients mandate that we also conduct a focused examination of the future while considering an entire paradigm shift in who we are, how we are educated, the duration of our training, how we practice, how we lead, how we add value, and how we equip graduates with the skills to adapt to future changing dynamics. The PSH may be a piece of a much larger and more serious reengineering of the specialty, extending far beyond the changes in resident training and subspecialization that have taken place during the past 2 decades. The time is now for the specialty and the ASA to take a much broader perspective that incorporates but does not let the PSH alone dominate our dialogue.

To move the discussion forward, we offer an alternative vision for consideration that is far ranging, still under construction, and is meant not to criticize past and current efforts, but on the contrary, to initiate a thoughtful and productive discussion about how best to accomplish the transformation of our specialty. This vision is based on 3 tenets:

  1. Anesthesiologists are most likely to be successful coordinating highly specialized, complex care by remaining active participants in procedural management of high-risk patients in traditional and nontraditional environments ranging from premature infants to the very elderly. That said, we simultaneously recognize that routine care will be by supervision, rather than by medical direction, of a pool of physician extenders, including certified registered nurse anesthetists, anesthesiologist assistants, and advanced practice registered nurses. These models of care will require that we identify, evaluate, and implement new ways to deliver anesthesia, sedation, and analgesia as well as monitor patients throughout the hospital environment and beyond. It will require that we incorporate disruptive technology that advances patient care, whether it be “Google glasses” or other advanced technologies.11c
  2. We propose a new paradigm that will reconsider the current curriculum for all residents and incorporate broader and deeper focused specialty training into the core curriculum within 1 of 5 fields listed in Table 2. The model will continue to include fellowship training. However, some subspecialties may be folded into a 5-year continuum as subspecialty modules selected by each resident. The implications of such changes are significant. As an example, had anesthesiology, like pulmonary medicine, incorporated critical care into the continuum of anesthesia residency when the residency program expanded to 4 years, our future might have been very different. Such an expanded residency might have facilitated our transition to the role of managing the PSH.
  3. The transition from the current model to these superspecialists of the future will require transformative alterations to our residency programs, program numbers, and number of anesthesiology graduates. Specifically, we speculate that there will be fewer but more skilled and more experienced anesthesiology graduates generated from the pool of highly resourced training programs. We simultaneously acknowledge that the number of anesthesiology graduates ultimately will be market driven, and the future might demand fewer or more graduates.
Table 2

Table 2

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Implications

We recognize the training implications of this proposal are substantive and that many elements of anesthesia practice are already well represented in the current curriculum. We will need a significantly expanded educational curriculum and alternative ways to provide clinical experiences to simulate rarely occurring events. Expansions of anesthesia training will obviously require the support of the Accreditation Council for Graduate Medical Education and anesthesiology residency review committee to foster innovative pilot projects and to allow programs greater flexibility in meeting the expanded educational needs of residents. It will also require the input and support of the American Board of Anesthesiology and other American Board of Medical Specialties boards, the ASA leadership, the ASA House of Delegates, our subspecialty societies, and, most of all, support from grass-roots practitioners. We need robust support from all stakeholders to achieve timely and meaningful change. Finally, we encourage broader liaison with primary training programs such as pediatrics and internal medicine to ensure that our residents gain clinical experiences in the care of medical and pediatric patients before and after initial recovery from anesthesia and surgery. As demonstrated in multidisciplinary critical care fellowship programs, interdisciplinary training can also benefit residents from other specialties. A broader liaison, including interactions with primary training programs, would advance the effective training of specialized perioperative physicians as well as enhance integrated training that draws on meaningful experiences across disciplines.

What we propose is a much more complex undertaking than the current efforts to develop the PSH as a major approach to securing the future of our specialty. We understand that the educational thought leaders in our specialty will define many of the elements of this new model of training. At the same time, we have extensive experience in educating not only anesthesiologists but also physicians in other specialties in aspects of anesthesiology and perioperative care. Anesthesiology has supported joint training in anesthesiology and medicine, anesthesiology and pediatrics, collaborative training of anesthesiologists, neurologists, physical medicine, rehabilitation physicians, and psychiatrists in multidisciplinary pain medicine, and anesthesiologists, surgeons, and emergency medicine physicians in critical care fellowships.

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Transformation of Anesthesiology Training

If implemented, our proposed paradigm for anesthesiology training represents a seismic shift in traditional education and practice. It would clearly impact the characteristics (and perhaps the number) of current anesthesiology training programs. It might naturally coalesce our best scholars to key institutions most recognized for research expertise. Even today, we note that current medical school, hospital, departmental, and other economic forces have already concentrated significant (defined here as >$1 million) federally funded, National Institutes of Health–supported research to a limited core (N = 35) of anesthesiology training programs (Table 3). But additional details of the innumerable futuristic transitions are well beyond the immediate scope of this discussion.

Table 3

Table 3

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CONCLUSIONS

In closing, our comments are meant to stimulate discussion and to provide a useful template for further dialogue among all of the interested parties, including but not limited to the ASA, American Board of Anesthesiology, Accreditation Council for Graduate Medical Education, and the Society of Academic Anesthesiology Associations to identify potential opportunities for the future of the specialty. The PSH pilots represent an innovative and important expansion in the practice of anesthesiology. It might, in a variety of models, improve patient care. It might provide an expanded role for some anesthesiologists.

However, the PSH alone is insufficient to secure our future. We need a national discourse about the viability of some of our current practice models, including the current models of perioperative care, pain medicine, and critical care. We need to assess the role we can play in palliative care and chronic disease management in general. We need to consider the implications of the PSH and its alternatives for anesthesiologists, health systems and, most importantly, for our patients. We believe that our best solutions will be derived from a constellation of alternative discussions. We believe that we need to hear more from colleagues in large and small community groups, consolidated multistate anesthesia corporations, and current academic practices.

Finally, we want to emphasize that these discussions and decisions are urgent. We cannot wait for PSH pilots to be implemented and their value defined. Even now, some futurists contemplate the role of robots as surrogate providers in the OR in accomplishing such “mundane tasks” as oral tracheal intubation, regional anesthesia, and moderate sedation.12–15 We believe we afford our specialty the best opportunity to thrive by intrepid resolve to change the way we educate a new generation of anesthesiologists who provide highly specialized care for individual patients, supervise the anesthetic management for all patients, generate new knowledge, and effectively coordinate care to add value to the perioperative process. We urge rapid efforts to initiate and continue robust debate, with decisions and implementation of large-scale changes within 5 years, by 2020, as we recall the admonition of Jack Welch, former Chairman and CEO of General Electric: “Change before you have to.”

As part of this robust debate, we direct readers to our dialogue with Drs. Warner and Apfelbaum that appears in this same issue of Anesthesia & Analgesia.16

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RECUSE NOTE

Dr. Sorin J. Brull is the Section Editor of Patient Safety for Anesthesia & Analgesia. The manuscript was handled by Dr. Steven Shafer, Editor-in-Chief for the Journal, and Dr. Brull was not involved in any way with the editorial process or decision.

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DISCLOSURES

Name: Richard C. Prielipp, MD, MBA, FCCM.

Contribution: This author helped in creating concept, outline, and core content of the article, and co-wrote the manuscript with all other co-authors.

Attestation: Richard C. Prielipp approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: Richard C. Prielipp is a member of the Executive Committee of Anesthesia Patient Safety Foundation (APSF) and on the Board of Directors of that Foundation.

Name: Robert C. Morell, MD.

Contribution: This author helped in co-creating concept, outline, and core content of the article, and co-wrote the manuscript with all other co-authors.

Attestation: Robert C. Morell approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Douglas B. Coursin, MD, FCCP.

Contribution: This author helped in co-creating concept, outline, and core content of the article, and co-wrote the manuscript with all other co-authors.

Attestation: Douglas B. Coursin approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: Douglas B. Coursin is vested in Isomark, LLC, which is exploring a novel method to identify early life-threatening infection. This constitutes no cash value.

Name: Sorin J. Brull, MD, FCARCSI (Hon).

Contribution: This author helped in co-creating concept, outline, and core content of the article and co-wrote the manuscript with all other co-authors.

Attestation: Sorin J. Brull approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: Sorin J. Brull is a member of the Executive Committee of Anesthesia Patient Safety Foundation (APSF) and on the Board of Directors of APSF. Shareholder, ADBV, a medical device company with no connection to the contents or subject of this manuscript.

Name: Steven J. Barker, PhD, MD.

Contribution: This author helped in co-creating concept, outline, and core content of the article and co-wrote the manuscript with all other co-authors.

Attestation: Steven J. Barker approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Mark J. Rice, MD.

Contribution: This author helped in co-creating concept, outline, and core content of the article and co-wrote the manuscript with all other co-authors.

Attestation: Mark J. Rice approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: Mark J. Rice serves on the Roche Diabetes Advisory Board.

Name: Jeffery S. Vender, MD, FCCM, FCCP, MBA.

Contribution: This author helped in co-creating concept, outline, and core content of the article and co-wrote the manuscript with all other co-authors.

Attestation: Jeffery S. Vender approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Neal H. Cohen, MD, MS.

Contribution: This author helped in co-creating concept, outline, and core content of the article and co-wrote the manuscript with all other co-authors.

Attestation: Neal H. Cohen approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: This author has no conflicts of interest to declare.

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FOOTNOTES

a The Burning Platform. Available at: http://www.connerpartners.com/frameworks-and-processes/the-real-story-of-the-burning-platform#sthash.RpgtJ1zA.dpuf. Accessed January 22, 2015.
Cited Here...

b We = A coalition of 8 senior anesthesiologists composed of 4 current and former department Chairmen, 2 private practitioners, physicians from all geographic regions of the country, who collectively have >250 years of anesthesiology and critical care practice experience.
Cited Here...

c Available at: http://www.newyorker.com/magazine/2014/06/23/the-disruption-machine. Accessed January 22, 2015.
Cited Here...

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