The difficulty of regulating x-ray radiation in the ER

by WhiteCoat, MD | in Conditions | 19 responses

A recent article in the New England Journal of Medicine touched off another salvo about how non-clinicians have no problems judging the abilities of clinicians in the world of medicine.

The article begins by presenting the case of a woman who awoke with facial paralysis and then went to the emergency department. On arrival, she received CT scans and MRI scans of her brain. When those were normal, she was diagnosed as having Bell’s Palsy. Two weeks later, she developed hair loss and other symptoms and it was found that during her first ED visit, the radiology department mistakenly exposed her to 100 times the normal dose of radiation for a brain CT scan.

She now has a federal class action suit pending against the CT scanner manufacturer and a medical malpractice lawsuit pending against the treating physicians.

The author of this article then uses her own calculations to conclude that the “risk of cancer from a single CT scan could be as high as 1 in 80 — unacceptably high.” The study she cites shows that radiation doses for the same tests vary – as they should. Giving the same dose of radiation to a 90 pound grandma and a 500 pound grandson would result in at least one uninterpretable study. Based on the 4 hospitals they studied, they disputed the risk of cancer being 1 in 2000 from a CT scan and stated that the risk to a 20 year old woman from a single chest CT or single multiphase abdomen and pelvis CT could be as high as 1 in 80.

The paper advocates lessening and standardizing radiation doses for examinations, noting that the improved image quality obtained with higher radiation doses often has no change in clinical outcomes. Diagnostic accuracy would not be affected if the radiation dose were reduced by 50%.

The paper also suggests tracking a patient’s dose of radiation over time and including that measurement in the medical records. Great idea, but how is a radiation dose from someone living in California going to help me when the patient has a potential cervical spine injury in my town while she’s on vacation?

Finally, the author suggests that we need to reduce the number of CT scans being performed. Each year 10% of the population receives a CT scan and 75 million scans are conducted each year – with the rate growing more than 10% annually. At the heart of the increased number of scans is “increasing ownership of machines by nonradiologists” and the resulting “self-referral” which increases the use of the scanners. Those bastard non-radiologists. Only radiologists should be able to self-refer and get away with it.

In general, I think that Dr. Smith-Bindman is on point with her suggestions. It would be great if patients’ total radiation doses could be tracked throughout their lives. However, assuming that could happen, would a high dose of radiation make any difference in determining whether an 80 year old lady with abdominal pain got a CT scan? How about in determining whether a hypotensive unconscious 50 year old trauma victim should undergo CT scanning? What about deciding whether the obese 30 year old complaining of severe difficulty breathing should get a chest CT to rule out a pulmonary embolism?

Can we reduce radiation dose at the sacrifice of less clear scans? That’s a radiologist’s call. Is Dr. Smith-Bindman following her own suggestions? If we missed a small nodule that later became metastatic cancer, would the defense that “at least the patient didn’t get as much radiation” be a sufficient defense in a medical malpractice trial?

The suggestions are good, but they don’t apply to clinical practice.

In addition, while the FDA does regulate “radiation-emitting electronic products” including diagnostic x-ray equipment, telling patients how many diagnostic radiographic studies they may “safely” obtain is likely an area of mission creep for the agency – akin to regulating how many hours of television people may watch in a day (yes, television receivers emit radiation) or how many hours George Hamilton may spend under his radiation-emitting sunlamp. I’m not so sure that having the FDA limit the number of scans a patient can receive is a good thing.

I also take issue with Dr. Smith-Bindman’s statistics that demonstrate greater than a 1% incidence of developing cancer from a single CT scan. If 1 in 80 patients can get cancer from a single CT scan and almost 80 million CT scans are performed every year, each year we are causing close to 1 million cases of cancer in US citizens. According to the American Cancer Society, it is estimated that 1.5 million total cases of cancer will be diagnosed in the US in 2010.

Is our use of CT scans really causing more than half the cases of cancer in the US each year? Even if we cut the incidence in half, causing 500,000 new cases of cancer each year is a hard allegation to substantiate.

While the number of CT scans is allegedly increasing at 10% per year, the number of new cancer cases in the US was 1.22 million in 2000 and is 1.53 million in 2010 – hardly an increase of 10% each year over 10 years. Those increases in new cancer cases also paralleled an increase in the population size – from 281 million in 2000 to 305 million in 2009. On a per capita basis, the incidence of newly diagnosed cancer went from 4.3 per thousand to 5 per thousand during those nine years.

Dr. Bruce Hillman wrote an accompanying article citing how “an unknown but substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care.” As some causes of the unnecessary use of diagnostic imaging he cites patients who “pressure their physicians to refer them for imaging studies even when imaging is unlikely to provide any value.” He also cites defensive medicine, self-referral, medical training programs that ingrain “shotgun” diagnostic testing to confirm diagnoses with the “greatest possible certainty.” He also acknowledges that radiologists also share in the blame for fueling the explosion in diagnostic imaging.

His ideas for changing the system are much more realistic and include tort reform, better physician and medical student education, engagement of radiologists as consultants, and “a change in mindset among physicians.”

I agree with Dr. Hillman on every point except the last one. Physicians have a “mindset” that is created by attorneys and by the public. In most cases, physicians are expected to be perfect or to exhaust all possible testing in finding a diagnosis (I still haven’t had one person who disagrees with me on this point present me with a diagnosis that it is okay to miss). If a diagnosis is missed, the lack of “appropriate” testing that would surely have made the diagnosis is a central theme in the physician’s malpractice trial.

We don’t need to change the physician’s mindset. We need to change the public’s mindset. If less testing is performed, more people will have diseases that won’t be diagnosed … or that won’t be diagnosed early enough. That is an inevitable result of reducing the use of diagnostic radiologic testing.

Will the public and the juries sitting in medical malpractice trials accept this fact? Can we say that a 95% possibility you don’t have a deadly disease or severe injury is “good enough” and non-actionable? Until society makes the commitment to lower the bars over which clinical physicians must jump, the incidence of diagnostic imaging – and all the radiation that accompanies it – will go up and not down.

There were many news articles published about this study, including USA Today and Forbes.com.

I didn’t see any clinical physicians interviewed in these articles – only radiologists. That should be the first clue that something is amiss — news articles with non clinicians commenting on how clinicians should do their jobs. How confident would we be if USA Today encouraged readers to pick up the paper next week when USA Today will have chemical engineers commenting on how mechanical engineers should stress test products more thoroughly? Hey – they’re both engineers, right?

The money quote from Dr. Hillman in a Reuters article really irked me, though: “We need to convince physicians that a quest for certainty is impossible, costly and is harmful because of indirect diagnoses.”

If radiologists are so certain that diagnostic imaging doesn’t need to be done, then cancel the test. That’s right. You think a test is a prospective waste of radiation? Refuse to perform it. Right now, you’re talking the talk, but you’re doing a face plant on the concrete when you try to walk the walk.

How about this: When the dumb ER doc orders the next total body scan, walk over to the emergency department, examine the patient, and come up with your own diagnosis without using your deadly CT scanner. Get rid of your hindsight bias and make a prospective diagnosis without having the benefit of a “normal” diagnostic test sitting on the computer screen in front of you.

Isn’t as easy as your little news sound bites make it seem, is it?

Want to regulate something to really stop the flow of radiation into patients? How about making the American College of Radiology start regulating the number of diagnostic radiology reports from their members that contain phrases such as “cannot rule out underlying lesion, recommend CT scan for comparison,” and then “CT scan non-diagnostic, recommend bone scan for further clarification”. We could cut down on costs if radiologists would stop recommending “MRI for clinical correlation,” also.

I’m betting that we won’t see too many sound bites about the implications from this radiology report lingo hitting the headlines any time soon.

WhiteCoat is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

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Comments

http://drpauldorio.com Paul Dorio
Ah, Dr Whitecoat. I feel like the Highlander, when he says “My old friend Ramirez…”
Anyway, you had such a nice discussion of the holes in Dr Smith-Bindman’s NEJM article. I agreed with most of your thoughts and was amused by your exposure of the faultiness of the “1 in 80″ cancer risk, when clearly CT scans have not caused 1/80 of 80 million cancers.
But, then you launch into the anti-radiology salvo with your comments about Bruce Hillman. You state: “[Bruce Hillman's] ideas for changing the system are much more realistic and include tort reform, better physician and medical student education, engagement of radiologists as consultants, and ‘a change in mindset among physicians.’”
That’s the positive-sounding comment. Afterward, you lambast the radiology specialty, citing various topics of obvious rancor, and essentially telling the world that all radiologists should just zip it and stick to their own little area of medicine.
Now, I like the part about “engagement of radiologists as consultants.” And, as a radiologist, I think that I could offer some assistance when it comes to what kind of scan and when to get it. But, in the very next breath, essentially, you state: “If radiologists are so certain that diagnostic imaging doesn’t need to be done, then cancel the test. That’s right. You think a test is a prospective waste of radiation? Refuse to perform it. Right now, you’re talking the talk, but you’re doing a face plant on the concrete when you try to walk the walk.” Not a very neighborly sentiment, eh?
I agree with your implication that radiologists should be a bit more circumspect with their criticisms of their ER colleagues. But nasty “tone” aside, I think that the adversarial mentality of various medical specialties is precisely one of the big things that is wrong with our current health care system. Maybe when bundled payments become a reality, doctors from the various medical specialties will be forced to take stock of one another’s expertise and put aside the criticisms. In my opinion, I think it is obvious that ER docs and radiologists work together and rely on each other. I act that way every day. Of course, it is easy to look at a negative series of CTs of the head, neck, chest, abdomen AND pelvis on the same person, with a history of trauma, and wonder what kind of trauma it was and whether the scans were totally necessary. Even in retrospect. That a series of scans were entirely normal does not mean they were not indicated. I’ll grant you that. But from our perspective, it is difficult to try to refute the general radiation-related comments of people like Dr Smith-Bindman when you’ve just read those normal studies.
I would ask that each physician try to show a little bit more respect to his/her colleagues in different specialties. We all have something to offer.
Bottom line:
1- ALL specialties can use some introspection and review on an ongoing basis. To think otherwise is dangerous hubris.
2- Radiation is an inherent aspect of CT imaging and every physician needs to respect that fact. Consulting with your fellow radiologists on a more frequent basis may help to make the public understand that all doctors care about their patients, even and especially those of us who happen to be radiologists.
Rusty
Dr. Whitecoat,
At the beginning of your comment you seemed calm and rational but as I read along your anger and resentment becomes more evident with each paragraph. You clearly have issues with the radiologists at your hospital. Please remember that they too feel the need to perform defensive medicine. Just as the ER doc is worried about the atypical presentation of an intracranial bleed or PE, the radiologist is worried about that little nodule in the lower lobe developing into a carcinoma.
You say that the radiologist should just not do the exam or cancel it if he thinks it’s unnecesary but that too is easier said than done. If the ordering physician feels that he needs the exam or wants it the only thing that will result from a radiologist canceling the exam is a meeting with a hospital administrator to address the complaint that the radiologist is uncooperative and interfering with patient care. I’ve seen it happen.
I do understand how the wording in some radiology reports essentialy forces a clinician to order additional exams. Part of the reason behind that is there are documented lawsuits against radiologists because the report did not state that an additional study should have been done. Every physician knows that when the lawyer comes knocking fingers start pointing. The bottom line is no one wants to miss something, be wrong or be sued.
http://www.drfenyves.com Paul Fenyves
I’d like to echo the other Paul’s point about introspection. While I do agree with many of your points, the overall tenor of the argument is so defensive, it suggests that there is no room for clinicians to take a step back, examine their practices, and determine if ALL of their scans are truely necessary. Yes the NEJM article certainly exaggerated the cancer risk of CT scans, but the risk is definitely not zero. I do think there would be utility to tracking a patient’s cumulative radiation exposure. No, it wouldn’t change my practice if I thought a patient had a fair chance of having appendicitis. But sometimes I (like most other physicians) find myself sitting on a fence… knowing a patient’s past radiation exposure might push me one way. Also, if the patient is aware of their cumulative risk, they might help you make the decision, by asking for watchful waiting.
http://drpauldorio.com Paul Dorio
Thx Paul.
And I particularly like that last part: “Also, if the patient is aware of their cumulative risk, they might help you make the decision, by asking for watchful waiting.”
In today’s e-patient world, ongoing current discussions revolve around communications between doctors and patients. Everyone who discusses lawsuits says similar things also: the risk of a lawsuit is decreased as the quality and frequency of communication increases. Clearly, many patients want to be included in the decision-making process. And not every patient wants all imaging no matter what.
Thanks for making that point.
http://www.epmonthly.com/whitecoat WhiteCoat
Dr. Dorio, you and I agree on just about everything. And I also agree with Dr. Hillman, but, as I clearly explained, the mindset of the patient needs to change before we work on the mindsets of the physicians.
I don’t think that bundled payments will change anything. Rather, my prediction is that the whole “bundled payment” model will be an expensive and collosal failure. Look at how well capitation worked with HMO panels.
Your admitted retrospective bias when reading a normal total body scan really proves my point. You see a “waste” of several thousand dollars. The trauma team that ordered the scans see someone with blood from every body orifice who just wrapped their car around a tree. Again, if you question the utility of the tests from a remote location, you need to walk over to the ED, evaluate the patient, and accept the liabilty that comes with not ordering a test. I’m sure the trauma team wouldn’t mind signing over a patient to your care for discharge without wasteful radiologic testing.
Dr. Rusty, I actually get along very well with the radiologists in our hospital. That is what troubles me about the holier than thou comments I see coming from other radiologists. One of the points in my post was that it is rather ironic that a radiologist would berate a clinician for practicing defensive medicine in one breath and in the next breath recommend further defensive testing in a radiology report.
If you faxed a report to the ED saying that a test was canceled and that you accept full responsibility for any liability attached to doing so, I don’t think you’d get much push back from the ED physicians. Are you willing to do that?
Dr. Fenyves, you misunderstood my argument. I think introspection is an important part of medical practice. But I also realize that certain physicians have higher risk tolerance than others. It’s like the old George Carlin line – everyone that drives slower than you is an idiot and everyone that drives faster than you is a maniac. If docs don’t order enough tests, they’re cowboys and malpractice risks. If they order too many tests, they’re poor clinicians. I would love it if radiologists would show some prospective radiologic studies to back up their retrospective assertions that radiographic studies aren’t needed. That’s not what the NEJM article did. Instead, the NEJM article encouraged “introspection” based on the retrospective assertion that there are too many radiographic studies being performed. My point is that you should walk a few miles in someone’s shoes before you criticize their thought processes.
The whole shared decisionmaking model is a warm fuzzy concept that I generally agree with, but unless you disclose all the risks of not performing a test, you can still be on the hook even if a patient agrees to “watchfully wait.” Just ask Dr. Daniel Merenstein.
http://overlawyered.com/2004/08/update-commentary-on-merenstein-lawsuit/
http://www.kevinmd.com/blog/2010/03/psa-screening-prostate-cancer-continue.html
Finn
As a patient who’s had already had 3 pelvic & abdominal CT scans for ovarian cancer & is genetically at increased risk for pancreatic and other cancers, I can tell you that if a doctor recommends another pelvic and/or abdominal CT scan, my first question is going to be “Is there another way you can get the information you need without exposing me to so much radiation?” If not, so be it.
Also, it seems that the author of the NEJM article failed to address what I think is the real issue in the anecdote–the massive overdose of radiation delivered during the scan, which suggests equipment malfunction, calibration failure, or operator error–and went traipsing off on a tangent about unnecessary scans.
bev M.D.
As a pathologist, and therefore decidedly neutral observer, I also think this post is defensive and fails to exhibit any introspection. The author cherry picks every instance of when a CT scan may be necessary and fails to acknowledge that many CT scans are, in fact,not necessary – such as the ones my mother received of her brain for r/o stroke in an ER, solely because the medical records from her recent previous one were not available.
I agree with the radiologists that clinicians need to be more respectful of so called ‘non clinicians’. The author’s comments betray a lack of respect that is, frankly, passe. Time to get over it and start acting like a doctor, please.

http://www.epmonthly.com/whitecoat WhiteCoat
Interesting how different people have different perspectives using the same fact pattern.
What I see from your comment is someone who has an axe to grind because she was upset that her mother received an “unnecessary” CT scan when her mother went to the emergency department with some type of neurologic deficit or complaint of weakness.
Again, we have a non-clinician criticizing the decisions of someone in clinical practice. Like me criticizing you because you called something a burr cell when I didn’t think it really was a burr cell.
If you were so sure that your mother wasn’t having a stroke, why did you allow her to go to the emergency department? Why did you allow them to perform the CT scan?
I’m sure that if the doctor didn’t do a scan and missed a stroke you’d be the same one condemning him for not performing the scan.
I certainly don’t think every radiographic study that is performed has a rational medical basis, but I also accept the fact that different physicians practice medicine in different ways and have different tolerances for risk.
In the emergency department, we don’t have the luxury of presenting slides during a grand rounds before coming up with a final diagnosis on difficult cases, do we?

anonymous
Whether CT scans are necessary is only one of the issues here. The bigger issue, IMO, is the lack of safety checks and balances on CT scanning software, dose computation and the competence of the technologists, as well as the design of the equipment and software itself.
Even when every CT scan you order is clinically necessary, you can still be tripped up by all these mechanical factors. The news story to which you refer is essentially about a patient receiving an overdose. The radiation studies to which you refer were based on computer modeling, not actual late-effect cases of cancer due to medical radiation exposure.
I don’t think it’s necessarily bad that these issues are coming to the fore. The average person does not think about the risk. Medical imaging equipment has become exceedingly complex and I’m not sure that safety oversights and staff competence have kept up. What we need is a rational approach to how we use this technology, and I’m not sure that angry pontificating is going to accomplish this.
Rusty
Dr. Whitecoat,
In your reply you state, “My point is that you should walk a few miles in someone’s shoes before you criticize their thought processes.” I completely agree with this but it should go both ways. By trying to understand another’s point of view we can all learn something that might help us improve the way we practice. This means that clincians can learn from “non clinicians” and vice versa. Your tirade against radiologists and “non clinicians” in your original comment was just as inappropriate as the comments made by the people that you were refering to that got you all fired up in the first place. What do the radiologists at your hospital think about what you have written?

http://www.epmonthly.com/whitecoat WhiteCoat
First, you’ll note that my “tirade” agreed with most of the NEJM article and only disagreed with a few premises.
My “tirade” began by disagreeing with the number of patients who contract cancer from CT scans. My “tirade” continued with the presumption that it is inappropriate for non-clinicians to berate clinicians in the media and to hold themselves out as authorities for issues that the non-clinicians have never dealt with.
Then my “tirade” showed how those who criticize others for practicing defensive medicine are just as guilty of the practice as those they criticize.
If exposing these ironies are a “tirade”, then I am guilty as charged.
Perhaps you would prefer we just kept the whole defensive radiology reports thing a little dark secret?
As for what the radiologists at my hospital think … we have a very good working relationship. They call me for clinical findings before giving me a report and I call them to see what test they think would be best to look for certain pathology. In most cases, we are in phone contact multiple times during an average ED shift. If they question whether or not a test would be appropriate, they pick up the phone and ask me about it. Often their questions involve a previous test for the same problem that I was not aware existed. Maybe I’ll ask a patient if they had any surgeries, the patient will deny it to me, but then will ask the radiology tech why I’m ultrasounding her appendix when her appendix was taken out. The radiologist will ask me if I still want the test. And I’ll thank them for helping me.
Amazing what can happen with a little communication over the phone rather than through a NEJM article.

Thirdparty
Dr. Whitecoat certainly has valid points as do others in this discussion. What I think people have a hard time with is the tone that Dr. Whitecoat seems to use in his replies. There is a lot of anger coming across and that’s what people are reacting too. Let’s all calm down and have a civil discussion. If neither side is willing to listen to the concerns of the other then this discussion will go nowhere.

http://drpauldorio.com Paul Dorio
Actually, I think this stream of comments has been quite useful and interesting. So Dr W has a bit of rancor here and there. He’ll get over it. And the rest of us might learn something from his points, as hopefully he and others can learn from the comments offered. I think I know where he’s coming from.

http://drpauldorio.com Paul Dorio
Reasonable response, Dr W. I gotta agree here:
“I don’t think that bundled payments will change anything. Rather, my prediction is that the whole “bundled payment” model will be an expensive and collosal failure. Look at how well capitation worked with HMO panels.” — I COMPLETELY AGREE!!!
And you’re right: questioning the utility of a CT scan from a remote location is best done privately and with no one else listening.
One last thought though – ALL physicians need to continue to work together to care for our patients to the best of our collective abilities. (Not that that is in dispute/discussion here. Just thought I’d throw it in)
Good response btw.
http://drpauldorio.com Paul Dorio
Whitecoat, my friend, you made two recent replies that I think belie a certain animosity towards “non-clinicians,” regardless of your “good working relationship” with your radiologists.
I, too, have a good working relationship with, in my case, the ED physicians. In fact, they are some of my favorite docs. We rads and ERs can get to a spot in medicine where we feel like brethren. We basically deal with the same issues over and over together.
But here’s the thing I would ask:
You say you rely on your rads a bit and they help you out with certain things – like the appendix example – happens all the time! So, why not acknowledge the fact that the ER experience for patients, ER docs, radiologists, and everyone else, is enhanced by our cooperative efforts. We should be celebrating our specialty differences, rather than complaining that non-clinicians should close their traps and just read films. And radiologists, you’ve shown me, should be a bit more circumspect before complaining about the reasons for obtaining this or that scan.
I also remind you that being a non-clinician does not mean that a radiologist doesn’t know squat about patients, symptoms, ailments, etc. In fact, the radiologist you are talking to may be an interventionalist who happens to run his own clinic. Or he may have been tops in his class and continues to excel at clinical diagnoses. It’s at least a reminder that we all have something to add (hopefully) and to respect our similarities and differences. Not just you, but everyone should do that – patients included.
You don’t have to touch and commune with every patient to have great clinical acumen. Why else would the art of physical examination have waned over the last twenty years!

http://www.epmonthly.com/whitecoat WhiteCoat
We’re on the same page, Doc.
Working collaboratively is the way to practice medicine. The published article – which I believe overstates some conclusions and which provides no basis for other conclusions – while also throwing under the bus those specialties who order “unnecessary” testing – is not an exercise in collaboration. What do
The fact that I read my own x-rays and CT scans or the fact that I look at some peripheral smears under the microscope in the lab doesn’t make me a radiologist or a pathologist any more than a radiologist’s or pathologist’s tangential involvement with clinical care and physical diagnosis makes them clinicians.
The docs writing the article wouldn’t be qualified to testify in court about whether a clinician was negligent for missing a diagnosis based upon physical findings, so why do they suddenly become authorities on the standard of care for how radiographic testing should be utilized (or not utilized) in clinical diagnosis — just by virtue of a paper published in NEJM?
Sorry, but we’re going to have to agree to disagree on that point.
I won’t muck up Kevin’s comment section with more rancor. Thanks to everyone for participating in the discussion.

Dr Coughin’
Yon anonymous clinician here. In my pulmonary role I am routinely second-interpreting chest films on our patients we screen and follow. I’m certainly not doing every scan the rad read indicates, or even the majority the read suggests, because I’m making the clinical judgment that in my experience this nodule is well calcified, or that’s a nipple-not-a-nodule, or a followup film or an apical lordotic would be a better choice than a chest CT.
Certainly in the ER there are different concerns to bear and radiologists ultimately bear responsibility when they blow a call. From a clinician view, however, I think we are better served making a gestalt assessment rather than relying on what may be a decision informed by incomplete history and no exam. And, yes, read a few of your own films you order. I don’t agree with every read, and many radiologists don’t agree with each other. It’s a tool in diagnosis, not a diagnostic end in itself.

http://drpauldorio.com Paul Dorio
YES, Dr Coughin’
Very nice comment. I wish more docs would appreciate the fact that radiologists make “recommendations” and “suggestions.” You don’t have to follow our “advice given from within a vacuum.” My philosophy, though happily not legally tested, is that proper documentation will explain any differences of opinion in the medical record, especially when those differences have the benefit of a clinician’s first-hand knowledge of the patient. For this reason, I will always say something like “…may be helpful if felt to be clinically appropriate.”
I suppose they could teach radiology residents the proper way to hedge. But with as many doctors as there are… how can we ever get one opinion to be the standard?

richard scott
Good discussions I have been pushing in our hospital to start more rational approach to the use of radiation for the last six years. Not much interest. Collegial discussions and consultations between specialists would be a big help. The young docs have been taught a ct scan is a necessary tool for most problems…sometimes patients can have dozens in a year. As health care providers we need to teach ourselves to protect us and our assistants in the operating room, at the bedside, wear lead, keep records of exposures and discuss the relevance and need of special imaging before sending the patient off on a gurney.

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