David A. Lubarsky, MD, MBA, serves as professor and chair of the Department of Anesthesiology, Perioperative Medicine and Pain Management at the University of Miami School of Medicine. He is also Chief of the Anesthesiology Service at Jackson Memorial Hospital. In this interview he discusses his plans for the Anesthesiology Service and residency program, his interest in informatics and the technological advances being introduced to increase efficiency and improve patient care.
Lunch with Lubarsky:
The Long-Awaited Follow-Up Interview
By Eric Scot Shaw
UM: Let’s jump right in and discuss the residency program, how has it come along over the last ten years, or so?
DL: Well, the Department transformed itself from providing a clinical experience to people who might, or might not, turn out to be great physicians, to simply focusing on turning out great physicians who will have a great clinical experience. The difference is a change in philosophy: from doing a service – and perhaps getting an education in the process – to getting an education, and doing a service in the process. That was the fundamental shift and it drove all the beneficial changes that took place. These changes were due not only to the people I recruited but to all the people that decided to stay and embrace the new philosophy. My first recruit was my executive Vice Chair Dr. David Birnbach, one of the preeminent anesthesiologists in the United States and an icon in his specialty, obstetric anesthesia. The two of us spent almost every waking hour, for those first 2 years, finding and recruiting more than 30 academic anesthesiologists. The group of existing doctors were great, but they never had had the opportunity to do research, nor did they feel the extra effort of providing a great educational experience was paramount. When given a little help, many of them became academic superstars. There was never a “new” contingent versus “old” contingent. Right from the start of our regime change, everyone shared the mission and worked together. We decided that we were going to put the needs of the residents above the simple need to cover a case, and eliminate the unspoken scheduling rule that considered what would be best for the attending physician and make their life easier. It became all about making the residency experience optimal.
UM: And how do you measure the philosophical change in the residency program?
DL: We went, ten years ago, frankly, from a class that had mediocre performances on national examinations to one that has stellar performances, especially for a program our size, the largest in the nation, and probably the largest in the world. One might expect us, at our size, to be somewhere in the middle, but we’re not. We are always in the top 1/3 or top ¼ as a class in virtually every standardized test that our residents take. Perhaps more importantly, these residents become lifelong learners. We really promote independent learning and dedication versus spoon-feeding; they are actively involved in the education process. I think we’re turning out great physicians and it’s been a great success.
UM: Speaking of resident needs, specifically, why should a medical student consider your program for residency?
DL: Well, I think that the benefits of Miami can be summarized in a few different areas. First, the clinical experience is unparalleled. We have some of the highest numbers of high-risk obstetric cases, some of the highest numbers of liver transplants, kidney transplants, multi-visceral transplants in the country and superior outcomes. There is no clinical experience that is missing from the mix. Whether it’s doing peanut sized kids at the largest NICU in the United States, with 128 beds – with some of the best outcomes too I might add, to rotating through one of the Top 25 freestanding children’s hospitals in the US, to rotating at our main teaching hospital that has more ICU beds than the entire state of Israel! It is an amazing accumulation of clinical opportunity. Why else do people come to UM? It has the only Level One Trauma Unit in the area, and in some places (not near our homes!) it can be violent and high speed car wrecks along I-95 are frequent; we train the US Army because there is no other place like it to learn how to take care of the large, invasive traumatic cases. From the clinical perspective, it’s clear-cut; we have no equal.
Secondly, from an educational perspective, it’s also clear-cut that this is a superior program. Last year, two out of every three applicants applying to an Anesthesia program in the US, applied to this program. And the reason that’s the case is because we do put education first. We have used our size to leverage educational opportunities. If you want to do something unusual, it’s not a big deal because if one person disappears from a big class, to do a six-month research rotation, which we support, or go to a foreign country to learn a little bit about social medicine, they’re a very, very small percentage of our workforce. And so, we’re able to accommodate special interests. More importantly than that, the routine needs of the didactic program are overseen by amazing and uniquely qualified individuals. Our Vice-Chair of Education, Dr. Varon, has a Master’s Degree in education, a rarity, and creates a didactic continuum for three years. So, a resident doesn’t get the same lectures year after year. We don’t mix our CA 1, 2 and 3 classes for lecture: instead, we tailor each and every lecture to a specific learning level. Meaning, when our residents are junior, they get junior lectures. When they’re senior, they get problem-based learning discussions.
UM: That’s pretty unique…
DL: It’s very unique; there are very few, if any, other programs that have a three-year didactic lecture series like ours. And even fewer programs guarantee and deliver a 100% attendance record – even though we’re a big, spread out program, at several different facilities, we have a 100% clinical relief record. And for those locations that are ten minutes or so from the main hospital, for the convenience of the resident, so they don’t get caught in traffic or such, we have tele-medicine setup. It’s pretty amazing. It is also part of the educational “contract” – we certainly expect engaged and prepared residents if we are spending our efforts to provide protected time for didactics.
UM: And the faculty teaching these lectures…
We actually have our faculty fighting to give the lectures. In fact, they have to get good grades from the residents in order to get put on the lecture schedule, there’s virtually no other program like that in the country. And that’s shown in our board scores, and in our oral board passing rates both of which are exceptional. Last year we finally got to a point that I could call a success. 100% of our residents passed the written boards immediately following their completion of the program. Again, for a program our size, that is an amazing statistic and several standard deviations above the national average.
So, we put our money where our mouth is, in that, 100% of our faculty have 10% of their salaries totally dependent on getting good teaching scores from the residents. And that again is a positive spiral because the attendings are interested in teaching, of course, that’s why they’re here, but that is reinforced every 6 months when 5% of their salary shows up as a lump sum based upon resident scores. They have to pass a threshold, so, on a 5-point scale, 3 is good, 4 is very good, they have to average greater than 3.5, that is, they have to be closer to very good than good, just to qualify for 10% of their annual salary.
UM: This all sounds like a business plan that might have been conceived by an MBA?
DL: (chuckles) It is! One of the things I do teach is negotiations and incentive planning in the University of Miami Business School, and to the medical community. Aligning incentives to promote doing the “right thing”, harnessing one’s rational self-interest in building something for the common good that is the hallmark of a successful business practice.
And you know, people think about business sometimes as a dirty word, they don’t like to mix it with education, but the whole idea of being an MBA, a master of business administration, is understanding what product you are producing. For us, the product is not a profit. For us, the product is a great physician, the product is a great education. So, we optimize the delivery of that product by using time-honored techniques. There’s nothing really new or special about it, it’s just that frankly, there aren’t that many anesthesia programs in the country that use business techniques to optimize what they do.
UM: Let’s talk about what brought you to doing what you do. Your background, family, childhood. Did you come from a family of physicians?
DL: No! I’m the only doctor in an extended family.
UM: So, when did you first get exposed to medicine?
DL: I want to go back further than that though for a second, to cover something…
DL: One of the things that pertain to our recruitment philosophy, with residency and training, is that we welcome international graduates. And the fact is that Miami is one of the most international cities in America, and welcomes immigrants and we do not believe that brains stop at the border of the US. In fact, in the last couple of years, we have had two residents score in the top five scores in the country, and both of them have been IMGs. Sometimes U.S. applicants come to our department, and see foreign names and wonder, “Do they have to take foreigners?” And the answer is ‘Yes, we have to take the best and the brightest human beings we can find and they’re not all from the United States.’ And I would point out that my family, maybe 100 years ago, immigrated too, and I never forget they were given a chance and I like to feel that we treat everybody the same way my family would have wanted to be treated.
And this brings us to my family doctor, and your question. Leonard Shaftan lived in the same building in the Bronx, where I grew up, across the street from Yankee Stadium. He and his family, who were close family friends, followed my family’s move up to Scarsdale a year after we moved up there when I was about 10. And somewhere around that time, I got a horrible flu and I remember him coming over and making a house call, and I knew definitively at that time that’s what I wanted to do, be a doctor like him and make kids get better (even though in retrospect, I probably only got Tylenol and warm coke and tincture of time!). And actually, up to my fourth year of medical school, I thought I was going to be a pediatrician based on that one experience. I wanted to do well, and help people. By ‘doing good,’ that was my favorite mantra, all through college and medical school, I was ‘going to do well and do good.’ When you have an immigrant family that originally grew up poor, doing well is a necessary part of the equation.
UM: The beneficent doctor…
DL: Yes! And then it turned out, my love of pharmacology and physiology overtook the pediatric impulse and I ended up in anesthesia. But that was the impetus. I never waivered, from the time I was 10 or 11 years old, I knew I was going to be a doctor.
UM: So, after med school, and your first impulse to practice pediatrics, after then deciding upon anesthesiology, what brought you to cardio thoracic anesthesiology?
DL: Well, you know, it’s funny, each step along the way, my thinking about my career evolved. I wasn’t planning on doing a fellowship. So, I worked very, very hard and at the end I thought I would just finish up and…go into anesthesia and just be a doctor. And then I decided that, when I got close to the end of training, my love of learning and my investigative focus wasn’t really going to be satisfied by that. So, I had to pick a fellowship and the most complex one at the time was cardiothoracic anesthesia, and that’s what I ended up doing.
UM: Was there a specific mentor involved in your choice?
DL: I didn’t really have one specific mentor, I had a lot of great attendings who taught me extremely well and I’m still in touch with many of my teachers from NYU and I hold them in the highest regard. As for making the decision to come here to Miami, Dr. Manny Papper was a brief but incredibly helpful mentor who gave me much guidance. He died only a year after I arrived. Manny, the Dean of UM’s School of Medicine from 1969-1981, was also one of the “fathers of anesthesia”, a founder of both modern anesthesia practice and academic anesthesia departments. I still remember his personal call to me (I was surprised he had any idea of who I was or what my information system based research was about, but he did), and his opinion that this was a good match for me when I was deciding whether to leave Duke was instrumental in my deciding to accept the job here. Holding a Chair in his name is very special to me and I think of him often. His wife, Pat Papper, remains an ardent supporter of our department.
UM: (starts to ask next question…)
DL: Actually, certainly, of all the people who had the greatest impact on me, it would be Jerry Reves. (former Anesthesia Chair at Duke and recently retired Dean of Medical University of South Carolina and cardiothoracic anesthesiologist). I was at his retirement dinner, recently. And from him, I learned how to be, what I hope, is a great boss. And the hallmark of his success can be summed up threefold: one, when you think there might be a better way to do something, you keep at it. It doesn’t mean you always do it that day, sometimes you come back to it. Over the last eight years, I’ve had a lot of ideas, some of which had to be put on the back burner, but that doesn’t mean they’ve been forgotten. It just means you have to do it when the time is right. But you don’t give up: if it was once a good idea, it is still a good idea.
Second, you never take credit for somebody else’s work, as a matter of fact you go out of your way to promote the contributions of your faculty member and not yourself. When I was just getting into anesthesia, there were Chairs in the country that took credit for every paper, put their name on every paper. During his time at Duke, Jerry Reves never did that. He was the most selfless leader I think, Duke ever had, and he was certainly a champion of his faculty. And to think, there are six or seven of us now, successful, longstanding Chairs in the nation who came out of his department at the same time…we are a testimony to his leadership.
And third, at a time when there was tremendous financial pressure, Jerry understood that to run a cheap private practice in the middle of an academic medical center was no way to succeed. Even in the worst of times, in the mid 90s, he always kept the academic light burning bright and he always refused to succumb to the idea that we either take advantage of faculty who couldn’t find work elsewhere, or otherwise, strip the academic enterprise to make things work financially. His priorities were always set straight, and again, that’s why all of us who came up through his tutelage were uniformly successful because these tenets are the right ones by which to run an academic department.
UM: Is this when your own research career began?
DL: Well, I did fellowship at NYU. But, I was then recruited to Duke to do cardiac anesthesia; Jerry Reves wasn’t the Chair then, but the Chief of cardiac anesthesia. So, I did cardiac anesthesia at the VA and ran their SICU for the first couple of years and then I actually decided I preferred to do vascular anesthesia. At that time, everything was open AAAs and carotid endarterectomies and the complication rates were sky high and it seemed to me much tougher to do these complex cases when the heart wasn’t fixed at the end as compared to when it was. So, I shifted my practice to doing primarily vascular and thoracic anesthesia. Which was a separate division at Duke. And I set up the lung and liver transplant programs, from the anesthesia perspectives, ran the SICU, ran the pre-op unit there, took on a lot of administrative roles and I was appointed to run the finances of the department and helped, frankly, turn it around. The department had a $250,000 negative balance in the bank and within four years we were $10 million in the black. And that helped Dr. Reves be successful as he took that money and invested it back into the Department.
UM: So, speaking of financial constraints, when you first came to Miami and set out goals pertaining to operating room efficiency and patient safety, what was the department’s financial circumstance and how has it evolved? Were you able to hit these goals?
DL: The good news is, the last time the department had a deficit was the year before I arrived, which was 8 years ago. We were forecast to have a $2.5 million deficit that year. Within six months, I cut it down to $1 million, and we’ve never looked back and we’ve never been at anything less than a profit. So, that’s very positive. And we’re one of the only departments in the University who are consistently in the black. And that’s because of very active management getting the greatest productivity reasonably possible out of the resources we have, and that management does not come at the expense of what we are here to do. The educational excellence was detailed above. Certainly, Dr. Mike Barron, who was the Vice Chair for Clinical Service at the time, was the clinical glue that kept the department together, literally, prior to my arrival and in the first few years after I arrived. He was instrumental in moving us to the subspecialty focused practice we have now, a hallmark of a dedicated academic faculty. He has since been promoted to Medical Director of Perioperative Services for JMH. Exceptionally difficult tasks, like changing how long time faculty are assigned to do their work, become exponentially easier when you have people around you like those surrounding me.
In terms of patient safety, our department has an enviable record in terms of decreasing malpractice settlements at the same time our clinical enterprise has grown about 300%. I have a sensational clinical leadership team, led now by our Vice Chair for Clinical Services, Dr. Gitlin, that I count on to help me steer between competing currents of productivity and excellent clinical practice. Trust me, they have no problem telling me when we are off course! But our clinical goals did not stop at just improving our Department, we set out to build a great safety program. We have an ASA certified simulation center (one of 21 currently in U.S.) that is 8,000 sq ft, a beautiful space that incorporates almost every department in the medical center, a super high-tech environment. We’ve set up safety training programs for medical students,that have been lauded as being national examples; Dr. Birnbach’s work in that regard garnered specific praise from the LCME’s most recent review of the medical school. Our UM/JMH Center for Patient Safety trains every single incoming resident (all specialties) in basic safety principles, no other school does that; we also send our own residents to simulation regularly. Not only do we have a simulation center, we have one that we use as well to train our own anesthesia residents, so I think we’ve done a very, very good job. Is there more to be done? Sure, and we’re constantly moving forward. The center itself had a million dollars in grants last year.
UM: Where does the anesthesia program stand with its current ACGME accreditation?
DL: We just got our 5-year accreditation (this is limited currently to only the top 15-20% of programs. Dr. Mike Lewis, our Vice Chair for Residency Training and program director, along with his dedicated team of assistant program directors, did a fabulous job of showcasing what we do every day for every resident. The team’s dedicated performance, not on the review but in providing a great educational experience, was recognized and rewarded.
UM: Back to patient safety, what would you like the average patient to know about anesthesia, before, say, an operation here at UM? Here we are, a century and a half after the “discovery” of anesthesia…
DL: Well, things today are different than they were in the days of Ether. We employ very high technology here and anesthesia continues to get safer and safer, even as patients get sicker and sicker. But it’s not only the anesthesia, it’s about the entire perioperative care environment. So, what can we control about providing safe anesthesia? First, we only employ board certified anesthesiologists, or board equivalent – if they are a physician that we’ve recruited from abroad. And board certification is a marker of a sophisticated “MacGyver” level of intelligence and thought organization – it says this person not only knows the routine, but can successfully rescue you from the rare event because he knows how to thoroughly approach almost any problem that might arise in the entire lexicon of anesthesia. I believe all patients should have the opportunity to use doctors who have successfully passed the boards. A great doc can’t necessarily prevent the random bad event, sometimes it’s just bad luck. But our literature shows that physicians with a higher level of knowledge rescue patients from these bad events with a greater rate of success. So, that’s why board certification is important. Secondly, the perioperative environment isn’t just about giving an anesthetic, it’s also about giving good pain control, about great control of post-operative nausea and vomiting, the common things that come up.
We have an acute pain service at all of our hospitals, led by Dr. Gebhard, and we are very aggressive in the use of peripheral nerve blocks, to stem pain, and are experts in using narcotics, and non-narcotics as the case may be, to control and alleviate pain. And it’s also about working closely with our surgical colleagues. We have very aggressive data information in every O.R. We are among the highest performing departments in the country in terms of the accurate and adequate delivery of perioperative antibiotics in the operating room. Why? Because, we have automated information systems…if someone is not doing the right thing, it prompts us, if someone is doing the wrong thing, I actually get an email saying “Doctor so and so did not give the perioperative antibiotics.” And I can assure you, that’s the last time that doctor ever forgets. So, we don’t tolerate anything less than 100% performance in standard of care issues, that’s our goal in terms of delivering the right drug, at the right time, to the right person, the right way. And we continue to tweak our methods of collecting data and helping physicians do the right thing 100% of the time; we’re very aggressive in this regard.
UM: So, how often is Dr. Lubarsky, Department Chair, in the Operating Room?
DL: I go to the OR two days a week and I specifically work with the residents when I’m there. This is a lot for someone with my level of responsibility, not for just running a more than $50 million a year anesthesia department, but I also chair the governing board for the medical center’s self-insurance program, and am responsible for all safety and quality programs for the health system, and I teach at the business school from time to time, not as much now. I can still give anesthesia quite well (as a chair, sadly, you have to make that statement), but I do limit my practice, somewhat, I prefer to do abdominal aortic aneurysms, carotid endarterecotmies, liver resections, radical urologic procedures and other giant cases because that’s what I love doing. I’m still (thankfully) considered a national expert on abdominal aortic aneurysms – I write the chapter in Barash, give the review course lecture at ASA, and I think it’s appropriate, an obligation, to share that level of expertise with the residents; so I make sure I get to do that.
And that’s another aspect of our educational goals, I expect the best and the brightest that we have not to closet themselves in the office and write papers…. well, I expect them to do that too, but I expect them to come out and interact with the residents who are our most important responsibility.
UM: On that note, speaking about responsibilities, on a day-to-day basis, what is the most gratifying part of your job?
DL: The most gratifying part of my job, the thing I like doing the most, is problem solving. And in a department this size, working within a residency program within a county hospital, there are no lack of problems to solve on a daily basis. (laughs). I like the challenge of running a very large organization, and I like seeing us optimize the results of what we seek to do. In this case, it’s patient care, number one; education, number two; and research number three. And, we really haven’t talked much about number three, but that’s an important component of the residency program.
When I got here, I’ll be honest, there hadn’t been a peer-reviewed paper published in several years. Last year, we had close to fifty peer-reviewed papers published. And that’s just the beginning. We’ve developed one of the largest commercial research organizations for anesthesia, under the purview of Dr. Candiotti, our Vice Chair of Clinical Research, along with many other clinical researchers here. And we are now moving, quite aggressively, toward becoming one of the Top 20 NIH-funded anesthesia departments in America, under the leadership of Dr Roy Levitt, our Director of Academic Affairs. We anticipate hitting that mark in 3 to 4 years, and again it’s all about investing in the right people, focusing your resources and hopefully turning out truly meaningful research.
Our Center for Patient Safety has wonderful research funding as well, and the other two research areas we are really pushing are Ischemia Reperfusion Injury and Pain. We have several NIH grants in that division now and are anticipating several more and are continuing a strategy to grow this research. There’s a tremendous need in society for an increased attention toward pain relief, there’s a tremendous knowledge, we think, that’s yet to be discovered around basic neural mechanisms, and we have a great neural science partner in the Department of Neurosurgery and Neurology and their Miami Project to Cure Paralysis. They’re doing a lot of basic neural mechanism research, and it fits in very nicely with what we are trying to do.
UM: The next five years, what do they look like?
DL: Figuring out what matters in terms of patient outcomes. This is no longer often about life and death; anesthesia, as the field matures, is ever safer. However, we have a long way to go in optimizing the decision making around a myriad of decisions – transfusion and fluid therapy, pain therapy, drug choice and cognitive impairment – that require an expansive knowledge of the co-morbidities of the patient and how they interact with the anesthetic, not just putting someone to sleep and putting a tube in, but really optimizing the medical management during the perioperative period. That is going to be the future of anesthesia. And it may not be an anesthesiologist sitting in a room, and I would dare say, that it’s a waste of incredibly expensive talent to have an anesthesiologist sitting in a room doing a knee arthroscopy on a 24 year old. What we need is the board certified anesthesiologist who is a super physician who is able to rescue that 24 year old in the event they have some sort of undiagnosed heart condition that manifests itself during anesthesia. Now, how common is that? Well, I don’t know, but the other day I did a 95 year old, who manifested a cardiac arrhythmia, upon being wheeled into the room, a little bit of anxiety, and had a previously undiagnosed condition, that had been mistakenly diagnosed by their cardiologist as a potentially unstable angina that he ruled out finally. Turns out, it was ischemia caused by episodic supraventricular tachycardia, and the patient was rescued and immediately sent to the catheterization lab, got a stent in, and eventually had their cancer removed – safely – because there was a physician who knew how to deal with such an event. You still need those types of physicians, and those types of physicians will be in high demand. You will need a deeper level of knowledge and I believe fellowships will be de rigueur. I believe that supervision ratios will be relaxed for healthy patients – i.e. one doc will oversee many nurse anesthetists (10?) in a healthy patient population but that doc on another day may only take care of one patient who is extremely sick. That is, there will be a much greater gradation in terms of how we apportion physician labor in the future. So, the future is the extremely well trained anesthesiologist who remains an expert, a super-sped-up intensivist, who will be of tremendous value. I think people who are looking for an easy road, well, anesthesia is not the way. Currently, there are some easy jobs out there doing ambulatory anesthesia, eyeball anesthesia, that aren’t, frankly, that taxing mentally all the time, and will no longer be the province of the anesthesiologist, per se.
For the Department, we know we have great clinical faculty, and we know we provide a great clinical experience to our trainees. We also have a student nurse anesthetist school at the University of Miami (also with the highest level of a 10 year accreditation); we train those students to be great nurse anesthetists, true partners of the anesthesiologists in the operating room. There are so many great cases that we can provide a superior clinical experience to everyone we train. We fully embrace the care team concept, and expect our resident training to deliver a physician capable of leading that care team because of an extensive knowledge base that not only includes anesthesia, but a tremendous amount of critical care medicine along with the requisite understanding of advanced monitoring and physiologic support devices. We have created specialized and unique rotations that actually teach our senior residents how to supervise multiple rooms and multiple CRNAs, as an advanced part of their training. Why? Because most anesthetics in America are delivered in the care team model, and we believe that is actually the safest and most efficient model. We’re very proud of that. We’re on the cutting edge in that regard and we continue to move in that direction. For example, in my opinion, if you have, like us, 6 rooms doing back surgery a day, it would be better if a resident did 6 fiber optic intubations and 6 SSEP interpretations a day than if they sat in one case all day long and did one fiber optic intubation and interpreted one SSEP when you might or might not see a problem. The RRC (anesthesia residency review commission) doesn’t really recognize this yet, so we’re stuck in the traditional model, but pushing hard to make it different. So, we’re really going to be making a move to turn our physicians into super-docs. That’s our long-term goal.
UM: So, speaking of the future, have you met the newest class of residents?
DL: Yes, I have! It’s hard, I admit, but I do try to personally interact with the 500 or so people in the department, the 40 or so new residents and fellows who come here each year. We take the new residents out a couple times a year, we always make sure about a month into the residency we have a good time with them and about five of my senior clinicians who run the various hospital clinical sites, and openly discuss what was good and bad about the residents’ initial impressions. We do this to tweak what we think is already an excellent beginning to a wonderful residency program. And, I do personally speak to each resident within the first month of them joining the program to try and seek their opinion as to how we can make it better. , I also always lecture to the incoming residents. And I personally give 4 or 5 lectures a year to various resident classes each year as a means of both sharing knowledge and being accessible. I’m not sure there are too many Chairs who do that anymore
UM: And to wrap up, Miami…
DL: Loving Miami! My wife, who lived her entire life in North Carolina, before I dragged her down here, she has taken to this like…a water sports fanatic would! She wasn’t one before we moved here, coming from land locked Durham and Chapel Hill, but she is on the Bay five days a week rowing, as is my 17 year old daughter, while my 11 year old is on the diving team. My son found his niche in the vibrant downtown arts world, graduating from DASH, a magnet applied arts school that is consistently ranked among the best in the country. Me – avid bicyclist and member of UM’s mostly undergraduate triathlon club, the Tricanes, doing whatever I can in my spare time (laugh) to train and keep up with super competitive 20-year olds. Multi-cultural Miami has helped my entire family develop broad world views while leading a constantly happy if frenzied existence, so, we seem to have landed in the right place!