A PhD thesis in knowledge translation: Improving medical management through research and training

When I tell people that I have been doing clinical research for the better part of my last decade of life I usually get a few or more of the standard questions that are asked of higher degree research students like, “what did you do your PhD on?”, “what did you find?”, “was it hard?”, “why did you do it?”, and “what’s next?”.

These questions can be asked in a matter of seconds, but to answer them even briefly can take from 15 minutes to hours, depending on the level of interest. Now that the PhD is finally wrapped up, I feel inspired to write down some of the answers to these questions. I write in the spirit of what my thesis was all about “knowledge translation”, in other words, getting research off the shelves and into practice.

What was your PhD thesis on?

The title was “Improving the medical management of organophosphorus poisoning (OP) throught health services research and training”. Self harm is a big problem worldwide, and anyone working in an emergency department will be no stranger to this problem whether it is from people cutting themselves or taking overdoses. In many parts of rural Asia people drink pestices as a means of self harm resulting in over 300,000 deaths annually.

The vast majority of these pesticides are a particular form called organophosphate agents. This is much more toxic that the common weed killers used in Australia, such as round-up which is a glyphosate, and organophosphorus agents result in high case fatality rates, in the order of 15-30%, despite best practice.

The research collaboration that I worked with to conduct my research, the South Asian Clinical Toxicology Research Collaboration (www.sactrc.com), was a project that aimed to address many aspect of the public health problem of pesticide self-poisoning.

My work focussed specificially on two areas;

1) Improved medical management through the use of point-of-care tests that could provide information (acetylcholinesterase, ACHE, levels) that was thought to be useful in guiding antidote therapy
2) The evaluation of a train-the-trainer system of education to address training deficits in resuscitation education in the rural Sri Lankan setting

Both of these streams of study were different vehicles on the same journey of aiming to close the knowledge practice gap surrounding the management of OP poisoning. Thus the overall theme of my thesis was to do with this process of “knowledge translation”. The studies have been liked together using this conceptual framework.

They say a picture says a 1000 words so perhaps a figure from the introduction section of the thesis of the conceptual frame work , and two figures from the conclusions sections would aid to this strategy (ie 3000 words!?)

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Was it hard? Why did you do it?

These two questions are perhaps best answered together.

Yes it was hard.

I did it for multiple reasons, but most of all, it was the journey of trying to make a difference in the world. I have always wanted to do this, and when I started doing educational research I realised that there is an immense potential to improve the world by creating, and then assessing different systems of education.

The following video/slideshow shows how this happened in a poetic format.

The course of the PhD offered many challenges for my Emergency Medicine training that I was doing concurrently, as well as the ups and downs of life.

However, despite the knocks and triumphs, I strengthened my resolved to follow the dream I initially had with making a difference through training in Emergency Medicine training and International Research, and so far it has paid off in ways that I cound’t have imagined.

What’s next?

The first step was to stop, appreciated, and then reflect upon lessons learned, and wisdom gained that will hopefully help myself and other in the future. The next step is to become an Emergency Medicine consultant by finishing off the training, through training and sitting a fellowshop exam next year in 2016.

As for the future, I have some dreams and visions. I would like to continue as a clinical academic, teaching medical students and junior doctors. The vision I have is to help address many challenges in health care training, by fostering better “systems of training and education”. Perhaps one way this could be done is through research that also takes into account the important human factors of communcation and compassion, but who knows – tomorrow is still a mystery?

Some key publications;

The Effectiveness of a ‘Train the Trainer’ Model of Resuscitation Education for Rural Peripheral Hospital Doctors in Sri Lanka – Plos One (2013)

Evaluation of the Test-mate ChE (Cholinesterase) Field Kit in Acute Organophosphorus Poisoning – Annals of Emergency Medicine (2011)

Effect of acetylcholinesterase (AChE) point-of-care testing in OP poisoning on knowledge, attitudes and practices of treating physicians in Sri Lanka (2014)

PDF of Thesis

Current research projects;

Enhancing employee engagement and wellbeing in at risk units

 

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The Golden Day – PhD submission

Oh the joy of finally submitting the bound, accepted thesis. Thank you! ‪#‎love‬ ‪#‎gratitude‬ ‪#‎PhD #ANU #perseverance

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“Improving the medical management of organophosphorus pesticide poisoning through health services research and training” – Bishan N. Rajapakse, PhD , Australian National University, February 2015.

Abstract

Organophosphorus (OP) self-poisoning is a major global public health problem resulting in over 200,000 deaths each year with a case fatality of 15-30%. Early medical management consists of effective resuscitation and targeted antidote therapy.

This thesis argued that health services research and rural doctor training could be used to improve the medical management of OP poisoning in a resource limited rural Sri Lankan setting, where the delivery of critical care is limited by a lack of diagnostic tests and resuscitation skills. Research investigating the use of AChE in guiding clinical management, and research that measured the effectiveness of rural resuscitation training, were the two streams of research that were the founding pillars of the thesis. These two elements were linked together through a conceptual framework of knowledge translation, each operating at different points in the continuum of evidence being translated into practice.

An AChE point-of-care test (Test-mate ChE) was demonstrated to provide accurate and reliable results in acute OP poisoning when compared with a reference laboratory. A survey based analysis of clinician’s knowledge, attitudes and practices found that most doctors valued the test, but also surprisingly found that doctors who were more experienced with AChE valued the test less. Low proportions valued the test in guidance of acute poisoning management (e.g. to direct oxime therapy and early discharge).

A systematic review highlighted a lack of supporting primary evidence for the use of AChE in relation to oxime use and discharge decisions. Advice on interpretation of AChE and caution about pitfalls in measurement were also lacking. These areas need to be addressed to optimise provision of AChE POC devices.

A train-the-trainer (TTT) model of resuscitation education was effective in improving resuscitation knowledge and skills in rural peripheral hospital doctors, and improvements in most components were sustained for 12 weeks. This demonstrated the effectiveness of using non-specialist doctors to conduct peer-led advanced life support (ALS) training in a low resource peripheral hospital setting, using objective knowledge and skills endpoints according to standardized metrics.

A systematic review of resuscitation of OP poisoning found no texts solely focused on acute initial management. An ‘OP specific’ ALS guideline was proposed based on consistent literature recommendations highlighting the importance of rapid atropinisation (doubling dose regimen) to be delivered simultaneous with immediate airway, breathing and circulation management. Other antidotes such as oximes should not be in the ALS guidelines.

A participatory action research approach was used to address practical problems through close engagement with health services and local training systems. The experience from both streams of research showed that such strategies were integral to the completion of the studies employed in the low resource rural setting. The thesis demonstrated health services research and training could be used to close the evidence-practice gap, and may have a role in the improvement of the medical management of OP poisoning. Future research should investigate clinical endpoints associated with the use of AChE in guiding OP poisoning management, the development of decision rules offering practical guidance in measurement and interpretation of AChE, the evaluation of OP specific ALS guidelines, and the sustainability rural resuscitation training programs.

PhD Thesis – the story behind the questions..

I was once told that good writing is all about the narrative. When I started writing up my doctoral dissertation I soon learned that I was collating, and weaving together, a series of narratives into a cohesive story with some scientific value.

I also learned that the key to good research is having useful and relevant research questions. In my thesis some of the most important questions only came clear to me whilst I was already on the ground doing research in a rural hospital in Sri Lanka. Here, I remember vividly observing many critically ill patients who had intentionally consumed deadly pesticides, and wondering what their fate would be given and how we could improve the medical management in order to save lives. Thus, for me it made sense to try and provide a story about the “context” where I embodied the research questions that would culminate into the ensuing scientific narrative.

Below is a poem that never made it into the final thesis, but in perhaps captures the passion of enquiry that sustained me through the long journey of formulating hypothesises, collecting data, and publishing my final findings.

Too young to die

Side by side in the intensive care they lie,

Multiple family members hoping they won’t die,

I can’t help but ask myself why,

Surely this lady is too young to die?

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Was this the result of frustration in the home,

Did she really want to leave this world for good?

Would her family and kids not worry and feel pain,

Everything seemed like it was all in vain,

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Back to the room with the lights and the constant beeping,

Things are getting tense, she is more than sleeping,

Deep down I feel strongly that this lady should not go now,

I want to help, but the real question was “how”?

14/2/07 (21:24hrs)  The above poem was written whilst observing a 36 year old woman, from a rural town in the north central province of Sri Lanka, fight for her life whilst on an intensive care ventilator. She was the mother of 3 children, and took an organophosphorus pesticide poison following an argument with her husband. She died within 2 days of presentation to hospital.

My PhD research was dedicated to the countless patients, like this lady, and to the numerous health staff and researchers who who were all a part of the effort to save and improve these patients lives.

The following two PDF excerpts show the contextual story which lead to the eventual scientific document that comprised the final thesis.

A strategy for hope in the face of death…

This slideshow requires JavaScript.

Download here (phd-thesis-preface )

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The table of contents

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The entire thesis can be downloaded from ANU digital thesis at this link  – however, I’m happy to be emailed (bishan.rajapakse@gmail.com) and send you a pdf copy if you would like to read it. I would also be delighted to hear any reflections or comments on this work that occupied my attention for the better part of a decade.

Failure and Success

Some of the greatest people,

Are the ones, who have faced failure and pushed on anyway,

They seem to look on the bright side and continue to move forward,

Facing their obstacles with barren simplicity.

They can walk with humility and confidence within the same stride,

And this is the kind of success to which I abide,

For perhaps the highest achievements in life,

Come from greatest hardships,

Recognising that either way we win,

For the next step is always available,

But what we do with it,

Is only up to us.

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I refuse to accept defeat unless this is for my benefit. Even when I fail, I always try to see it as training for the next attempt, or preparation for the new direction that I am taking. This attitude isn’t always easy, but it is possible.

Tonight I watched an inspiring TED talk that spoke straight to my heart (the amazing story of Sam Berns, a teenager who has lived through the premature aging condition of “progeria”, and talks openly about his philosophy for a happy life – well worth the watch if you can spare 12:45 minutes) –  his story reminded me of a philosophy that has guided me through many difficult times.

 

So many times throughout the journey of PhD I faced failure. The “feeling of failure” seemed to come up repeatedly;- when studies were not approved to be carried out, or when help seemed like it was far away, when journals rejected preliminary submissions, and when I had to complete a thesis that seemed like it was against the odds. However, I made it through all of these things, securing 3 scientific publications in a peer reviewed journals, 1 book chapter, and a completed PhD thesis of 363 pages long. When I submitted my thesis in January this year it was late, requiring more than one extension, but still I delivered the goods.

Recently I heard back from the Australian National University, and that the thesis had been accepted for the degree, pending some minor revisions. It was a powerful moment for me to read their reports that indicated that the thesis was worthy of the degree to which I was submitting it towards, but the ideas contained within were likely to make a difference in the world, particular in rural areas of the developing world. This was already a dream come true.

To make a difference through research was something I kept close to my heart all the time when I was conducting studies and writing up the thesis, which took me through some lonely but also inspiring periods. The gratitude I feel for all the help I’ve received cannot be expressed in words alone (although I tried in this post years ago) – and this is why I created a short film about the experience some years back.

However, now that I am almost there, it is clear to me that I needed to go through all that I went through to arrive here– for I believe the “journey” is what makes the destination worthwhile.

This concept inspires me for the next journey, and I hope it will be as good as the last one. Even if I have to again face failure and overcome obstacles in order to move forward, I accept this wholeheartedly, knowing this what I have chosen to do and will appreciate it accordingly.

Thank you for being there!

For all of you out there, who are walking down towards a vision of success may all your dreams come true  – after all as a wise friend once said to me “perhaps the only failure is the failure to try”

🙂

Ps I don’t think I’m alone in this philosophy, for many others seemed to have had a few obstacles along their inspirational paths.

Academic Work

 

What is Academic work?

Is it just a series of responsibilities that one must shirk,

 

In favour of a goal that seems like a mirage?

Or perhaps a slow moving barge?

 

Changing directions all the time but still keeping to its destination,

That seems like an ever-moving target?

 

No it is not!

Don’t worry if you are cold and you are hot?

 

Because this is in keeping with the rhythm of the beast,

And once you are finished you will have a feast!?

 

On the accomplishment of your stamina,

For you will have stripped yourself down to every crevice, and every lamina,

 

Only to find yet another room full of “stuff”,

Making all of what you have done so far seem like “fluff”,

 

This is PhD~!

It is a sea of knowingness into the unknowingness,

 

Looking for what answers you can find,

Only to be lost in an ocean of questions that do not bind.

 

So pick up your paddle and steer your raft,

Even if you don’t know how this is how you develop your craft,

 

You will get there with work and the force of the occasional swell,

Even thought it sometimes seems like you are paddling in hell,

 

You will survive!

And if you “like” the unknown then you will thrive,

 

For this is your drive,

Choosing to be either dead or alive,

 

Every moment of your existence,

Learning that the key is in persistence,

 

So get back to the grind,

And never forget to be kind,

 

To yourself and others on the way,

For this is the most important part of each and every day!

 

 

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Overcoming the obstacles of PhD writing…


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 Ego is the Challenge

 

The ego will betray you,

“Let go of it” – I pray you!

For only then you will see your true soul,

 

It is what makes you whole,

Even beyond your imagined goal,

For the ego is but an imposter,

 

So don’t give it the food to foster,

And fret in you head,

Otherwise it will make your spirit dead!


 

Advice of a Sage…

 

“How then do we manage it?” dear sage,

If I don’t learn the secret soon I am sure to age,

And it will happen so swiftly that I will not be able to gauge,

 

It is true my ample student,

And to ask of this truth is prudent,

For you already know the answer,

 

What you should do is let go of “thought”,

Do it soon before you are caught!

To the eddy currents of the mind.

 

But Sage I feel it is already too late,

Is this really my fate??

It is as if I am blind to common sense,

Surely letting go is ‘too hard’ if you are “this” tense!?

 

Wrong again my worthy learner!

For ‘letting go’ is the way to put thought into the burner,

Releasing the veil to the consciousness that lies beyond,

Both the flower and even the lotus pond,

 

Thank you dear sage,

For even though you speak in riddle and rhyme,

I feel the wisdom of my inner bell chime,

And I will, for sure, let go next time!


 

The feelings of a new consciousness

 

It feels like a bird soaring in the sky,

Why did I for so long deny,

Myself of this great aptitude,

All for the false promise of what my friend ‘Ego’ brewed,

 

 

But at least now I am aware,

And with you I will share,

That the Ego is always there,

Weighing you down, like a ripened pear,

 

 

Nevertheless it’s okay – you don’t need to frown,

Or even run around,

Just accept it as a very necessary part,

For to live on this Earth, identity is where we all start,

 

 

But it is certainly not where we end!

The new journey is starting,

And today is where we mend,

So keep going and I’ll see you around the bend!

ANU Research Fest 2010 – Going beyond the Endpoints!

Last week was the Australian National University’s research festival week. The ‘Research fest’, as it is know to ANU’ers, is like an orientation week for research students (MPhil and PhD candidates) where research and teaching life is celebrated. In addition to seminars on “thesis writing” for new students and “strategies for completion” for more advanced students, the University holds a series of social and creative activities including competitions for a research note, presentation of a thesis, acting in skits or presenting a short film clip.
The creative part of university life is something I was loved in my undergraduate years, but unfortunately in the four years that I have been enrolled at ANU for my PhD, I have never been able to attend this Research festival because of the demands of my fieldwork in Sri Lanka. This year was no exception, but this time it was because I am back in New Zealand writing up my thesis, and I am presently on quite a tight schedule to complete this! However, I did enter two competitions ‘on-line’ despite the mounting pressures.

Research Note

For the “Research Note” competition I wrote a Poem synopsis about my research experience that was titled “Going ‘beyond’ the endpoints!”. This is about an aspect of research that I discovered along the way and is something that I feel strongly about (ie. that life is more about the journey than the destination).

Going “beyond” the Endpoints!

Beyond the endpoints are the bits that are not seen,

The thoughts and emotions that lie behind the PhD’s sheen,

And whilst they will not appear in the final binding,

They are the reminders of how the road was so very winding.

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Research is more about the journey than its destination,

It is to respect the ‘process’ as well as the final creation,

And the process lies within the changes we experience in “ourself”,

Which sometimes speaks more than that book up on the shelf.

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My story is long, but I’ll try and keep it short,

It won’t be like some kind of scientific report!

For this is about a journey of mind and soul,

How this process has helped me feel whole.

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I collected data in the depths of Sri Lanka,

Amongst my very own first culture,

Where beautiful rivers flow, and green paddy fields glow,

With coconut trees that surround, where wild elephants can easily be found.

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I studied suicidal poisoning and its medical cure,

In villagers who drank pesticides when they felt desperate and insecure.

Some would say it was a cry for help,

Either way, they did not do well.

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We tried to understand how to ease the terrible prognosis,

By studying a portable machine that could help in treatment and diagnosis,

But whilst collecting this data, an additional vision was to develop,

Another study – “training doctors in resuscitation”- was soon to envelope.

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Whilst in Sri Lanka my mind expanded more than I would have believed,

Working with different cultures and systems into which I’d soon be weaved.

And with this I began to see my thesis as more than a mere ‘cog in a wheel’,

For perhaps, it may bring about change in the world, in a way that is real.

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Film Clip

I also put together a 5 minute short film (see below) which is a story along the same theme titled :-
“Beyond the Endpoints – sights, sounds and emotions of the international journey of research”.

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I didn’t want to let the movie get in the way of my thesis write-up, because I know that whilst film making and photography are a real passion of mine, they are also a huge consumer of time. However, to overcome this challenge I had a plan of waiting until the day before the film clip deadline before I started to put something together, and in the end I managed to come up with an entry! Nevertheless, it was still an incredibly difficult task for sentimental reasons.
All I could think about when creating this film clip was, “there are just so many people to honour and thank for this incredible journey”, “where do I begin?”.
I also kept thinking to myself “this isn’t ‘my’ project, it belongs to everyone who helped me along the way”, and it really is, including the patients we were trying to help. For without the help of everyone involved in this research I would not have been able to have carried it out, and I wouldn’t have been able to have learnt as much as I did during those years.

Gratitude

I guess really wanted to write this blog entry in honour of these people. Rather than publish a long list of names of people whom I feel indebted to for helping me get even this far, I thought a better approach is to bring back the poem I wrote not too long ago called “An Ode to my friends”  (see below). Please have a read of this Poem, it’s a favourite of mine because it seems to achieve the difficult task of expressing the magnitude of appreciation I have towards so many people who have helped and supported me through these incredible years.

I guess there is really one group of people, apart from my family and friends, who I really want to thank at this stage, even before I’ve finished writing up my thesis, and that is the “SACTRC crew”. The South Asian Clinical Toxicology Research Collaboration (www.sactrc.org) is the research collaboration between the Australian National University and University of Peradeniya (funded by the Wellcome Trust/NHMRC (GR071669), who provided my academic base and was the “lifeline” and the vision behind my work.
In addition to this I am really grateful for my two supervisors Professors Andrew Dawson and Nick Buckley, because without them none of this would be possible. Beyond this I have to thank “all” those people in Sri Lanka, and of course my family and friends, but the list really is too long, which is why I have left it to my poem to do the work J

Ode to my friends

This is an ode to my friends,

Those beautiful people who are like precious gems.

The ones who help me stay on track,

Who keep me together when I want to crack.

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They are always ready to comfort me,

To give me sight when I just can’t see,

And give me might when I feel like a flea,

Yes these are my friends,

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And if you think that I’m not talking about you

Well then – think again!

For when it comes to friends, each and every one counts, I truly believe this!

For we are all at different stages of different journeys.

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And it is the togetherness and interaction itself,

That creates the movement,

That is necessary and bodes well for improvement,

And the sanctity of ‘what is’.

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They say friends will come,

And friends will go,

But this doesn’t matter,

If our acquaintance is more than chatter!

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For whether it is now, in the past, or perhaps in the future,

There will be a bend,

And I will see you beyond that my dear friend,

For, after all, there is no beginning and no end.

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It is just an ever-growing flow,

Of love, energy. and much much more,

That lies here and also beyond this shore,

This is what we must grow!

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And knead it like freshly made dough,

And bake a beautiful loaf of humankind,

One love, one world, and together – one mind!

With this, we leave all our troubles behind..

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Thank you for your friendship.

The competition

I haven’t yet heard the results of the competition from last week, but for me it was not about winning, but rather about ‘participating’ in something that struck a chord with me, and provided another dimension to this work that has been a huge part of my life over the recent years.
Interestingly, both these competition entries have helped me in the daunting psychological task of ‘writing up’. One of the hardest things in writing up the thesis is dealing with the situation of feeling like there is ‘too much’ information to put into a logical linear format. I found the situation with the competition entries to be similar in that there appeared to be too much emotion, too many memories, and too much experience to be able to string together a concise videographic or poetic story. It was a daunting task… but I did it!
Similarly with regards to my current thesis write-up, it is daunting but I “AM” doing it, which feels good.
To me these competition entries were an example of the beauty and power that exists when ‘the arts’ are in support of ‘the sciences’, and where one of these two disciplines can help carry out the tasks of the other.
[Ed Note – in the end the Film ended up winning third prize in it’s category]

Feedback

As always I would love to hear you feedback on the poems or the film clip. Regarding the film clip, I have been very selective and I do not think there is any footage that would breach confidentiality, or cause any embarrassment to anyone – even the elephants and monkeys who have been captured, (but please let me know if there are any concerns, and I will take note and action). Also, I want to make it clear (for the purposes of my own research integrity) that I have not included any of the study data from the actual studies that I conducted.
On the contrary, what I tried to do was present an overview of the four years that I had in Sri Lanka, and I think many of my Sri Lankan friends and colleagues will enjoy seeing this, even though by no means is this a comprehensive account. Hopefully, will be much  more to come after I have finished this write up.
Anyway, I look forward to hearing your feedback.
Photos
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Finally I have included a few photos of Sri Lanka below. I literally took thousands of photos in Sri Lanka during the past 4 years, and I plan to present these in some way of form after completing my PhD. However, for the moment I just to put together about 60 photos from the first half of the journey (most of these pics are of the early SACTRC days, a lot of them social pics, in honour of these people who made my stay there so nice.) This collection of pictures is by no means comprehensive, as there are so many other pictures that I would like to include, but for the moment perhaps this is something.
This is the motto I am using to get through the write up of my thesis chapters, when I feel like I don’t know where to begin because there is just so much i want to write about – and the answer that works for me is is “Sharing ‘something’ is better than sharing nothing”.

 

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