tigerlily Posted October 27, 2012 Share Posted October 27, 2012 I can see 30-40 a day no problem, some very intense primary care cases included along with the usual urgent care procedures. two things make that possible ... excellent support staff and adequate time for charting, at least 30 minutes with possibly some spillover of 10 mins the next morning. i'm not a new grad anymore tho ... but i started seeing about 25 a day in my first position. and yes, i address everything. As far as support staff, how many "screeners" do you have. Also, what are your work hours? And are you running on 15 minute appointment blocks? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 27, 2012 Moderator Share Posted October 27, 2012 it is possible to see large volumes of pts if all the complaints are pre-screened as minor and if the documentation system is easy. as a new grad better to focus on quality than quantity. I have seen 60 in 12 hrs before at a flu clinic at which we had a special template form for charting that included the rx. realistically if you are seeing pts with undifferentiated(not presecreened) complaints it is hard to see more than 3/hr if you are keeping up on your charting as you go. I agree you made a good choice to look for another job. Link to comment Share on other sites More sharing options...
Hemegroup Posted October 28, 2012 Share Posted October 28, 2012 As far as support staff, how many "screeners" do you have. Also, what are your work hours? And are you running on 15 minute appointment blocks? "screeners", hmm. I'm in charge while I'm there, meaning the MAs actually involve me regularly in the 'screening' process. We work as a team to decide how things get done. Of course, they'll sneak in the easy ones and that's part of what being 'good support staff' means. We usually have two front office and two back, one of those being an MA/x-ray tech. They/we all screen. My work hours are 9 to 6 with no breaks. We block for anywhere from 10-20 minute appointments, and you can play with that as far as stealing a few minutes (here) with an easy case so that you have ample pillow-time for what could be a "I have a lot of things to talk about" cases and/or the walk-ins (there). That being said, I was given 15 patients in 3 hours one morning ... that MA knows how to work me to the bone ;) I can also type very fast which helps a lot. I make sure to document everything explicitly in my HPI/ROS, PE and Plan so that there are no questions should anyone need to refer to my charting. We have EMR in our rooms and so I'll often type while the patient talks. And as emed acknowledged, sometimes all you can do is jot notes and chart later. I should state tho that I had prior experience in a number of medical environments and was already aware of what working quickly and efficiently entailed. I'm not suggesting that anyone take on a high-load position without being absolutely sure of themselves ... and without being absolutely sure that they are adequately compensated. In the end, I would not recommend a 30-40 patient load for a new grad who wasn't fully aware of what they were getting into. Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 28, 2012 Moderator Share Posted October 28, 2012 I can see 30-40 a day no problem, some very intense primary care cases included along with the usual urgent care procedures. two things make that possible ... excellent support staff and adequate time for charting, at least 30 minutes with possibly some spillover of 10 mins the next morning. i'm not a new grad anymore tho ... but i started seeing about 25 a day in my first position. and yes, i address everything. really now you have an entire group of highly experienced PA's saying that 30 is likely to many and you claim to be giving excellent care to 30-40 in a 9 hour work day You are truly the exception then - unlikely that you are slowing down to talk and communicate with your patients if you are seeing 10 and 20 min appointments including doc time Honestly I see 30 in a day every day - mostly urgent care - some scary one's, have seen up to 33 = but also ended up with a 10+ hour day I have known Pa's and Np's that think they can see 30-40 and do great medicine, but I have never seen one in person that actually did great medicine - to many, to fast, to much to cover in a short time - not where primary care needs to go - no if it is urgent care with sniffles and sneezes maybe..... but not with procedures - sorry don't believe it Link to comment Share on other sites More sharing options...
Hemegroup Posted October 28, 2012 Share Posted October 28, 2012 really now you have an entire group of highly experienced PA's saying that 30 is likely to many and you claim to be giving excellent care to 30-40 in a 9 hour work day You are truly the exception then - unlikely that you are slowing down to talk and communicate with your patients if you are seeing 10 and 20 min appointments including doc time Honestly I see 30 in a day every day - mostly urgent care - some scary one's, have seen up to 33 = but also ended up with a 10+ hour day I have known Pa's and Np's that think they can see 30-40 and do great medicine, but I have never seen one in person that actually did great medicine - to many, to fast, to much to cover in a short time - not where primary care needs to go - no if it is urgent care with sniffles and sneezes maybe..... but not with procedures - sorry don't believe it Is it 30-40 every day? No. But it does happen, and yes my care stays excellent whether you believe it or not. I work (and talk) hard and fast, what can I say. Do I experience burn out sometimes? Yes. Which is why the other PA at our clinic and I swap the full and part time shifts when need be. And yes, sometimes on my days off I go in and finish up what needs to be done in order that the patient care stays excellent. Patients also have my cell phone, so I do a bit of work on that side as well. But can I see 30-40 and do great medicine? You betcha. Link to comment Share on other sites More sharing options...
Hemegroup Posted October 28, 2012 Share Posted October 28, 2012 ... Honestly I see 30 in a day every day - mostly urgent care - some scary one's, have seen up to 33 = but also ended up with a 10+ hour day I have known Pa's and Np's that think they can see 30-40 and do great medicine, but I have never seen one in person that actually did great medicine - to many, to fast, to much to cover in a short time - not where primary care needs to go - no if it is urgent care with sniffles and sneezes maybe..... but not with procedures - sorry don't believe it Well, then I guess you are the exception and the only one who can see 30 in a day, every day, but others can't. (?) Link to comment Share on other sites More sharing options...
Hemegroup Posted October 28, 2012 Share Posted October 28, 2012 I NOW see about 6-8 patients per day..at the most 10 or 11. I'm starting up a side job where I'll be seeing the same number of daily patients in home house calls ... quite lucrative if you're with the right company and everyone is located within the same general area. Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 28, 2012 Share Posted October 28, 2012 My record is 72 in a 12-hr urgent care shift. I was out about 6 mos at the time and most were uncomplicated but I was exhausted and catching up on dictations for days. Not paid enough to do that!! Certainly not then when it was about $28/hr IIRC. My comfort zone is 25 or so in a 7-8hr day which allows for plenty of time to address complex issues, prevention, health counseling and getting to know the patient. More than 4/hr really cuts down on my ability to do any of these things well. My bigger concern with the OP was that the SP expected to be hands-off and "not bothered" after a very short orientation period. THIS IS DANGEROUS. So glad the PA took our advice to heart and trusted his/her gut--your education and license is too precious to sacrifice to an employer's selfish and short-sighted whims. ;) remain humble, folks. Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 29, 2012 Moderator Share Posted October 29, 2012 Is it 30-40 every day? No. But it does happen, and yes my care stays excellent whether you believe it or not. I work (and talk) hard and fast, what can I say. Do I experience burn out sometimes? Yes. Which is why the other PA at our clinic and I swap the full and part time shifts when need be. And yes, sometimes on my days off I go in and finish up what needs to be done in order that the patient care stays excellent. Patients also have my cell phone, so I do a bit of work on that side as well. But can I see 30-40 and do great medicine? You betcha. So first you make it sound like every day you see 30-40 - in a 9 hour day - then the story changes to only some times and you come in after hours to finish doc time. This is exactly what I mean - 30-40 in 9 hour day is just not good care unless all simple urgent care stuff - and certainly not with procedures thrown in. you prove my point. also, the talking hard and fast - where in PA school did it state that great care is talking hard and fast? Yeah when I am way behind I do the same thing to move them along, but it is at the expense of great care - commonly patients don't understand the "hard and fast" talks that we all give so they leave confused. Try this - when you give the "hard fast" talk then ask them what they are supposed to do - see how much they retained..... I was alarmed when I did this and now altered my practice pattern to make sure I repeat directions at least 2 if not 3 times to allow the patient time to absorb it. then we are supposed to think that you are burned out and still delivering great care?? again not really believing it.... Well, then I guess you are the exception and the only one who can see 30 in a day, every day, but others can't. (?) Read my statement again - I do see 30 a day, but commonly this is FAR longer then a 8-9 day - many times 11 hours with all the doc time included..... Just to restate for the OP 40 patients a day is too much 30 patients a day is too much 20 like to much 10-12 for a new grad is good and speed up as you feel like it - learn, absorb, ask questions, talk to the patients, get this whole medicine thing figured out... And don't get sucked into the chest pounding, testosterone driven - "I can see X # of patients in so many hours and give great care" Instead let your knowledge base dictate what your speed is.... Link to comment Share on other sites More sharing options...
Joelseff Posted October 29, 2012 Share Posted October 29, 2012 I was first seeing 20 low acuity urgent stuff, u know URIs, msk, minor stuff. Now that I have my own caseload, I've scaled back and see 10-12 a day and remain hella busy with charting to take home. It doesn't help that my typical pt is a middle aged diabetic, hypertensive, hyperlipidemic, HIV positive pt with exacerbations of depression.... Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
Hemegroup Posted October 29, 2012 Share Posted October 29, 2012 So first you make it sound like every day you see 30-40 - in a 9 hour day - then the story changes to only some times and you come in after hours to finish doc time. This is exactly what I mean - 30-40 in 9 hour day is just not good care unless all simple urgent care stuff - and certainly not with procedures thrown in. you prove my point. also, the talking hard and fast - where in PA school did it state that great care is talking hard and fast? Yeah when I am way behind I do the same thing to move them along, but it is at the expense of great care - commonly patients don't understand the "hard and fast" talks that we all give so they leave confused. Try this - when you give the "hard fast" talk then ask them what they are supposed to do - see how much they retained..... I was alarmed when I did this and now altered my practice pattern to make sure I repeat directions at least 2 if not 3 times to allow the patient time to absorb it. then we are supposed to think that you are burned out and still delivering great care?? again not really believing it.... Read my statement again - I do see 30 a day, but commonly this is FAR longer then a 8-9 day - many times 11 hours with all the doc time included..... Just to restate for the OP 40 patients a day is too much 30 patients a day is too much 20 like to much 10-12 for a new grad is good and speed up as you feel like it - learn, absorb, ask questions, talk to the patients, get this whole medicine thing figured out... And don't get sucked into the chest pounding, testosterone driven - "I can see X # of patients in so many hours and give great care" Instead let your knowledge base dictate what your speed is.... Your bickering is petty, and your attempt to belittle my practicing is unprofessional. You are welcome to contact my references to attest to my excellent standard of care. When I mentioned that I talk "hard and fast", it's YOUR interpretation that is somehow lacking ... I am extremely proficient in speaking and highly comprehensible which is why I have grown our patient base substantially since I began at this clinic ... patients know that I will explain to them concisely and accurately in a means that they will understand and that they will be well taken care of as expediently as possible. If you're trying to transfer your own insecurities onto my words, that's your issue and not mine. I always confirm (sometimes two or three times) that my patients understand why and what we're doing what we are. FYI, my story never "changed". I said that I can see 30-40 patients a day, no problem. I didn't say it was every day. As well, in my original words I stated that there was often next day follow-up. Yes, after a week of 40 patient load, I will go in for an hour or two on my day off to finish up paperwork. Does that somehow mean that their care was lacking? I don't get your impetus. But for a 30 day patient load, 10 minutes to catch up the following morning will usually suffice. I DO see about 30 patients every day, in a 9 hour setting. 40 is pushing it, but 30 is normal for me. 25 patients is an 'easy day' for my team. In the end, I could care less what you "believe" about me ... my career and patients matter to me, not you. I don't even know you. I do know that you seem to think seeing 30 patients and providing excellent care in a 9 hour day is difficult ... it isn't, for me. It's unfortunate that seems to rile you in some way. As for getting burnt out, you must have missed the part where the other PA and I swap full and part-time shifts to prevent that from happening, because it can definitely happen if you don't have support for each other (including support from office staff as well). Your assumption that I jumped into this conversation for the reason to somehow sway the OP is off-base. I jumped in for those who would be in a different situation, reading this thread. That's with no intent towards the OP to infer that they are incapable ... as I stated, I started seeing 25 patients a day in my first position so perhaps that's what got me ready for 30-40 patient days. Some new grads can jump straight into an ER position, others can't. That's no reflection on either party, it simply is what it is. It took me years to reach the level of capacity I'm at now. So, to others reading this thread, don't let the "chest-pounding testosterone driven" rantings persuade you to feel only competent enough to see 10-12 patients a day. Or, if that's where you're comfortable, take ventana's words to heart. Different people, different situations, different systems, different circumstances. There really is no one answer for the entire new grad population and ALL possible answers should be presented on the table since we don't know you personally. Link to comment Share on other sites More sharing options...
surgblumm Posted October 29, 2012 Share Posted October 29, 2012 As mentioned before , this may be 30-40 between you and the NP. It would be an unacceptable figure for a seasoned or new PA. What would you do with a first time diabetic, hypertensive, psych patient, obesity patient. Even Minute Clinic does not do that type of volume. Bob Blumm Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 29, 2012 Moderator Share Posted October 29, 2012 Your bickering is petty, and your attempt to belittle my practicing is unprofessional. You are welcome to contact my references to attest to my excellent standard of care. When I mentioned that I talk "hard and fast", it's YOUR interpretation that is somehow lacking ... I am extremely proficient in speaking and highly comprehensible which is why I have grown our patient base substantially since I began at this clinic ... patients know that I will explain to them concisely and accurately in a means that they will understand and that they will be well taken care of as expediently as possible. If you're trying to transfer your own insecurities onto my words, that's your issue and not mine. I always confirm (sometimes two or three times) that my patients understand why and what we're doing what we are. FYI, my story never "changed". I said that I can see 30-40 patients a day, no problem. I didn't say it was every day. As well, in my original words I stated that there was often next day follow-up. Yes, after a week of 40 patient load, I will go in for an hour or two on my day off to finish up paperwork. Does that somehow mean that their care was lacking? I don't get your impetus. But for a 30 day patient load, 10 minutes to catch up the following morning will usually suffice. I DO see about 30 patients every day, in a 9 hour setting. 40 is pushing it, but 30 is normal for me. 25 patients is an 'easy day' for my team. In the end, I could care less what you "believe" about me ... my career and patients matter to me, not you. I don't even know you. I do know that you seem to think seeing 30 patients and providing excellent care in a 9 hour day is difficult ... it isn't, for me. It's unfortunate that seems to rile you in some way. As for getting burnt out, you must have missed the part where the other PA and I swap full and part-time shifts to prevent that from happening, because it can definitely happen if you don't have support for each other (including support from office staff as well). Your assumption that I jumped into this conversation for the reason to somehow sway the OP is off-base. I jumped in for those who would be in a different situation, reading this thread. That's with no intent towards the OP to infer that they are incapable ... as I stated, I started seeing 25 patients a day in my first position so perhaps that's what got me ready for 30-40 patient days. Some new grads can jump straight into an ER position, others can't. That's no reflection on either party, it simply is what it is. It took me years to reach the level of capacity I'm at now. So, to others reading this thread, don't let the "chest-pounding testosterone driven" rantings persuade you to feel only competent enough to see 10-12 patients a day. Or, if that's where you're comfortable, take ventana's words to heart. Different people, different situations, different systems, different circumstances. There really is no one answer for the entire new grad population and ALL possible answers should be presented on the table since we don't know you personally. wow still don't get it..... before you reply again please go back and re-read the previous posts - you clearly stated that you typically see 30-40 in a regular day and that you practice great medicine.... again I point out that by far the majority of highly experienced PA's and NP's (not just me mind you but in fact ALMOST EVERY OTHER POSTER) feel 30-40 is to many - any typically the low 20's is the magic number. As for contacting your references???? what? why? where did that come from? why on earth would I do that? The problem I see is that the # of patients seen a day some how is linked to how good of a provider you are - maybe you are all that you say you claim - mybe you can see 40 patients in a 9 hour day and talk about everything that needs to be discussed about health, chol, bp, dm, diet, exercise, smoking, healthy living and sexual health while still going home at a reasonable hour - oh wait you changed the story and said that you actually had to stay late on those days and sometimes get burned out..... so I really don't know what you are saying other then you can see upwards of 40 patients. By my opinion, I will not speak for others on this board but you can read there thoughts earlier in this post, this is to many if you want to really get to know you patients. I honestly would like to learn from you how you are doing this in a reasonable amount of time. I have a great EMR, voice to print, very fast at typing, have great support staff, run 3 rooms all day and still can manage about 30 (+-2) a day(10-11+ hours). I must be spending to much time doing something like counseling on risks of smoking or benefits of exercise, or the avoidance of trans fats to get through all them on time. How do you do it? What tricks do you have that can change the way we all deliver care and speed up the whole process - I would love to learn them.... Do you do complete physicals and if so how long are the appointments? Do you do gyn care, breast exams, pap smears, rectals, and other time consuming items? What about EKG's and labs - obviously not doing the actual EKG but it takes time for the MA to get it and then to review, compare to old, and go back into room? By the time I have compared to an old one, and made a copy for the patient to carry if any abnormal findings it is easily 10+min. How do you talk about safe sex practices and building relationships with friends and family, or encouraging a more balanced work/home life? Again I would love to learn from you on how I too can see 30-40 patients a day, accomplish all the above, and still get home with only a 9 hour day under my belt - please share your tricks as I come up with about a 11 hour day to accomplish this and I still feel I am not doing enough.... BTW - went and looked at your blog - seems you LESS THEN 2 YEARS OUT OF SCHOOL - Seems like you Graduated in Dec 2010 - likely started working in 2011 - this means you have LESS THEN 2 years of clinical practice. I am scared for you if you are truly believing that you can see 40 patients in a day and not miss anything, and deliver gold standard medicine. My friend you are at the very beginning of your career - you likely have only had 1 maybe two jobs as a PA, have really limited clinical experience (although it is getting better at this point almost 2 years out) and likely have not seen how badly things can turn and how fast something can be missed. I am truly concerned that you do not necessarily know what you don't know, and this the crux of medicine and especially primary care. I can honestly say I have never seen anyone < 2 years out of school who was truly comfortable in their skin and practicing proficiently. I for one said I was going to work in IM for a year to burn in the knowledge I learned in school and it took me 5 years to get really comfortable...... 2 years - is still a very new clinician. I do not mean to come down hard, but it is important to realize and qualify where advice is coming from. I am a 10+ year PA and have extensive experience in Medicine, chronic pain management, occ health, did a year in the ER, 2 years in Radiology and per diem in physiatry and Ortho and I only in the past year feel like I am really growing into a competent clinician who has YEARS and YEARS more knowledge to learn......... competency in medicine is not the number of patients you see or the grades you got in school - it is time and learning over the years...... sorry if this came off as a rant - I just really think it is important that we all have reasonable goals and having a 22 month clinician saying they can do full spectrum primary care to the tune of 30-40 patients in a 9 hours day is in my opinion excessive and possibly dangerous and if and when things go wrong that patient likely for ever will think a PA is less of a clinician then a NP or Doc...... I will no longer discuss this topic on a public forum - if you would like to continue the conversation please PM or call me to discuss. 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Hemegroup Posted October 29, 2012 Share Posted October 29, 2012 wow still don't get it..... before you reply again please go back and re-read the previous posts - you clearly stated that you typically see 30-40 in a regular day and that you practice great medicine.... again I point out that by far the majority of highly experienced PA's and NP's (not just me mind you but in fact ALMOST EVERY OTHER POSTER) feel 30-40 is to many - any typically the low 20's is the magic number. As for contacting your references???? what? why? where did that come from? why on earth would I do that? The problem I see is that the # of patients seen a day some how is linked to how good of a provider you are - maybe you are all that you say you claim - mybe you can see 40 patients in a 9 hour day and talk about everything that needs to be discussed about health, chol, bp, dm, diet, exercise, smoking, healthy living and sexual health while still going home at a reasonable hour - oh wait you changed the story and said that you actually had to stay late on those days and sometimes get burned out..... so I really don't know what you are saying other then you can see upwards of 40 patients. By my opinion, I will not speak for others on this board but you can read there thoughts earlier in this post, this is to many if you want to really get to know you patients. I honestly would like to learn from you how you are doing this in a reasonable amount of time. I have a great EMR, voice to print, very fast at typing, have great support staff, run 3 rooms all day and still can manage about 30 (+-2) a day(10-11+ hours). I must be spending to much time doing something like counseling on risks of smoking or benefits of exercise, or the avoidance of trans fats to get through all them on time. How do you do it? What tricks do you have that can change the way we all deliver care and speed up the whole process - I would love to learn them.... Do you do complete physicals and if so how long are the appointments? Do you do gyn care, breast exams, pap smears, rectals, and other time consuming items? What about EKG's and labs - obviously not doing the actual EKG but it takes time for the MA to get it and then to review, compare to old, and go back into room? By the time I have compared to an old one, and made a copy for the patient to carry if any abnormal findings it is easily 10+min. How do you talk about safe sex practices and building relationships with friends and family, or encouraging a more balanced work/home life? Again I would love to learn from you on how I too can see 30-40 patients a day, accomplish all the above, and still get home with only a 9 hour day under my belt - please share your tricks as I come up with about a 11 hour day to accomplish this and I still feel I am not doing enough.... BTW - went and looked at your blog - seems you LESS THEN 2 YEARS OUT OF SCHOOL - Seems like you Graduated in Dec 2010 - likely started working in 2011 - this means you have LESS THEN 2 years of clinical practice. I am scared for you if you are truly believing that you can see 40 patients in a day and not miss anything, and deliver gold standard medicine. My friend you are at the very beginning of your career - you likely have only had 1 maybe two jobs as a PA, have really limited clinical experience (although it is getting better at this point almost 2 years out) and likely have not seen how badly things can turn and how fast something can be missed. I am truly concerned that you do not necessarily know what you don't know, and this the crux of medicine and especially primary care. I can honestly say I have never seen anyone < 2 years out of school who was truly comfortable in their skin and practicing proficiently. I for one said I was going to work in IM for a year to burn in the knowledge I learned in school and it took me 5 years to get really comfortable...... 2 years - is still a very new clinician. I do not mean to come down hard, but it is important to realize and qualify where advice is coming from. I am a 10+ year PA and have extensive experience in Medicine, chronic pain management, occ health, did a year in the ER, 2 years in Radiology and per diem in physiatry and Ortho and I only in the past year feel like I am really growing into a competent clinician who has YEARS and YEARS more knowledge to learn......... competency in medicine is not the number of patients you see or the grades you got in school - it is time and learning over the years...... sorry if this came off as a rant - I just really think it is important that we all have reasonable goals and having a 22 month clinician saying they can do full spectrum primary care to the tune of 30-40 patients in a 9 hours day is in my opinion excessive and possibly dangerous and if and when things go wrong that patient likely for ever will think a PA is less of a clinician then a NP or Doc...... I will no longer discuss this topic on a public forum - if you would like to continue the conversation please PM or call me to discuss. You assault me in an all-out public attack and then want my reply in private. Sorry, no. In response to your question about what might be different in our environments, I have 7 rooms compared to your 3. That's probably it right there. Again, yes I see about 30 patients on a normal day, and yes, I practice great medicine. My SPs opinion matters to me there, along with my own, my patients and the other providers I deal with in networking, not yours. Again, I don't even know you. Why on earth would you contact my references???? <-----nice dramatics. Well, it would be to put you in your place. As to the rest, your attempts to portray me as "dangerous" just make me laugh, as they would my SP and other Docs who know me well. You come across as very pompous, having no idea what my prior healthcare experience consisted of or how I practice. Yes, as I stated in a prior post, I address absolutely everything ... rarely will I say, 'I wish we had more time to address this, let's plan it when you follow up in two weeks'. Where did I say I know everything or that I operate completely autonomously? I have a very solid phone connection with my SP as well as to the specialists in our referral network. Are you questioning his and their judgement now too? You just keep digging your hole deeper and deeper. Whatever insecurities this all brings up in your own ego, please keep them in check. People who attempt to bring down others usually do it for a reason. You don't frighten me, you don't intimidate me and you seriously don't bother me. You sound very accomplished and good for you. That being said, I remember a Peds preceptor who had worked for 50 years and stated that she "knew but a drop in the bucket of Pediatrics." Always a good attitude to keep in mind. It's unfortunate that you "still don't get it", but there's nothing I can do about that. Good luck. Link to comment Share on other sites More sharing options...
Hemegroup Posted October 29, 2012 Share Posted October 29, 2012 One other point of suggestion ... Paps and DREs shouldn't be "time consuming items". Thorough and properly executed, yes. Time consuming, no. Edited to note: 30 patients in 9 hours = 3.3 patients in an hour ... I really don't see what the big deal is about that. Does anyone definitely know if they're taking Histrionic out of the DSM-V? Link to comment Share on other sites More sharing options...
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