Can you Really Trust Medical Advice?

Do you trust what medical researchers tell you? Or are you suspicious of their motives? Do money and greed steer the results of research? Or is there some real value in it all? But really, how can you trust what you hear? One time something is good for you, the next time it’s not.

From My Perspective
Trust
Me in my office

Sometimes I just want to express my thoughts without getting all technical and having to do a bunch of research. Not that I’m lazy. Well, not too lazy, anyway. But I really just want t0 open up and say some things on my heart. So with that, allow me to share what I feel are roadblocks to learning.

Wait a minute, you say, I thought this was about trusting medical advice?

It is.

Who can you Trust?

We hear over and over that knowledge is power. And I’ve said that myself many times. But it’s really not quite that simple. There’s more to it than that. For instance, I can tell you the truth about something, but if you don’t trust me, will you believe me?

Think about the last time you heard of some new medical advancement.  Did you instantly take hold of this new knowledge? Because you know that research comes out saying something is bad for you. Then, new research comes out, showing that thing really isn’t so bad. And we can’t say that science has reached the end of all knowledge. So who knows what’s really good and what isn’t?

In addition to all this, information can be worded to make it say what the writer/speaker wants you to hear. You can hear two opposing viewpoints on the same topic; drawing two different conclusions based on how the information was presented.

But something else is preventing you from learning.

Those Thoughts can Kill you

What keeps us from learning something new? Why can it be so hard to get something through to us? It’s not like we want to be stupid. In fact, it’s usually just the opposite. We really want to know stuff. So why, when presented with something new, do we resist this new knowledge?

I can tell you something, but if what I tell you goes against what you firmly think is right, will you believe me? And because we don’t like to be wrong, we can get quite defensive when told we are. That’s why once you do believe something as fact, it can be pretty hard to change the way you see things.

O.K., maybe you’re one of those in search of the truth, and you really keep an open mind. Ya, you’re out there too. But for the rest of us, we can be pretty stubborn when it comes to changing our minds about something.

And, we tend to hear what we want to hear. Therefore, we can subtly re-interpret what we’ve just read or been told, making it say what we want it to say. As a result, we can go through life like that; defending our position with a passion…Because we don’t want to be wrong, right?

So, when you’re confronted with information that goes against what you want to be true, something has to give. And what you want to be true usually won’t easily give way.

However, honest research is going on, and…

You can Trust Established Facts

Medical research is ongoing, and we’re constantly finding better ways to manage all kinds of disorders. And much research is also advancing how we treat sleep apnea. Additionally, new research is built on what’s already been established.

For instance, we know that we need to breathe, and when we don’t we could die. So, treatment for sleep apnea involves holding your airway open so you can breathe. That fact won’t change. And research is ongoing as to what the best way to hold your airway open is. Right now, Continuous Positive Air Pressure, or CPAP  is the ‘gold standard’ for treating sleep apnea. But with more research, new and better ways are in the works.

Also, we’ve also learned that there’s a link between sleep apnea and heart disease. Studies that determine cause and effect have established this link by following patients through the years. And new research is based on this. Therefore, when it comes to sleep apnea, we’re basing treatment on time-tested results.

So while we might not know all there is to know about sleep apnea, we can trust the knowledge we have so far. And treatments will just keep getting better as we continue to learn about this disorder. It’s fun to think about where we’re going to be in the near, and far future.

Conclusion

So, we’ve taken a little look into the issue of trust. And while we know we can’t believe everything we hear, we can trust some things. And to say that knowledge is power is a bit of an oversimplification. We not only need to trust the source of the information, we may need to ‘get past’ certain mindsets that get in the way of learning.

Till next time…Blessings.

How Exercise can Help you Sleep Better

Exercise doesn’t have to be hard in order to gain something from it. You don’t even have to work up a sweat to get the benefit of a better nights sleep. And that’s what this article is all about. I’ll show you some easy exercises that can not only improve your sleep but also reduce both snoring and the severity of sleep apnea. And you don’t need any special equipment. How cool is that?

Sleeping in Space is Better

Astronauts report they sleep better in space. And some studies done on sleep in Earth orbit show an improvement of both obstructive breathing and snoring.

So while being in zero gravity, (or micro-gravity in Earth orbit), has its benefits, it comes with a price. You see, weightlessness does some things to your body that aren’t so nice. These effects include loss of muscle and bone mass; as well as a decrease in strength and endurance. Exposure to weightlessness also increases your risk of Kidney stones.

However, these effects are reversible once you return to Earth. This is because gravity provides the resistance our bodies need to maintain health.

exercise
Astronaut Sleeping on board the International Space Station

Thus, when we’re weightless, we can sleep better, but our bodies deteriorate more quickly. Yet while on Earth, our sleep is worse, but our bodies deteriorate more slowly.

Therefore, zero gravity is ideal for sleep. Yet, while we’re awake and actually doing things, we need gravity; something we can push against, or our bodies weaken. Gravity is good in that it gives our bodies the resistance it needs for health. But at the same time, it causes lower quality sleep; with an increase in the severity of OSA. Too bad we all couldn’t have a zero-G chamber to sleep in.

Anyway, that’s why astronauts need exercise to provide the resistance their bodies need while in space. But even us Earthlings can benefit from a proper workout.

Better Sleep for us Earthlings

We know that we need some resistance just to maintain a semblance of health. But again it’s all about balance, neither too little or too much. Remember, we’re not talking about muscle building exercise here, we just want to improve our sleep. And in that case, not only the type of exercise but the timing of the exercise is important. Not only that, but you don’t need a bunch of fancy equipment. In fact, you can get by without any equipment!

There’s actually a bit of a debate as to the best time of the day to exercise. Some reports say it’s best right after you get up. Although other studies show that people who exercise before going to bed benefit as much as those who worked out right after they woke up. So maybe it’s really based on what works best for you.

Let’s start with a walk. Even a stroll as short as 20 minutes can be beneficial. And if the sun’s out, you can get your daily dose of vitamin D as well. And by the way, a deficiency of vitamin D  leads to osteoporosis, increases your risk of heart disease, and makes you more susceptible to cancer; so it’s kinda good to have enough of that vitamin available.

But walking can also reduce the severity of OSA. Here’s how.

Fluid accumulates in your legs during the day. Then at night, when you lay down, that fluid shifts to your upper body/neck. This makes sleep apnea worse. Lack of exercise encourages the fluid build up in your legs. Therefore, regular brisk walks can reduce the severity of OSA. And the longer and more frequent the walk, the greater reduction in OSA.

However, walks outside, sun or no sun, aren’t always possible. Sometimes the weather just doesn’t co-operate.

Other Types of Exercise

Any physical activity that increases your heart rate is good. But you don’t want to increase your heart rate too much. So if you’re feeling a little more oomph, there’s a target zone you should shoot for. Click here for an interactive target heart rate zone calculator. Some good cardio exercises include: Walking, riding a bike, running, swimming and jumping rope. But if you have an injury, consult your healthcare professional before doing any type of exercise.

Sleep apnea some of your problem? Did you know there are exercises you can do that reduce snoring as well as the severity of obstructive sleep apnea? Let’s look at a couple of these.

Speech Therapy Training strengthens your upper airway. studies show these types of exercises significantly reduce the severity of obstructive sleep apnea.

exercise
Aboriginal man playing a Didgeridoo

You can either get yourself a digeridoo which can effectively strengthen your upper airway. Or you can try the following upper airway strengthening exercises. But be patient, it could take a few months of being consistent before you began to see any results. So hang in there. But, yes, these exercises have been proven to reduce both snoring and the severity of sleep apnea.

Ain’t Gonna Happen

I know how it is, even if you have the energy, and the time, other things can still get in the way. And good intentions alone usually don’t get very far. You need to not only plan to exercise but actually write down specifics. Put it on your calendar. Set realistic goals, and write them down. It’s been proven that people who write down their goals are 80% or more successful than those who don’t.

But what if you really do want to exercise, but just don’t have the energy?

I’m too Exhausted to Exercise

“If I could get more sleep, I’d have more energy, and then, maybe I could exercise.” And really, when you’re truly exhausted, just the thought of any kind of exercise can be overwhelming. Especially if exhaustion has now led to depression.

When people think of exercise or ‘working out’, thoughts of hard physical effort usually come to mind. But as you’ve seen, exercise doesn’t have to be strenuous in order to be beneficial. Remember, we’re not talking about working out to get physically fit, the goal is to get a better nights sleep.

So if nothing else, a good walk on a sunny day can be just what the Doctor ordered. And if you have sleep apnea, you can work on those upper airway muscles at the same time. Weather permitting, of course. But, don’t feel bad, or be hard on yourself if some days you really just can’t do anything, even if the weather’s co-operating.

Conclusion

We’ve seen how exercise can help you not only sleep better but can also reduce snoring and the severity of sleep apnea. We’ve looked at some specific exercises needed for this purpose; as well as how setting goals and writing them down will increase your chance of success.

If you have any exercises you do, or some success story you’d like to share, please leave a comment below.

Till next time…Blessings.

My Wife Always Complains About my Snoring

My wife’s made me aware of my snoring for several months now.

Snoring
Me, chillin’ by our Lilac Bushes

So I’ve finally decided to talk with my Doctor about having a sleep study. Please join me in my journey as I share some personal experiences and other insights.

This then is my story…kind of.

Is it More Than Snoring?

A sharp jab to my side jars me from a sound slumber.

“Kent, you’re snoring!” (It’s never “Honey, you’re snoring”. No, when it’s bad, I’m always on a first name basis). I usually end up mumbling something, turn over, and go back to sleep. There are, however, times when I wake myself up choking or something else that’s quite disturbing.

For example, I travel to different hospitals and occasionally stay at hotels. One time in particular, I was rudely awakened; finding myself totally unable to breathe. I also had a bad burning sensation in my throat and the most horrible taste. I was literally halfway onto my feet before I fully woke up, and ran to the bathroom.

Not being able to breathe was bad enough. But with only a locked door between me and any chance of rescue only made it worse. I did end up catching my breath but also threw up some crud. That only happened once (so far). But more and more I wake with some real thick phlegm stuck in my throat. I can still breathe o.k., but it’s a bit uncomfortable.

My wife’s complaints of my snoring surprised me at first. But now that surprise has turned to concern. And because I’m aware of the dangers of untreated sleep apnea, I began to wonder if I might have fallen victim to this thing. So while I don’t fit the profile of a typical person with obstructive sleep apnea (OSA), that doesn’t automatically rule me out.

But just what does a typical person with sleep apnea look like?

A Typical Sleep Apnea Person

Although the average person with OSA is an overweight middle-aged male, almost anyone can have sleep apnea. In fact, I’d be willing to bet that 100% of the population of planet Earth has moments throughout the night where they stop breathing for a time. So it’s not just a matter of if you stop breathing, but how often do you stop breathing. And how long do you stop breathing for?

As for me, I’m 6 ft. tall (72 inches), and I weigh 180 pounds. That puts my  Body Mass Index (BMI) at 24.4, which is average for a fellow my age (I’m 60). Yet I’m displaying some of the symptoms of OSA.

And my wife has made me aware of my snoring for some time now. Plus, every now and then I do wake myself up choking; though it doesn’t happen often. But, I rarely wake up with a headache, and only score a 3 on a sleepiness questionnaire.

Also, my dad died of a heart attack at 71; although I don’t recall snoring being an issue with him. I’m also not on any prescription medications, and really don’t feel too bad. And even though I spend many hours a night (and day), at a computer, I do try and stay pretty active. For instance, I have a couple road bicycles, and my wife and I like to go for walks as well. But, I figure I should at least get a checkup.

Would you Have a Sleep Study?

I’m trying to imagine what it would be like to not know what happens during a sleep study. What if I wasn’t aware of the dangers of sleep apnea? Would I even have any reasons to talk with my Doctor? I’m not sure, but the following are some things that come to mind:

My wife says my snoring is really bad, and sometimes I breathe really shallow.  I’m tired sometimes, but isn’t everybody? Why should I waste my money on some expensive test, and for what? What if I don’t have this sleep acne, or whatever they call it? And if I do and get this breathing machine, what will that do? Help me sleep better?  I really don’t sleep all that bad now. Oh, I won’t snore, and that’ll make my wife happy. But I could just get some of those breathe right strips and be done with it, no?

The problem with that thinking is that breathe right strips open your nasal passages, and can stop the snoring caused by that. However, they do nothing in the way of holding your airway open. And that’s where the problem is. Besides, CPAP does more than give you a better nights sleep. That’s really just a beneficial side effect. It can literally save your life.

What if it’s More Than Just Snoring?

On the one hand, I hope that I don’t have obstructive sleep apnea. Or should I say sleep apnea that needs to be treated.

You see, there are various degrees of OSA. The severity of sleep apnea is based on a formula we call the AHI scale. This AHI scale stands for Apnea Hypopnea Index. It’s calculated based on the number of times you stop breathing each hour. But we don’t even count every time you stop breathing, only those times you stop for 10 seconds or more.

Also, if your airway is going to collapse, it will after you’ve breathed out. So try this once, breathe out and then stop breathing for at least 10 seconds. This describes apneas. That’s when your airway closes completely. If your airway only partially collapses, we call that a hypopnea.

Now consider that you usually will stop breathing for way more than 10 seconds before waking. And your heart is taking quite a beating during this time. But you’re not going to die from suffocation. Your brain will wake you long before then. However, your heart can only take so much.

So, if I do need CPAP, I’ll be very compliant with treatment. ‘Cause, even though I’m not afraid to die, I don’t want to just yet.

Now What?

So I met with my Doctor yesterday(Friday), and I have some doubts about having sleep apnea. And although he did order a sleep study, we both agreed that it’s not really that much of an issue with me. I think I’d still feel better if I had the test, and at least rule it out. However, I’m going to spend some time looking more into this and see if I really need to go through with it.

I’ll keep you updated.

Conclusion

I’ve shared some of my personal concerns about snoring and sleep apnea. And this has also made me more aware of what a person might be thinking who doesn’t know the dangers of OSA.

Now, what about you? Whether you’ve had a sleep study or not; or even if you suspect you might have sleep apnea, I want to hear your insights. Please leave an appropriate comment or question.

Till next time…Blessings.

How do you Manage Chronic Pain?

Pain is our bodies warning system, alerting us to a problem. But pain can outlive its purpose and become chronic pain. When that happens, it causes even more harm. Let’s see what can be done about that.

Good Pain bad Pain

Short-term, or acute pain, is good pain.  This pain not only draws our Chronic Painattention to a problem, it also protects a damaged area from further harm (more on this later). There’s also long-term or chronic pain. This type of pain has outlived its purpose and is no longer useful. In fact, it now begins to cause its own injuries. But why does pain sometimes persist long after it’s needed?

Let’s explore these things, shall we?

Acute Pain is Your Friend

Imagine life without pain. What would it be like? If you’re suffering from chronic pain, living life pain-free probably sounds pretty good about now. Imagine how it would be to not feel pain…ever. But pain is our bodies warning system, alerting us to a potential problem.

But think about it.

You’re walking along barefoot somewhere, step on something, and slice your foot open. But, you don’t have any pain, so you pay no attention. Then there’s that sunburn, which makes your skin hypersensitive to light and touch. This keeps you from touching that area or exposing it to further light so that it can heal faster.

Or if you dislocate your hip, the pain will (hopefully) keep you from putting weight on it; thus causing more damage. And what about that chest pain that sent you to the hospital. That pain possibly saved your life. Think of the damage caused by not feeling any pain. So then, pain serves an initial purpose.

However, the very pain that saved your life can become your enemy.

Chronic Pain is Your Enemy

So that injury you had a while back is healed, but you’re still in pain. Or maybe some pain just started.  There seems to be no reason for it, but it won’t go away. What causes this?

First of all, chronic pain complaints increase with age.  And there are many causes. For example, just the changes that accompany normal aging can result in joint pain. Yet, on the other hand, older people tend to cope with pain better than younger people. This is due in part to peoples life experiences, and also health expectations in general.

But what damage does chronic pain cause? To begin with, it takes more effort to do daily tasks. Over time, this saps your strength. And that can make social interaction more difficult; as a result, you began to isolate more and more. Now it’s quite natural to become anxious about this. Eventually, depression can set in. However, anxiety and depression increase the sensation of pain; so it takes on a bit of a snowball effect.

But that’s not your only problem

Studies show that chronic pain actually changes your brain chemistry. This leads to memory and concentration problems. But perhaps the damage caused by stress is the most serious. And pain causes stress. And when stress becomes chronic, it causes chronic inflammation. Now you’re vulnerable to a whole bunch of other diseases.

And of course, pain also affects your sleep.

Chronic Pain and Sleep

If you have chronic pain, you’ll also suffer from fatigue and sleepiness. Your memory and quality of life will be reduced as well. The reason it has this effect is at least two-fold. First, chronic pain can cause you to wake up many times at night. But it also changes the amount of time spent in each sleep stage.

This is important because we need to spend a certain amount of time in each sleep stage. For instance, specific hormones are released in stage 3 sleep that help with the growth and restoration of your body. And Rapid Eye Movement (REM) sleep is important for memory consolidation. Additionally, some sleep stages affect your perception of pain.

And while pain causes sleep fragmentation, poor sleep can cause an increase in perceived pain. This starts a vicious cycle. Because the anxiety and depression from pain and lack of sleep increase the feeling of chronic pain.

When Mice Don’t Sleep

When lab animals were deprived of sleep, their body temperature dropped, internal organs shut down, and they died fairly quickly. How does this happen?  One study indicated these mice used up their energy almost twice as fast as other mice that were left to sleep. And because they couldn’t keep up with the energy loss, they died within 32 days!

With humans, hallucinations and paranoia set in long before more serious physical symptoms do. And although no human has been reported to die from sleep deprivation, it still has done some serious harm. Thus the once beneficial pain that alerted you to trouble, has now turned against you and is actually causing damage itself.

So if poor quality sleep leads to increased pain, it follows that getting a good nights rest can reduce pain. But how are you supposed to get some good quality sleep when you can’t even get comfortable?

Let’s look at some treatment options that can help us achieve this.

Treatment Options 

Conventional

A group of medications known as Nonsteroidal Antiinflammatory Drugs are commonly used to treat pain. Some of these are Motrin and Aleve. However, studies now show there are dangers in taking these medications. These risks include:

1-Increased risk of Heart failure.

2-Ulcers and internal bleeding.

3-Kidney failure

4-Serious allergic reactions

5-Dangers to children and teenagers.

Then there’re the narcotics, such as Tylenol with codeine, and Vicodin. However, these not only slow down your breathing but cause you to breathe more shallow as well. And if you already struggle with breathing in your sleep, these medications will only make things worse. Additionally, narcotics also reduce Stage 3 sleep, which is essential for the growth and restoration of your body.

So, whenever possible, treat the cause of the pain, don’t just numb it.

Alternative 

Exercise and other stressors release a chemical in our brains called Endorphins. The word Endorphin comes from 2 Greek words: Endo (from within), and Morpheús (The god of dreams), where we get the word MorphineThis is why physical exercise can make you feel good. Think runners high here.

But physical activity does more than just release endorphins. Additionally, physical activity (exercise) can prevent, or at least delay, pain;  because pain can increase with immobility. So although being too physical can increase pain, lack of physical exercise has the same effect. Therefore balance is the key.

Cognitive Behavior Therapy (CBT) is another interesting thing you might want to check out.

So again, doing things to reduce pain can help you sleep better. And when you sleep better, pain is further reduced. In all this, the real challenge is to allow the good acute pain in, but keep the bad chronic pain out.

Conclusion

Acute pain protects us from further injury. But chronic pain just causes more damage. We need to be able to reduce chronic pain as best we can, while not affecting the benefits of acute pain. If you’ve found something that has helped your chronic pain, please leave a comment. You can help others suffering from this as well.

Till next time…Blessings.

 

Do you Have What it Takes to be a Sleep Technologist?

The life of a sleep technologist is far from boring. Are you one of the many that think we just sit there all night watching you sleep? Think againIn this article, I define what a Sleep Technologist is and does.

What is a Sleep Technologist?Sleep Technologist

I can’t speak for all Sleep Technologists, but when I first heard of this field of study, I was immediately interested. What’s so fascinating about staying up all night watching people sleep, you ask? I have no idea, I don’t do that. Although, it’s amazing how many people think I do.

Let’s clear this misconception up a bit shall we? But before I go into what a Sleep Technologist does, let’s define what one is.

First of all, not just anyone can be a Sleep Technologist. And I don’t think everyone would want to be one! For one thing, we’re up at night and sleep during the day. Also, many of us work alone and spend hours at a computer. Actually, we’re usually working 2 computers at the same time because we routinely test 2 patients each night.

But really, I enjoy working by myself; especially at night when it’s nice and quiet. And by quiet I don’t mean sitting there twiddling my thumbs…that would drive me crazy!

No, a quiet night just means a nice pace where I’m able to keep up with everything. And because not everyone’s the same, what works for one person might not work for someone else. So it’s good to keep ahead of things in case something unexpected happens. Thus, good time management, with an eye for detail, is a must.

And while you’d think it would get boring doing the same thing every night, it’s not at all. That’s because, even though I have the same routine every night, I deal with different people. And it’s the people that make my career most interesting.

Not that everything else isn’t interesting. As one of my patients put it “You have a really cool job!” And while that may be true, they were wrong about one thing. It’s not just a job. I’m helping people live a longer, more enriching life. It’s what I’ve become.

But just what does a Sleep Technologist do?

What Does a Sleep Technologist do?

One of the more frequent comments I get is ‘It must be boring watching people sleep.’ Another question people ask is ‘Did you have to go to school for this?’ It’s tempting to answer that question with, ‘No, I’m smart enough to have figured this out all by myself’. But I don’t. ’cause I’m not.

Of course, people who say such things just don’t understand the complexities of this position. And for the record, we don’t watch you sleep. That would be a silly, boring and quite useless job, no?  However, after I explain what I do, the question usually becomes “How much schooling did it take you to learn all this?”

With that, let’s take a look at some of the things that take place during your sleep study.

Let’s begin with the hookup. There’re a lot of wires attached to you. These sensors measure leg movement, breathing, oxygen levels, heart rate, and brainwaves; as well as muscle tension, eye movement, and snoring. And while I’m hooking you up to all these sensors, I like to explain what I’m doing as I go. I also explain what Obstructive Sleep Apnea, or OSA, is. And this naturally leads to a brief discussion of CPAP.

After you’re hooked up, I have you try on different CPAP masks, just in case I decide to start you on treatment. This not only gets you accustomed to the mask but also helps you relax, as you now know what to expect. Then, during your sleep study, I need to determine if you need CPAP or not. And if I start you on treatment, when to adjust pressure to get you breathing well.

Once I have your study up and running, you’re reduced to a bunch of crisp clear squiggly lines on my computer monitor. All these lines show me what your version of sleep looks like. At that point, I settle into my chair and began the process of helping you live a longer more enriching life…Literally.

But in order to do this, I need to be knowledgeable about a few things.

A Sleep Technologist Does Know Some Stuff

A Sleep Technologist wears many hats. And once we pass a board exam, our ‘official’ title is Registered Polysomnographic Technologist or RPSGT.

Among the many skills we possess are:

♦ Basic EKG interpretation One of the things I record is your heart rate and rhythm. It’s not a full EKG but still gives me a heads up if something isn’t right, that is as long as I know what I’m looking at. Additionally, when I’m at a lab in a hospital, I can always call the charge nurse and get a second opinion on anything questionable.

♦Charting. Accurate assessment of your condition. Knowing what’s significant and what’s not. And with proper spelling and medical terminology (so I don’t look dumb to the Doctor)

♦ Computer skills.

♦ Medical knowledge. Diseases, medicines, medical terminology. I need to know how different diseases affect sleep. Also, medications that are prescribed for these diseases have their own effects on the sleep-wake cycle. All these variables not only affect your sleep but also influence how you respond to CPAP.

♦ Pattern Recognition-When I look at the computer monitor, all I see are a bunch of squiggly lines. But each squiggle means something. And I need to be able to determine whether a squiggle is significant or not. By morning, I’ll have around 900 pages of data recorded on you, so I really need to know what I’m looking at. Therefore, I’m the eyes and ears of the Doctor.

♦ People skills-The hook up process is 1 on 1 time. Not only is that the time to gather information on your medical history. It’s also the time to help you relax and prepare for the night. Interpersonal skills are very important. Especially at this time.

♦ Troubleshooting both equipment and computer. Although I do have access to an on-call person, I need to be able to handle problems as best I can. Of course, experience alone helps there.

We also attend monthly classes that keep us up to speed on the ever-evolving fields of sleep.

Conclusion

I hope this rather brief description of what a Sleep Technologist is and does helps you better understand this complex and highly technical field.

I’m a Sleep Technologist and I love what I do. Helping people live a longer more enriching life is awesome!!

Till next time…Blessings.

There are different ways to qualify for a Sleep Technologist. Our exact titles are Registered Polysomnographic Technologist or RPSGT. And depending on your medical background, there are the various ways you can become one of us.