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From One Syndrome to Many: Incorporating Geriatric Consultation into HIV Care
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'time to create Geriatric Programs in HIV Clinics'...."understanding frailty
"Aging-related syndromes can be seen among HIV-infected adults before they are chronologically elderly....Aging-related (geriatric) syndromes are distinct from classic medical syndromes[15, 16]. They are common and often seen in combination. Examples include frailty or functional decline, which are distinct from specific motor or sensorineural losses. These syndromes, rather than comorbidity, are often the primary focus of geriatric evaluation and interventions.....Just as there is a shortage of well-trained HIV providers [30], the supply of geriatricians is insufficient [14]. As of 2012, there were 7,428 board certified geriatricians in the U.S [14]. The first hurdle to creating a program is finding a geriatrician who has time, interest, and salary support to work in an HIV practice"
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From One Syndrome to Many: Incorporating Geriatric Consultation into HIV Care
Harjot K. Singh MD, ScM1, Tessa Del Carmen MD2, Ryann Freeman MSW2,3, Marshall J. Glesby MD PhD1, Eugenia L. Siegler MD2
1Division of Infectious Diseases, Weill Cornell Medical College, New York, USA,2Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, USA,3ACRIA, Center on HIV and Aging, New York, NY
Clinical Inf Diseases April 6 2017
40-word summary: Geriatricians can help HIV providers meet the needs of an aging HIV population. In this article, we summarize the evidence for this approach and describe several methods of incorporating it into an HIV clinic.
Abstract
Antiretroviral therapy has enabled people to live long lives with HIV. As a result, most HIV-infected adults in the US are over 50. In light of this changing epidemiology, HIV providers must recognize and manage multiple comorbidities and aging-related syndromes. Geriatric principles can help meet this new challenge, as preservation of function and optimization of social and psychological health are relevant to the care of aging HIV-infected adults, even those who are not yet old. Nonetheless, the field is still in its infancy. Although other subspecialties have started to explore the role of geriatricians, little is known about their role in HIV care, and few clinics have incorporated geriatricians. This paper introduces basic geriatric nomenclature and principles, examines several geriatric consultation models from other subspecialties, and describes our HIV and Aging clinical program to encourage investigation of best practices for the care of this population.
see below full text
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2 reports below
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Download the PDF here
Download the PDF here
Commentary - Geriatric-HIV medicine is born....
"Every advance in medicine brings new questions and new opportunities. It is an exciting and welcome challenge now to have to address how best to care for people living with HIV as they enter old age"
"it can inform more generally the care of people with complex needs, especially as they age"
"understanding frailty...As a measure of biological age frailty, better that chronological age, can describe both a health state and a geriatric syndrome. Frailty, more than multimorbidity, allows us to grasp the complexity of age-related pathophysiologic changes and does so in ways that can alert us to effective clinical interventions12."
Clinical Infectious Diseases April 6 2017 - Giovanni Guaraldi MD
Associate Professor of Infectious diseases. University of Modena and Reggio Emilia, Italy
Kenneth Rockwood MD, FRCPC, FRCP
Professor of Medicine (Geriatric Medicine & Neurology) Dalhousie University, Halifax, Nova Scotia, Canada
Ten years ago, the first modelling studies showed that the life expectancy of people living with HIV who demonstrated good immunological recovery is close to that of the general population 1. Now we know that aging with HIV is a fact of life. With this realisation has come a move to understand healthy life expectancy in people living with HIV. In this effort, the remarkable progress in HIV/AIDS medicine can benefit from what has been learned in geriatric medicine. Over many decades, geriatrics has developed clinical principles and practices that, in their focus on function (and not just disease), aim to enhance the quality of life of elderly people.
In this issue of Clinical Infectious Diseases, a review by Singh and co-authors [current issue] celebrates the birth of "geriatric-HIV medicine". They forecast how it can rapidly catch up with related medical specialties, such as "ortho-geriatrics" 2, "cardio-geriatrics" 3, or "onco-geriatrics" 4. The prerequisite for geriatric medicine and HIV medicine to interact is that they share some basic geriatric nomenclature. This is not an option: by speaking the same language, we can share principles and tools.
Some concepts are key. First, as they point out, there is more to understanding the complexity of health in aging than assessing non-infectious comorbidities and multi-morbidity. Another centrepiece of the argument is that as people with HIV infection live longer, many are developing conditions and syndromes that are common in older adults, but are only loosely related to disease counts. Two people with the exact same comorbid conditions can have very different functional aging trajectories; in contrast, the degree of frailty provides a reliable prognostic guide, something seen in many settings, and across the life course5 6,7 8. This also appears to hold in HIV9. The transition from evaluating co-morbidities in HIV to implementing comprehensive geriatric assessment requires both structural and cultural changes in patient evaluation. Such changes will gain by understanding frailty10 11. As a measure of biological age frailty, better that chronological age, can describe both a health state and a geriatric syndrome. Frailty, more than multimorbidity, allows us to grasp the complexity of age-related pathophysiologic changes and does so in ways that can alert us to effective clinical interventions12.
Geriatricians in HIV clinics?
Singh and colleagues examine several geriatric consultation models: referral to a geriatric clinic, assessment within a PLWH practice, and/or assessment in home. We do not yet know which is the most effective combination of resources, and but whatever is available should be explored. We will need to learn how to screen for frailty, how to assess and treat common geriatric syndromes such as delirium, impaired mobility, falls and polypharmacy. Some of this will require adaptation of what otherwise happens in aging. For example, will there be more specific pathways to delirium reflecting specific neurological consequences of HIV or of the medications used in its treatment? Likewise, tools that have worked well in geriatricassessment may need to be adapted to the assessment of HIV-infected persons. Vulnerabilities for disability and obstacles to care that are HIV-specific must also be taken into consideration, including social vulnerability and interaction between HIV and aging stigma. Each of these questions can help make up a rich and important research agenda, likely to advance disciplines in both care of older adults and persons living with HIV.
Opportunities for innovation in care of people with complex needs
Given the shortage even now of geriatricians in many developed countries, although some centres may lead in developing a needed Geriatric-HIV Medicine academic core, most HIV clinics wishing to incorporate the lessons of geriatric medicine can expect to add to their current offerings what works well in the assessment of aging people in general. Such work should be undertaken in the spirit that it can inform more generally the care of people with complex needs, especially as they age13 14. Further, we need not repeat their more painful lessons to learning from geriatricians. For example, confusion arises from the variable meanings of the term "comprehensive geriatric assessment". In the UK in particular, it is understood to also incorporate management, and not just evaluation. In contrast, in many North American context geriatric assessment can be synonymous with mere risk stratification – reflecting an assumption (of people unaware of the active and evolving evidence base for its effectiveness) 15 16 17 that there is little to be done for frail patients other than to "place" them appropriately (for example by assigning them to the correct level of long term care). Similarly, as with other cognitive (as opposed to procedure-based) specialities, physician costs historically have been inadequately captured in the fee-for-service environment. Singh et al. note the increase in subspecialty consultation (citing for example cardiology, nephrology, oncology) for people living with HIV. In frail patients, this has proved to be a mixed blessing: left to their own devices, subspecialists constitutionally have a narrow focus, typically merging their own interventions with what is desirable. This is not restricted to physicians: a painful lesson, oft learned, is that multidisciplinary teams do not always make for effective interprofessional collaborative practice. One useful remedy, somewhat worked out in the care of older people and sometimes used in HIV care18, is patient-centred language and individualized outcome measurement19.
The HIV community also offers opportunities particularly for evaluating innovative communication strategies. Younger groups of people ageing with HIV represent the first "digital generation", who are likely to benefit from information and communication technologies designed to address health needs both in wealthy and resource-limited countries 20.
Particular opportunities arise in relation to polypharmacy. With the adoption of combination antiretroviraltherapy (ART), most HIV-infected individuals in care are on five or more medications. In a geriatric medicine context, this puts them at risk of harms such as decreased medication adherence, organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. What can be considered as polypharmacy in HIV/AIDS? Which medications put ageing people at risk? Will broad principles of de-prescribing in polypharmacy hold or require adaptationI? ID physicians have learned little by little to deal with an increasing number of co-morbidities and apparently have progressively added drugs for comorbidity treatment and prevention above ARV. We still complain under-prescribing of drugs like statins in HIV but in fact over-prescription of drugs is already present in HIV care21. Geriatric consultation often results in de-prescribing drugs rather than adding more and geriatric medicine. Even so, emerguing evidence that polypharmacy per se might be less important than frailty in understanding risk in relation to medication use22 23.
Research tools in HIV-geriatric medicine are much needed. Current clinical trials are unlikely to inform or enhance the treatment of older HIV+ patients. The choice of appropriate investigative clinical endpoints is important to assess the benefit of interventions, including ART therapy. The standard HIV research endpoints of virologic suppression and CD4 improvements may not be the most important tools with which to evaluate the risk/benefit ratio, even in ART clinical trials involving older HIV+ persons. Competing non-HIV risks for death and morbidity, and greater risk for acute and chronic ARV-related toxicity must also be considered.
The European Medical Agency (EMA) recently suggested combining physical performance and patients reported in formal clinical trials (e.g. using a combined outcome of walking faster than 0.8 m/s AND reporting Short Physical Performance Battery improvements) in assessing investigational drugs for treatment of sarcopenia in frail patients 24. This seems like a useful precedent to apply to investigational antiretroviral agents for elderly people, as might also be differences in the degree of frailty between treatment groups. Geriatric assessment has been incorporated into many clinical trials, involving cancer treatment. Even so, challenges remain in using such assessments as criteria for interventional stratification or randomization, in part because of the lack of standardization of definitions of frailty and disability, and due to lack of studies about their measurement properties in clinical trials, although recently this appears to be changing. What is needed however is a better understanding of their responsiveness / sensitivity to change.
Every advance in medicine brings new questions and new opportunities. It is an exciting and welcome challenge now to have to address how best to care for people living with HIV as they enter old age.
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From One Syndrome to Many: Incorporating Geriatric Consultation into HIV Care
Harjot K. Singh MD, ScM1, Tessa Del Carmen MD2, Ryann Freeman MSW2,3, Marshall J. Glesby MD PhD1, Eugenia L. Siegler MD2
1Division of Infectious Diseases, Weill Cornell Medical College, New York, USA, 2Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, USA, 3ACRIA, Center on HIV and Aging, New York, NY
40-word summary: Geriatricians can help HIV providers meet the needs of an aging HIV population. In this article, we summarize the evidence for this approach and describe several methods of incorporating it into an HIV clinic.
Abstract
Antiretroviral therapy has enabled people to live long lives with HIV. As a result, most HIV-infected adults in the US are over 50. In light of this changing epidemiology, HIV providers must recognize and manage multiple comorbidities and aging-related syndromes. Geriatric principles can help meet this new challenge, as preservation of function and optimization of social and psychological health are relevant to the care of aging HIV-infected adults, even those who are not yet old. Nonetheless, the field is still in its infancy. Although other subspecialties have started to explore the role of geriatricians, little is known about their role in HIV care, and few clinics have incorporated geriatricians. This paper introduces basic geriatric nomenclature and principles, examines several geriatric consultation models from other subspecialties, and describes our HIV and Aging clinical program to encourage investigation of best practices for the care of this population.
Introduction
Survival among HIV-infected adults has dramatically improved with the introduction of effective antiretroviral therapy. Modeling now suggests near normal longevity, especially for those who did not acquire HIV via injection drug use and who have restored or maintained CD4 counts [1]. Recent models from the Netherlands predict that >70% of HIV-infected patients will be 50 years of age or older by 2030.[2] That same study estimates that 28% of HIV-infected patients in 2030 will have at least three age-related comorbidities [2]. In addition to multiple comorbidities (multimorbidity), the aging HIV-infected population is at risk for geriatric (henceforth termed aging-related) syndromes, such as frailty, falls, delirium, and functional impairment [3].
While the Centers for Disease Control and Prevention's original designation of Acquired Immune Deficiency Syndrome (AIDS) in 1982 was based on the occurrence of "a disease, at least moderately predictive of a defect in cell-mediated immunity, occurring in a person with no known cause for diminished resistance to that disease" [4], AIDS is now defined by the occurrence of opportunistic illness or nadir CD4 count <200 cells/mm3 in a host with HIV infection. The term AIDS has become anachronistic; its etiology understood, it is no longer a syndrome per se. Instead, as most persons with HIV infection are living longer lives, they are developing not only medical comorbidities but also multiple, syndromes related to aging.
These aging-related syndromes and multimorbidity - common to elderly patients and well understood by geriatricians - may go unrecognized by HIV providers. To date, there is no formal guidance on incorporating assessment and care for these problems among HIV-infected adults. Preventive health care poses similar dilemmas. Cancer screening, for example, is now part of the primary care of all HIV-infected patients, but there are no guidelines on when or whether to stop preventive screening.
How can geriatric principles assist with the health care of this population? Awareness of these problems has increased, and there are now regional and international scientific andclinical conferences on HIV and aging, but clinical care recommendations are still largely based on expert opinion. This article will review the principles of aging with HIV and then examine the literature of geriatric consultation for corroborating evidence to support geriatric input in the care of people aging with HIV. We will conclude with issues to consider when incorporating geriatric consultation into the care of this population.
The Importance of Geriatric Principles
Antiretroviral therapy (ART) has controlled HIV infection and improved quantity of life; the primary care of adults with HIV infection has become more complicated as they live longer with other, often multiple comorbidities [5]. Management of multiple aging-related syndromes and comorbidities may require far more of the clinician's time and attention than the HIV infection itself. People aging with HIV are at risk for a diminished quality of life [6, 7]; even though they are not chronologically geriatric, they may benefit from a geriatric approach to evaluating and maintaining functional status.
How HIV infection itself affects aging itself is a controversial topic. The debate centers on whether HIV speeds up aging processes through established mechanisms for aging in general or whether HIV infection is an additive or synergistic risk factor [8]. Arguments for the biologic plausibility of HIV causing accelerated aging typically draw parallels between the pathophysiology of treated HIV infection and aging in general, including the prognostic significance of low CD4:CD8 ratios, potential shared immunosenescence phenotypes, and the roles of co-infections such as CMV. A detailed discussion of this controversial topic is beyond the scope of this paper and has been reviewed elsewhere [8-10]. Other approaches, such as through epigenetic analysis, are also being used to try to answer the question of whether HIV accelerates aging [11, 12].
Because the vocabulary of geriatrics and gerontology can be confusing, Table 1 provides definitions of commonly used terms. Several principles are noteworthy:
⋅ Aging cannot be defined or measured solely by the presence of disease. That is not to say that aging and disease are entirely distinct, but rather that it may be deceptive to ascribe comorbidities to aging, or in the case of HIV infection, attribute increased prevalence of comorbidities to "accelerated" or "accentuated" aging. [section deleted]
⋅ The impact of multimorbidity is not the same as that of adding the impact of multiple individual comorbidities. Clinical practice guidelines are designed for individual diseases and are often inappropriate/unfeasible for individuals with multimorbidity [13]; optimizing therapies in a patient with multimorbidity not only requires examination of the clinical evidence but must also take patient preferences, prognosis, and clinical feasibility into account [14].
⋅ Aging-related (geriatric) syndromes are distinct from classic medical syndromes [15, 16]. They are common and often seen in combination. Examples include frailty or functional decline, which are distinct from specific motor or sensorineural losses. These syndromes, rather than comorbidity, are often the primary focus of geriatric evaluation and interventions.
⋅ Aging-related syndromes can be seen among HIV-infected adults before they are chronologically elderly [3]. We recommend using the term aging-related to increase the likelihood that providers and patients will appreciate their relevance. This is essential, as these kinds of syndromes often frame the management of the older patient who may simultaneously have several comorbidities.
Caring for people aging with HIV has required negotiating several clinical challenges. The first is the predominance of non-AIDS defining comorbidities like cardiac disease, renal impairment, and non-HIV malignancies as causes of chronic illness and mortality [17], leading to an increase in subspecialty consultation (e.g., cardiology, nephrology, oncology) to co-managethe HIV-infected patient. The second challenge is the increased prevalence of multimorbidity, which requires coordination and prioritization of subspecialty care. The third is the high prevalence of aging-related syndromes and the need for geriatric care, even in those who are well below 65 years of age [18]. Clinical management requires preparing patients in their 50s for healthy aging (as a way of trying to forestall or prevent these syndromes) as well as assessment and care of those who have aging-related syndromes [5].
Recognizing these new crossroads in the field of HIV medicine, the American Geriatrics Society, American Academy of HIV Medicine, and ACRIA first published a set of guidelines in 2011 to address the management of the aging HIV population [19]. Since then, the major American HIV treatment guideline groups - the Department of Health and Human Services, and International Antiviral Society-USA have added in small sections on aging as well [20, 21] However, the majority of the guidelines (although not all, e.g., [22]), remain organ-based and do not address the methodology and value of geriatric consultation head-on.
Geriatric Evaluation and Consultation in Other Settings
The history of comprehensive geriatric assessment (CGA) began with Marjorie Warren, who in the mid-twentieth century devised a way to triage chronically ill neglected inpatients in a hospital by creating the first geriatric assessment/treatment team. She systematically evaluated patients to determine who would benefit from medical intervention or rehabilitation efforts and was able to discharge one-third of over 700 inpatient "incurables" to either home or to a residential facility [23]. Over the ensuing decades, CGA has been updated to include multiple domains (Table 2) encompassing biomedical, social, and economic concerns.
CGA has been studied both as a primary, hospital-based program and as an outpatient consultative service (integrated or separate) to other subspecialties of medicine such as cardiology [24], nephrology [25, 26], and oncology [27]. The evidence behind the effectiveness of CGA is mixed; it has resulted in improved outcomes or no effect [deleted text]. Geriatricevaluation has proven most valuable in inpatient settings. It has also helped clinicians prognosticate and identify problems that are often overlooked in standard medical visits. Table 3 includes recent systematic reviews and meta-analyses of studies in the general population examining the feasibility of geriatric assessment in both the outpatient and inpatient settings and the impact of CGA on treatment decision-making and outcomes (mortality and hospitalization).
CGA often provides important information when counseling about goals of care and determining the role of prevention. Eprognosis, a web-based prognostic tool, has aggregated and assessed a number of prognostic calculators for the general older population specific to location (e.g., community, nursing home) and time frame (http://eprognosis.ucsf.edu/bubbleview.php). While these calculators have not been validated specifically for HIV-infected persons, there is one mortality predictor that has been validated in the HIV population, the Veterans Aging Cohort Study VACS calculator (https://vacs-apps2.med.yale.edu/calculator) [28]. While prognostically useful, the VACS calculator is not descriptive; it does not incorporate function, cognition, or direct measures of all components of multimorbidity.
The literature on geriatric consultation in other subspecialties can provide some inferences about the feasibility and usefulness of CGA. Examples of clinical models relevant to HIV care include outpatient consultative, outpatient integrative, inpatient consultation, or CGA by primary care teams as illustrated by the following representative examples.
Referral to geriatric clinic: Kalsi et al. created an intervention where oncology patients aged 70 and older completed a screening questionnaire, and those found to be at high risk (or who were referred directly by their physician) underwent CGA by a geriatric consultant in an outpatient clinic prior to initiating chemotherapy. This model was evaluated in a non-randomized, prospective cohort study (N=135), and patients in the intervention group were more likely than controls to complete cancer treatment [27]. A prescreen model has been usedfor outpatient aging HIV patients; Ruiz and Cefalu used a CGA screen to identify appropriate patients for referral to a Geriatric-HIV program [29].
Assessment within the practice: Hall et al. compared two models of geriatric assessment within Veterans Affairs outpatient nephrology clinics. In the first model, an embedded geriatrician conducted CGA; in the second model a nephrologist with 16 hours of geriatric training or a nurse practitioner dually certified in gerontology and nephrology performed the assessments. In both models, geriatric assessment was able to identify high-impact problems like cognitive impairment, functional impairment, and difficulty with IADLs. The authors concluded that a geriatrician's treatment recommendations were necessary when nephrologists had limited experience, but that with limited training in geriatrics, nephrologists could learn how to use the basic CGA tools on their own. The authors also felt that CGA assisted in guiding care of chronic kidney disease and decisions about dialysis both by uncovering functional and cognitive problems and by identifying those who were aging well [25].
Assessment in the home: Parlevliet and coworkers described a model where a nurse performed CGA on 50 patients on dialysis who were age >65 years. After completing a chart review-based screening and sending questionnaires to be filled out by the patient and primary caregiver, the nurse then visited the patient's home and completed the CGA. Approximately 33% were found to be malnourished and 25% were depressed and/or in pain. Almost 60% had at least one IADL impairment. This model, while time consuming, has the advantage of not requiring a geriatrician, but may not be feasible for people who do not live close to the office and do not have caregivers who can assist with the completion of forms [26].
HIV providers with limited time and geriatric knowledge focus primarily on comorbidity, antiretroviral management, and preventive care during routine visits. While meta-analysesdescribed in Table 3 suggest there is value to geriatric consultation, and the above studies demonstrate feasibility of different consultation models, we do not yet know how to extrapolate these results for people aging with HIV. These populations all have serious, chronic illness in common, and it is not unreasonable to expect that CGA in people aging with HIV will uncover aging-related syndromes, prognostic information, and overlooked comorbidities, and in so doing, improve the quality of care. There are a few HIV and Aging clinical programs with published data [3, 29], but no trials that examine CGA's effectiveness in this population. With so few current geriatric models, experience with multiple programs is needed to determine the optimal approach.
Challenges to the Geriatric Approach
Just as there is a shortage of well-trained HIV providers [30], the supply of geriatricians is insufficient [14]. As of 2012, there were 7,428 board certified geriatricians in the U.S [14]. The first hurdle to creating a program is finding a geriatrician who has time, interest, and salary support to work in an HIV practice. Moreover, because many HIV-infected adults already see a multitude of specialists, the addition of yet another provider might be overwhelming to the patient or even appear to undermine the primary care provider. The mere presence of a geriatrician is no guarantee that people aging with HIV will receive adequate care. Lee et al. documented that even a geriatric primary care clinic focused on memory disorders found that constraints on time and resources limited their ability to manage aging-related syndromes and multimorbidity [31]. This may imply that CGA is not enough: training, collaborative structure, and access to resources are also needed to optimize care for aging adults.
Incorporating Geriatrics into HIV Care
When incorporating geriatrics into HIV medicine, defining the role of the geriatrician and ensuring buy-in from the primary care providers will maximize benefit and avoid additional risksto the patient from lack of coordination of care. Bringing the geriatrician to the HIV clinic is feasible. We have embedded geriatricians in a longstanding HIV clinic that already includes social work, nursing, psychiatry, gynecology, and substance abuse counseling. The text box describes the program. Ours is specific to New York City, but the approach to needs assessment, community engagement, and training could be applied to other programs. These are some of the factors that HIV centers should take into account:
⋅ Needs assessment of patients: How do patients feel about aging? What regional, national, or cultural needs should be explored and taken into account?
⋅ Needs assessment of care providers: What do staff want to learn about aging and geriatrics? How do they want to work with the geriatricians? Will they require extra in-services or back-up from gerontological nurse practitioners or social workers?
⋅ Choosing patients for consultation: Will there be a minimum age for consultation? Who will take priority? How will primary providers be reminded to refer? Will patients from outside your clinical program be recruited to see the geriatrician?
⋅ Clarifying the role of the geriatrician: Will the geriatricians see inpatients in addition to outpatients? Should the geriatrician provide palliative care in addition to CGA?
⋅ Space concerns: Where will the geriatrician see patients? How often?
⋅ Determination of workflow. How will the geriatrician communicate findings and recommendations? How will the clinic staff and physicians give feedback to the geriatricians? How will the geriatrician interface with the subspecialists?
⋅ Salary support: How will the physician bill? Is there foundation or institutional support for salaries?
⋅ "Advertising" the program: Once the program begins, how will patients and providers learn about it? How will the aging program and services be publicized?
⋅ Collaborating with community agencies: How will the staff reach out to other community-based organizations? How will they choose the most effective partners?
⋅ Creating non-clinical programs for patients aging with HIV: Will there be over-50 support groups and/or buddy programs? Are patients asking for specific programs, like arts- or exercise-based series? How will they be funded?
Conclusion
With continued improvements in ART, the HIV population is growing older and aging. Although recognizing and optimizing aging-related syndromes and comorbidities are the keys to ensuring patients' quality of life, HIV care providers face time constraints and lack training in geriatric assessment. Other subspecialties have successfully adopted comprehensive geriatric assessment, and HIV care can and should do the same. We have developed one such program that may improve the functional care of our aging HIV patients, and we encourage others to create geriatrics programs that take their patients' and clinical sites' needs into account. With time, we can determine the best practices to serve our patients.
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