Who Should Be Tested For COVID-19

As a physician working for one of the big local healthcare systems, starting Monday I will have the ability to order outpatient testing for the coronavirus. University Hospitals of Cleveland and the Cleveland Clinic are both offering drive-through swab testing with a doctor’s order.

Credit: bangordailynews.com

I’m anticipating a LOT of phone calls on Monday. Before you call, I want to go over the guidelines for who should be tested for COVID-19.

The very first question that will be asked when someone calls is “ARE YOU SICK.” This sounds silly but the worried well are going to want to be tested. I was at Costco Friday morning, am I at risk? I work in healthcare, am I at risk? Yes, of course. But I do NOT need to be tested because I am NOT sick.

The symptoms of COVID-19 include fever, cough, and shortness of breath. If you have a runny nose and cough, but no fever, you have a cold and do NOT need to be tested. And you don’t need to go to the doctor, urgent care or emergency room either! Stay home, drink fluids, rest and wash your hands until you are feeling better.

Suppose you do have a fever and a cough. If so, I guarantee that anxiety is going to make you feel short of breath! The next question is, have you been exposed? At this point, if you have not traveled and have not been in contact with a known or suspected case of COVID-19, and are well enough to stay home, you do NOT need to be tested. The exceptions are healthcare workers and those at high risk (like cancer patients and those 65 and older with multiple medical problems).

If you or a family member have any of THESE symptoms, you need to call 911.

  • Shortness of breath
  • Chest pain, pressure or discomfort
  • Bluish discoloration around the lips or fingernails
  • Confusion or difficulty waking up

If you need to call 911, let the dispatcher know what’s going on so they can give the paramedics and ER a heads-up and be prepared.

Social distancing, closing schools, avoiding large groups, good handwashing and sanitizing surfaces will help slow the spread of the virus. It’s inevitable that some people will be infected, and knowing who needs tested is important. We don’t have unlimited ability to test the general population. Just because you are scared and MIGHT have been exposed is not a reason to get tested.

If you need more information about this infection, here are some good resources for facts, not hype or hysteria:

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Caregiver Stress And The Sandwich Generation

I’m planning to give a talk on caregiver stress in a few weeks, and I figured I’d ask my lovely readers to help me make this talk awesome.

What is a caregiver?  A caregiver is defined as someone who provides care for another person in need.  Generally the person being cared for is unwell in some way and needs help with daily tasks.  Those with cancer, dementia, and many other chronic conditions may need help with dressing, bathing, eating, medication management and other critical tasks.

Who are our nation’s caregivers?  According to womenshealth.gov, over 20% of adult Americans will provide unpaid care to an elderly or disabled person each year.  61% of informal or family caregivers are women, and most are middle-aged.  59% of women who provide informal care to a family member are also employed. Over half of these employed female informal caregivers have made changes at work to accommodate caregiving, such as scaling back their work hours or changing their schedules.

There is an interesting term to refer to those providing informal or family caregiving:  The Sandwich Generation.  There are several types of Sandwich Generationers:

  • Traditional Sandwich – those caring for both aging parents and their own children
  • Club Sandwich – those caring either for both aging parents and their own adult children and grandchildren (4 layers!) OR aging parents and grandparents and their own children
  • Open-Faced Sandwich – anyone else involved in informal caregiving

Sandwich generation caregivers have an extra level of stress because they have competing priorities.  There is only so much time and they often feel they can’t do justice to any single task because they’re pulled in so many different directions.

Caregivers have definitely Got Stress.  How does one know when caregiver stress is becoming unhealthy?  The Alzheimer’s Association has a lot of information on their website about caregiver stress and burnout.  Symptoms can include anxiety, irritability, trouble concentrating, depression and anger.  Caregivers may be in denial about their loved one’s illness.  They may withdraw from friends and family, have trouble sleeping and feel exhausted.

Caregivers’ own health may suffer due to stress and burnout.  Researchers at the CDC found that 20% of caregivers surveyed rated their own health as fair or poor.

If you are a caregiver and find yourself struggling with stress and burnout, what can you do about it?  Better yet, if you find yourself (or know someone else who is) in the caregiver role, how can you minimize the risk of burnout?

  • Don’t beat yourself up because you can’t do everything.  Recognize you’re only human and be gentle with yourself.
  • Look for resources.  Check with the local Area Agency on Aging to explore what services are available near you.  There may also be disease-specific resources and services available.
  • Be proactive and take a problem-solving approach, rather than worrying and feeling helpless.
  • Do your best to take care of yourself.  Exercise, eat right, and get enough sleep.  See your doctor for your annual physical and other scheduled visits.  Remember, you can’t take care of others if you’re not well yourself.
  • Actively practice proven stress reduction strategies.  Meditation and yoga are good options.  Check out this recent post about Sudarshan Kriya Yoga.  Go to church, temple or other religious services regularly.
  • Don’t be afraid to ask other family members for financial help if you need it.
  • Ask for and ACCEPT help.  Have a mental list of things people can do and let them choose one.  For instance, a sibling can take Mom for visits on weekends to give you a break.
  • Be realistic and don’t be afraid to say no if you can’t commit to something.  Someone else will be able to chair the PTA and run the fundraiser.
  • Stay in touch with family and friends.  Isolation makes stress worse and accelerates burnout.
  • Keep a sense of humor!

I want to make sure you realize that there are significant upsides to the caregiver role too.  Many of my patients are providing care to aging parents and grandparents and find it incredibly rewarding.  For instance, one patient was the full-time caregiver for her father until he passed away in his 90s.  She has told me it was wonderful being able to share that time with him, knowing the time was limited and coming to a close.  Focusing on the blessings rather than the trials and keeping her (boisterous!!) sense of humor helped her keep burnout at bay.

Research has also shown that the healthiest and longest-lived people on Earth tend to live in multi-generational households.  Maintaining close relationships between generations is good for your health and for society.  One of my friends is a caregiver for her grandfather who has Alzheimer’s disease.  She is homeschooling her son and they spend the day together as a family.  Her grandfather is fascinated by his great-grandson’s schooling and the little guy adores spending time with him every day.

Providing family caregiving services to an elderly or ill family member is stressful, no doubt about it.  Caregiver stress is common and falls largely on women.  It doesn’t have to lead to conflict, burnout and physical illness though.  Acknowledging your limitations, asking for help, practicing good self-care, and seeking out the positive can help keep you healthy and make caregiving a rewarding experience for you AND your loved one.

QUESTION:  Are you providing caregiving services for someone you love?  What are you struggling with, and what helps you manage?

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How To Wash Your Hands

I was browsing the health news reports to get an idea of a topic for this weekend’s post. Literally every post is about the coronavirus outbreak and its spread to numerous countries.

While this is very important, unfortunately I’ve already written about this topic. I have seen a number of posts this week on social media about proper hand washing, and decided this was a good time to review the right way to wash your hands.

Everyone from Mayo Clinic to the CDC has put out guidelines about how to wash hands correctly. I have included a video at the end but here are the steps:

  • Wet hands with warm water
  • Use regular soap. Antibacterial soap actually increases the risk of staph infections and is not recommended.
  • Lather the hands thoroughly and rub them together. Get between the fingers, the tips, and the thumb.
  • Continue to rub the hands for 20 seconds. This is the time it takes to sing the Happy Birthday song or the Yankee Doodle song through twice.
  • Rinse the hands thoroughly under warm water.
  • Turn off the tap with a paper towel, NOT your clean hands
  • Open the bathroom door with a paper towel, NOT your clean hands

Studies have shown over and over that good hand hygiene is critical in preventing infection. This is true not only in hospitals and doctors’ offices but in the general public as well. Especially with the growing concern about coronavirus infection, proper hand washing is a critical measure everyone can and should take to reduce their risk of illness.

QUESTION: Are you washing your hands correctly?

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Sudarshan Kriya Yoga For Health

So many of my patients suffer with anxiety and depression. What’s worse, it is estimated that 90% of visits to primary care doctors are related to stress. Stress makes pain and other physical symptoms worse and harder to control. It interferes with management of medical problems like diabetes, high blood pressure and heart disease.

I’ve known for a long time that yoga is helpful for stress management and for your physical health. But there is one specific yoga practice, taught and practiced right here in Cleveland (and around the world), that has proven health benefits. Sudarshan Kriya yoga.

Sudarshan Kriya yoga (SKY) was developed and is taught by Art Of Living International, a nonprofit group led by Sri Sri Ravi Shankar. I was privileged to participate in a training course recently and can tell you from personal experience that there are real benefits to this practice.

I wouldn’t necessarily recommend this practice to patients and readers based on my own experience. It turns out, though, that there have been over 30 scientific studies published on the health benefits of this practice. Let’s review some of the evidence.

Anxiety is one of the most common mental health problems I see. It is a chronic illness that colors a patient’s entire experience and significantly impacts their quality of life. Sudarshan Kriya yoga was shown to produce improvements in symptoms in over 70% of subjects and complete remissions in 41% of subjects in only 4 weeks of practice. That is comparable to the effectiveness of medication and psychotherapy.

An estimated 20% of American adults will suffer with depression, and it is one of the most common problems I see in the office. Most patients respond well to medication but some do not. SKY is as effective as imipramine (a third-line medication choice) for patients who don’t respond to more commonly used medications.

Post-traumatic stress disorder is a terrible consequence of traumatic life events seen in survivors of natural disasters, terrorist attacks and childhood trauma, and especially in combat veterans. It is very difficult to treat and leads sufferers, particularly veterans, to even contemplate suicide to escape their symptoms. Sudarshan Kriya yoga produced significant and sustained improvements in symptoms in veterans suffering from PTSD, suggesting it should be considered in all patients with this awful illness.

With the attention being paid to the opioid epidemic, it is encouraging to be able to offer an intervention that improves quality of life for opioid users in recovery. One study did demonstrate this effect. SKY also helps smokers quit using tobacco products.

Stress, anxiety, and depression all have physical effects on the body. Many adverse effects of stress have been documented and they contribute to many chronic illnesses. How does SKY impact these physical illnesses and improve health?

Stress causes changes in the lipid profile and in hematological parameters such as platelet count. Over time, these changes may contribute to the increase in heart risk known to be associated with high levels of chronic stress. Sudarshan Kriya yoga has been shown to improve these changes in as little as 3 weeks.

It is also known that stress causes changes in the cardiovascular system related to the autonomic “fight or flight” system. Over time, especially in patients with high blood pressure and diabetes, dysfunction in this system can contribute to increased risk of heart attack and stroke. SKY improves measures of cardiac autonomic function which may in the future be shown to decrease cardiovascular risk.

Diabetics in particular can benefit from the practice of Sudarshan Kriya yoga. Glucose tolerance (postprandial glucose) improved significantly in people practicing SKY and, as mentioned above, cardiac autonomic function improved as well.

Those who are living with chronic, life threatening diseases such as cancer know that stress and anxiety worsens all their physical symptoms. Yoga, including SKY, improves pain and stress even in those with advanced stage breast cancer.

We are not just physical beings. Our minds, emotions and spirits affect our bodies as much as the foods we eat and the exercise we perform. Sudarshan Kriya yoga is an effective way to improve our mental health and our physical wellbeing. If you suffer with anxiety, depression, PTSD, substance addiction, diabetes, heart disease or any other chronic illness please consider taking the Happiness Course with Art Of Living International. Click this link to find a course near you!

QUESTION: Do you practice yoga? Would you consider trying it?

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Wuhan Coronavirus

OK, everyone is talking about the Coronavirus infection that started in Wuhan, China and is spreading throughout the world. What do you need to know about it?

This infection was first reported in late 2019 in Wuhan, China. A number of the first cases were reported in people who had connections to a large seafood and animal market, but later cases seemed to clearly show person-to-person transmission.

The infection is now here in the United States, and not everyone who has tested positive for the virus has been to China. Clearly the virus can pass from person to person. As of Friday, 1/31, there have been seven cases in the United States.

Wuhan Coronavirus is a respiratory illness that causes fever, cough and shortness of breath. Serious cases can involve pneumonia. Symptoms can be mild to severe. There is no vaccine, although scientists are working to develop one, and as of now there is no widely available treatment. A combination of medications designed for influenza and HIV seems to be helpful though.

Right now the best way to stay safe from this virus is to avoid infection. Travel to China has been restricted by the State Department. People returning from the Wuhan region of China are being quarantined.

If you have been to China and are sick with a respiratory illness, please see the doctor right away and tell the doctor immediately that you were in China. Follow sensible precautions like washing hands, covering coughs and disinfecting surfaces in your home.

The Wuhan Coronavirus can be deadly. About 2% of cases in China have been fatal. Compared to influenza, which kills about 1 in 1000 people who catch it, this is much more dangerous but also much more rare. 360 people have died in China from Coronavirus, compared to over 34,000 people who died in the United States in the 2018-2019 flu season.

Be aware of Wuhan Coronavirus. Don’t travel to China until the State Department announces it is safe. If you have traveled and get sick, see the doctor and make sure they know your travel history. Take sensible precautions. And don’t panic.

QUESTION: Are you worried about Wuhan Coronavirus?

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Cardiac Rehab After Heart Attack

If I tried to make a list of all my patients who have had a heart attack in the past year, unfortunately I probably would be here awhile. We are NOT good at identifying patients at risk, and many patients refuse treatments and lifestyle changes that are proven to reduce their risk of a heart attack.

AFTER a heart attack, though, we have a very good idea what will reduce the risk of having another one. Sadly, only a very small number of patients take advantage of one of the best measures to reduce the risk of an encore performance: cardiac rehab.

Cardiac rehab consists of 36 one-hour sessions which are covered by Medicare and most if not all commercial insurance. The sessions include

  • supervised exercise training
  • counseling on diet
  • counseling on stress management
  • smoking cessation (if needed)
  • guidance on other measures for heart-healthy living

Researchers at the CDC in Atlanta looked at heart attack and heart failure patients covered by Medicare and found that only 24% of the patients even started cardiac rehab. Of those, on average patients completed only 25 sessions, with only 27% attending the recommended 36 sessions.

Older patients, patients of color, sicker patients and women were less likely to go to cardiac rehab. The study wasn’t designed to figure out why this was seen. However, I can imagine transportation and family support may have been a problem with the older and sicker patients. Access to care is always a problem with patients of color and in this instance doesn’t surprise me. Women in general put their own needs last, and I can definitely see female patients being less likely to attend an extended series of rehab sessions. I can’t even get them to go to 12 physical therapy sessions to address an excruciating musculoskeletal injury!

Cardiac rehab reduces the risk of death in the period after a heart attack. It improves quality of life, mood and functional status. It also reduces the risk of hospital readmission. Every patient with a heart-related hospital stay should be offered (and should take advantage of) cardiac rehab.

If you or a family member find yourself diagnosed with a heart condition, ask your cardiologist or family doctor whether you qualify for cardiac rehab. If you do, GO. Go to ALL the sessions, go until they tell you not to come back anymore. Your heart will thank you!

QUESTION: Did you know about cardiac rehab? Do you know anyone who would benefit from it?

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Setting Goals For The New Year

Happy New Year everyone! Now comes the time of full parking lots at the gym and having to wait for equipment. Diet products are everywhere. Planners are selling out at the bookstore.

By February it seems like things are back to “normal” at the gym and elsewhere. Why does setting goals and meeting them seem like such a hard thing?

Generally there are three reasons why people don’t meet the goals they have set for themselves:

  • The goal is too vague: “I’m going to get healthier.”
  • The goal is too big: “I’m going to lose 100 pounds this year.”
  • No accountability

In management circles there is talk of setting SMART goals. SMART is an acronym that helps with effective goal setting. Goals should be

  • Specific
  • Measurable
  • Achievable
  • Relevant and
  • Time-limited

There are lots of resources to dive deeper into each of these characteristics but let’s start with our vague “I’m going to get healthier” goal from earlier. What would that mean? What does “healthier” mean?

In this case let’s imagine a diabetic patient. For him, “healthier” may mean getting better control of his blood sugar. If he is starting with a hemoglobin A1C of 8, he may set a goal of 6.5 in 6 months. This goal is specific, measurable, definitely achievable, relevant and time-limited.

If this were my patient, I would push him to make more goals to flesh out the plan. What is his food goal? What about an activity goal? Hopefully he already has taking his medication daily under control, LOL! After all, a dream with a plan (and a deadline, per Napoleon Hill) is a goal. The plan is important. How are we going to achieve this goal?

Once you have a goal and have broken it down into smaller pieces, it’s important to share the goal with someone who can support you. A spouse, a friend, a sibling, we need to have an accountability partner to remind you why you set the goal in the first place and pick you up when your motivation fizzles.

It doesn’t matter what your specific goal is. You can rock it this year!

QUESTION: What goals do you have? How can we make 2020 your healthiest year ever?

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Artificial Sweeteners And Health

Bonnie is a patient of mine who struggles with her weight. When she was younger she was slender, active, enjoyed exercise and enjoyed cooking. She is a nurse and has always been drawn to high-stress fields where she feels she can make a real difference for her patients. She married late and had two children and since then her weight has gotten out of hand.

At a recent appointment I asked whether she was ready to make some changes and tackle her weight. She has tried a number of weight loss programs without lasting success. At her last visit she brought a bottle of what turned out to be her favorite beverage with her: Diet Coke.

I asked her about it and she admitted she drinks almost nothing but diet Coke. She doesn’t like coffee so she relies on the caffeine in her soda to get her going in the morning. She justifies it by saying “at least it’s DIET Coke, there’s no sugar, so it’s OK.”

But is it? New research has come out suggesting that artificial sweeteners are not the weight loss magic they were designed to be.

Researchers in San Antonio, Texas, published a very thorough review of both animal and human research studies looking at the effects of artificial sweeteners on a number of health parameters. They found that animals fed a whole range of artificial sweeteners – including saccharin, sucralose, acesulfame potassium, aspartame, or the combination of erythritol+aspartame – had a number of adverse impacts on their health.

They tended to eat more. They gained weight. They developed higher percent body fat. They had worse metabolic markers including those for diabetes and for inflammation.

These changes were more pronounced in male animals and in those with a genetic predisposition to obesity. They were especially striking in those eating high-fat, high-sugar diets and diets meant to mimic our “Western” diet.

In the human studies those participants who reported daily (or more frequent) use of artificial sweeteners had more weight gain. They gained more weight around the abdomen, which is the most dangerous place to gain it. They were more likely to be overweight and obese.

I’ve always said there’s a difference between being fat and being unhealthy. You can be a fit overweight person. But those study participants who used artificial sweeteners tended to NOT be fit or healthy. Those who reported daily or more frequent intake of diet drinks (the most common source of artificial sweeteners) were more likely to have hypertension, metabolic syndrome, diabetes, depression, kidney dysfunction, heart attack, stroke, and even cardiovascular and total mortality.

Obesity studies tend to have a heavy participation of female subjects. Because the animal studies showed the impact of artificial sweeteners is more pronounced in male animals, the dangers of these additives may actually be more than what we are seeing (which is bad enough).

If you are currently drinking diet soda thinking it will help you lose weight, please stop. The science is clear that diet beverages promote weight gain and increase the risk of diabetes and other health problems. If you like fizzy drinks there are plenty of unsweetened seltzer drinks available to choose from. Even unflavored seltzer with a dash of fruit juice is a better option.

The good news is that diet soda consumption is on the decline. But people looking to lose weight are still susceptible to the lure of something for nothing. Remember, if it sounds too good to be true, it probably is.

QUESTION: Do you drink diet soda? Will this information cause you to rethink that?

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When Misleading Ads Harm People

My patient Brian is a gay man who has been taking the medication Truvada to protect him from HIV infection. Recently I saw him in the office and he said he saw an ad on Facebook suggesting this medication causes bone and kidney problems, so he stopped it.

When advertisers mislead people to make a buck, that’s one thing. When misleading ads lead to people being hurt or killed, that’s another.

Brian is at increased risk of HIV infection due to his lifestyle. He is a lovely, gentle man who is a talented musician. Whether you agree with his choices or not, he does NOT deserve to contract a deadly disease if it can be prevented. And Truvada reduces the risk of HIV infection by 99%.

The ads in question are being run by legal firms who, it seems, are attempting to organize class-action lawsuits against the company that makes Truvada. These misleading ads claim the medication is dangerous and imply taking it isn’t worth the risk. When patients without medical knowledge, like Brian, see these ads online they become concerned and sometimes choose to stop their medication.

All medications have risks. Doctors talk with patients and weigh these risks against the proven benefits of the medications. Often doctors run periodic tests to monitor for problems stemming from use of medications. Other medications can cause kidney problems (like blood pressure medications and NSAIDs like Advil) or bone problems (like some contraceptives and steroids used for severe arthritis) but we still use them.

Stopping blood pressure medication because some lots of generic medication have been found contaminated is one thing. High blood pressure is rarely dangerous over the short term – once it’s confirmed your pills aren’t from one of the affected lots you can restart them. However, stopping medication to prevent infection from HIV can be deadly over a short period of time, if one is exposed during that unprotected window.

Almost 40,000 new cases of HIV infection happen every year. Over 1 million Americans are living with HIV, and approximately 15% of these people don’t know they are infected. Gay and bisexual men, sex workers and IV drug users are at highest risk and most likely to benefit from treatment with Truvada.

If you are taking a medication, ANY medication, and you see something reported on TV or radio that concerns you, talk to your doctor before stopping your medication. Your physician should be able to address your concerns and, if not, you can decide together on a course of treatment that makes you comfortable and continues to meet your health goals.

It’s been said before, but bears repeating. Don’t believe everything you see or hear online.

QUESTION: How do you judge when you see concerning information online? How do you know what to believe?

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Meaningful Work And Joyful Play

“What do you do for fun?”

That may sound like a weird question for your doctor to ask you, but what can I say, I’m weird 😉 I’ve been doing some training on how to coach for nutrition and lifestyle change, and one thing I read this week really struck me.

Stress depends largely on a balance between meaningful work and joyful play.

So lately I’ve been asking my patients what they like to do for fun. If I’m seeing a patient for depression, chances are good they can’t tell me one single thing they do that they enjoy. One patient went so far as to tell me (tearfully) that she is not getting any fun out of life at all.

We’ll talk about Part Two in a minute, but I want to start by talking about meaningful work. Many of my patients, especially if they struggle with depression, have trouble with seeing their work as meaningful. They feel like they’re punching a clock, going through the motions.

I read once (probably connected with some small-business training or other) that all business boils down to making someone’s life better. Think about that. Why do you open your wallet and spend money? Because you believe that transaction will make your life better. Subscribing to Disney+, buying a new pair of shoes, sending your kids to private school, saving for retirement instead of taking an extra trip this year. Even paying taxes makes your life better (by averting the likelihood of prison for tax evasion)

There was a talk not long ago I attended about improving quality at a big hospital system. The speaker was talking about a time he visited an aircraft carrier. One of the airmen’s job was to clean up the deck. The speaker asked what his job was. He could have said “I’m the janitor,” or “I keep the deck clean.” But that’s not what he said.

When asked what his job was, the speaker said the airman stood up straight, looked him in the eye and said “Sir, I help planes take off and land safely to protect our pilots and further the mission of the United States Navy. Sir.” Wow! That’s a man with a clear idea of how his job makes people’s lives better!

When you go to work every day, your job will feel much more meaningful if you focus on how you are making someone’s life better. I challenge you in the comments to give me a job that DOESN’T make someone’s life better.

On the other side of the coin, no matter how meaningful your work is, you still need to make time for R&R, otherwise you’re courting burnout. My work is extremely meaningful, all of it, from doctoring to my Shaklee business to writing this blog. But if I don’t take time to play, I start to get irritable. I even have found myself feeling cynical.

For me, “play” means lots of things. I hang out with my kids and play video games sometimes. I practice martial arts with my family. I have a number of fiber crafts I love: spinning, crochet, knitting. I read novels. I practice my faith. I sing along with the radio and my music selection on my phone (not always well but with great enthusiasm, LOL). I do all these things to balance my incredibly meaningful but at times extremely stressful work.

In chasing the elusive “work-life balance,” it helps to focus on incorporating both meaningful work and joyful play in every day.

QUESTIONS: Two today! How do you play joyfully every day? And can you think of a job that would NOT make someone’s life better? Don’t pick politicians – that’s too easy 😉

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