Lynton Scholar Catherine Wolff, MS, Reflects on the SEM Consensus Conference, September 2017

The Walls of Medicine

In September, a group of incredibly accomplished, kind, thoughtful, and inspiring emergency medicine physicians gathered to start the process of defining a new focus within emergency medicine: social emergency medicine. Many of those present had been fighting for years to achieve some sort of momentum around their passionate belief that emergency medicine must both acknowledge and address the social context within which patients live in order to provide them the care they need. Health is influenced by factors at all levels, from geopolitical to microscopic. At some point in the evolution of healthcare in our country, lines were drawn to define which of these factors fell within the domain of “medicine”, and therefore were the responsibility of healthcare providers to address. These boundaries favored things that could be isolated and studied in laboratories, and interventions that could be completed on a timescale ranging from minutes to hours. Any factor influencing health outside of those boundaries, such as poverty, structural racism, or violence, was considered to be primarily a societal issue, not a health issue.

The problem with this compartmentalization is that what falls within the traditional definition of medicine is limited in its potential impact; as few as 10-15% of deaths could be prevented with better medical care.1 On the other hand, around a third of all deaths are attributable to social factors.2 Their impact on health is even greater when one considers that social determinants may influence behaviors that account for another third of all deaths.2 Patients aren’t the only ones harmed by this myopic focus; the difficulty associated with treating patients significantly burdened by social issues can contribute to burnout, which affects more than half of all emergency physicians.3

These walls around what constitutes “medicine” are socially constructed, and it is long past time to rethink where we put them, for the good of patients, providers, and society at large. September’s Inventing Social Emergency Medicine consensus conference was an embodiment of the momentum generated by the tireless efforts of those pushing back against the walls of medicine. It also served as a significant moment within the specialty of emergency medicine; the creation of a community where those interested in thinking more broadly about how emergency medicine can improve patient health could turn to find support and collaboration. While the first conference of its kind, it felt somewhat like a homecoming; there was a spirit of welcoming and excitement infusing the proceedings. One speaker commented that he’d never before been part of a conference where kindness was such a prominent feature.

In the time since the conference I’ve found the mere existence of this community, and my exposure to it through the generosity of the Lynton family, to be incredibly fortifying. As a MD/PhD student at Duke and UNC I’m fortunate to be receiving some of the best clinical and epidemiological training available, but I don’t often encounter those in either institution who share my particular blend of interests. More than once I’ve struggled to explain how public health, social epidemiology, and health policy fit with emergency medicine, and why I’m so committed to focusing on upstream causes of disease, even though I’m not going into primary care. Knowing that there’s a community of smart, passionate emergency physicians who share these interests is welcome and much-needed validation and motivation as I push through my dissertation and final year of medical school. I’m excited to see how this incredible group of people changes emergency medicine to better serve our patients and communities, and I’m eagerly looking forward to joining them.

  1. McGinnis, J. M., Williams-Russo, P., & Knickman, J. R. (2002). The case for more active policy attention to health promotion. Health Affairs, 21(2), 78-93.
  2. Galea, S., Tracy, M., Hoggatt, K. J., DiMaggio, C., & Karpati, A. (2011). Estimated deaths attributable to social factors in the United States. American Journal of Public Health, 101(8), 1456-1465.
  3. Peckham, C., & Grisham, S. (2017). Medscape lifestyle report 2017: Race and ethnicity, bias and burnout. Available at: https://www.medscape.com/features/slideshow/lifestyle/2017/overview. (Accessed October 26, 2017).

Lynton Scholar Austin Kilaru, MD, Reflects on the SEM Consensus Conference, September 2017

A week after returning from Dallas, I had lunch with my fellow fourth year residents. They are all compassionate, fierce advocates for patients, and without hesitation they support the principles of social emergency medicine. It would be difficult to not do so after training at our under-resourced county hospital. Yet they expressed valid skepticism for the implications of social EM in their practice. As grizzled senior residents, they have met frustration in trying to help patients with bleak housing situations or severe substance abuse disorder. They also have seen how fast and loose the practice of emergency medicine can be in the community. They did not doubt that social determinants of health were the key driver of patient outcomes, but they felt a lack of empowerment to recognize and intervene on those social determinants during a Tuesday night shift.

Empowerment is the key word that I reflect on even months after the Inventing Social Emergency Medicine conference. I believe that all emergency physicians want to practice social emergency medicine. But they need the tools to do so. And the tools have to meet the demands of our daily practice.

I was surprised with the outward-facing nature of the discussion in Dallas. The participants were a select group of researchers and community leaders with whom I was honored to even share the same room. Yet they recognized the need to make social EM relevant and vital to all emergency departments and providers.

How can we empower physicians and nurses to screen for social determinants of health? How can we help them help patients? I now believe this to be the central research and policy question in social EM, for whatever domain you might consider: housing, substance abuse, intimate partner violence, healthcare access.

Part of the conference discussion centered on the idea that to practice good emergency medicine was to practice social emergency medicine. None of us can adequately treat back pain if we do not ask whether patients use injection drugs. None of us can discharge a patient with pneumonia if there is no way for them to fill a prescription for antibiotics. These are the questions that we should be asking, and for the most part, many of us are.

Yet we can and should extend our work beyond screening and addressing acute illness. We should be able to initiate substance abuse treatment for the patient with back pain when their MRI is negative. We should be ale to find a medical respite or medication assistance to the patient with pneumonia and avoid a costly and preventable hospital admission. For this next level, we cannot expect emergency physicians to invent these solutions on the fly – there are twenty patients in the waiting room and a line of ambulances waiting for triage. These solutions must be developed outside of the shift. We should empower champions to engage in this work, making this part of the central administrative and quality efforts of every emergency department.

Another thread of the conference discussion focused on the need for both local and structural responses for social EM. Local solutions are needed for local problems, finding housing options, obtaining access to mental health resources, or developing programs for complex care management. One of the key strategies should be to find community partners and resources that already exist, and to integrate the work of the ED more fully into the community.

At the same time, there are larger policy and regulatory interventions that can drive and sustain these efforts. Policymakers, regulators, insurers, public health advocates – they can set expectations for every emergency department, whether urban, rural, county, private, or academic. We can enlist JCAHO and CMS to make sure every ED provides social work and case management, makes policies to screen for social determinants of health, and provides solutions to common patient problems. EMTALA, in some ways, was the first and most consequential policy to address social emergency medicine – we now have to deliver on its initial promise and truly provide people with the stabilizing care that they need. The role of research should be to find evidence-based, effective interventions that allow the development of policies and system changes.

My fellow fourth year residents are ready to embark on careers in emergency medicine, and we are all headed in different directions. One thing that unites us is the motivation to do our best for our patients. The promise of social emergency medicine is to make our best even better. Ultimately, empowerment does not just benefit our patients – we will have more rewarding careers, face less frustration and burn-out, and stay true to our original vision for becoming physicians.

Lynton Scholar Theresa Cheng, MD, Reflects on the SEM Consensus Conference, September 2017

The local Emergency Department (ED) is a microcosm of its surrounding communities and the social determinants of health impacting residents’ abilities to pursue individual wellbeing. As our societal safety net, EDs – and the providers within – are in a unique position to address medical and social emergencies. Emergency physicians are given the opportunity to intervene on behalf of patients as advocates of essential medical and social needs. Social Emergency Medicine (SEM) is a timely and increasingly necessary field as the future of our healthcare system is becoming more uncertain and more patients find themselves seeking the ED as a last resort. Institutionalizing SEM through the consensus conference “Inventing Social Emergency Medicine” formally establishes the field, providing context and space from which EM providers may work. As a Lynton Scholar, I was privy to this roundtable discussion that assembled leaders of the field, from experienced forebears of Emergency Medicine to current trailblazers in SEM research. While participants presented distinct research on topics such as homelessness and community violence, the common goal of health equity was palpable throughout – the conference was a chance to define, mediate, and enhance the interplay between medicine and social justice that naturally exists in the ED. Central to our discussions was the recognition of the need to expand the ED’s role in incorporating population-based health research and interventions while leveraging already-established resources in local communities. Stronger ties with fellow providers, such as social workers and nurse practitioners, would bolster our abilities to address social needs in the ED; meanwhile, connecting with unexpected allies, such as lawyers and anthropologists, would innovate the way we deliver this care. By integrating social structural analyses to medical and public health curricula, we would be providing future generations of health professionals with the lenses to identify, treat, and ultimately prevent social determinants leading to disease. The need for SEM, as reflected in the realities of many of the patients we encounter in the ED, extends beyond the moral imperative as this pragmatic approach can help to reduce ED recidivism and overall healthcare costs. By identifying and addressing our patients’ unmet social needs, we seek to disrupt the multi-faceted causes of their illness and improve the overall health trajectory. Through “Inventing Social Emergency Medicine” and future such collaborations and conferences, SEM has become not just a doctrine within medicine, but a way of practice and a way forward in advancing health justice.

Post Script: I am extremely grateful for the Lynton Scholarship that allowed me to take part in the inaugural conference of social emergency medicine. Many thanks to the family of Jamie and Michael Lynton as well as the Andrew Levitt Center for Social Emergency Medicine for this momentous opportunity.

Lynton Scholar Petrina Craine, MD, Reflects on the SEM Consensus Conference, September 2017

“Order groceries. Check.” “Schedule oil change. Check.” “Lead the charge in addressing social determinants of health. Uhhh…”

These are the thoughts spiraling in my head as I reflected over the inspiring and stimulating conversations about social emergency medicine at our consensus conference. A great feat had already been achieved in bringing together EM leaders from various sectors of healthcare to form a body of “movers and shakers” that could rival any think tank in our nation’s capital. Beaming like the sun from my interactions, I could not help but discuss the role of emergency medicine, in leading the dynamics on social issues integral to health, to anyone who would listen. Yet in my conversations, I was surprised how I was met with some negative feedback from other medicine colleagues who adamantly stated that the role of emergency medicine is to diagnose and treat emergencies and not “dabble” in social issues.

Indeed, we are experts in medical emergencies, such as differentiating a heart attack from heartburn, but what about social emergencies? Headlines such as “Insurance Companies Disagree with Your ER Visit and Refuse to Pay,” “Eleven Killed from Shootings over the Weekend,” and “Housing Crisis and the Surge in Homelessness” bombard our news feeds each day. But what many, including other medical specialties, do not realize is that these same issues bomb our emergency departments daily. We serve on the frontlines of these issues. We see and care for the victims of gun violence, homelessness, and poor-to-no insurance. Just as it is our duty to medically screen any patient presenting to the emergency department, it is our duty to lead the charge in not only sounding the alarm on social issues essential to patients’ medical diagnoses and overall treatment, but also to devise solutions. We do not dabble in these issues. To the contrary, we immerse ourselves in these issues. As a specialty, our core is rooted in our ability to readily do what is necessary in times of crisis for our patients. The social determinants of health have hit a fever pitch and we are compelled to address this emergency. Our conversations over the last few days are just the sparks needed to ignite our future efforts. Thus, I can confidently muse over my internal dialogue and think “Lead the charge in addressing social determinants of health. Check.”

A Skeptic’s Guide to Social Emergency Medicine

Most of us of a certain age have our favorite Sesame Street character. Mine? Oscar. That grumpy old green guy. Oscar sticks his head up out of his trashcan whenever something new is happening on the block and renders his assessment which is generally something fairly snarky. I identify with the green fella. (This will come as no surprise to the EM residents in our ED.) I prefer to think that beneath that mussed up hair and those big brown eyebrows lives a gimlet-eyed observer, one who generally ignores Big Bird’s cheerleading and prefers to make his own assessment of the Cookie Monster’s latest antics. Maybe the reason I’ve always liked Oscar best – I’ll admit it – is because he continually invokes that most critical yardstick, “What’s in it for me?”

If I’m Oscar, and the Emergency Department is my street, then any dreaded “new ED initiative” is what gets me to stick my grumpy head up out of the trashcan. And “What’s in it for me?” can be restated as “How much are my patients really going to benefit from this?” and “At what cost, in terms of additional work, for yours truly?” How many more forms and phone calls are required? We old timers find ourselves overwhelmed most of the time as it is. Just figuring out what’s wrong with our patients, and managing them correctly, is challenging enough. It’s a zero sum game here. Either I attend to this new initiative, or that one, or I spend a few extra minutes with my patient, but I can only do one of those things.

Now comes Social Emergency Medicine, and up pops my trash can lid. What are the do-gooders going to ask me to do now? Public health screening? Help desks? So nebulous. What does it all mean? It sounds like more work for me. How will this benefit my patients today? Am I right? People, am I right?!

Well, guess what? This old Oscar is now a believer, and I’m here to help all you other Oscars out there understand why. The concept of Social Emergency Medicine encompasses an almost infinite number of potential initiatives. But I can say first-hand, based on what’s been done in our ED, that several of them are actually pretty easy to get one’s head around. And, when executed well, they can provide rapid, concrete, clinical benefits for patients with minimal extra work for busy emergency physicians. Here’s my top four list:

  1. ED help desks
  2. Buprenorphine for opioid misuse
  3. HIV and hepatitis C screening
  4. Health coaches in the ED

Let’s start at the top. Here is the skeptic’s guide to what are known as “ED Help Desks.”

At the heart of Social Emergency Medicine is the notion that there is a set of all-important, yet often under-recognized, “social determinants of health” – things such as housing, food and financial insecurity, legal entanglements – which all too frequently are the real reason patients come to the ED. At a safety net hospital such as mine, the expectation that our heroic but harried ED social workers will be able to tackle most of these problems is not realistic.

Enter the ED help desk. In its classic form, a help desk is just that, a desk, located just outside the ED or clinic, staffed by volunteers, often undergraduates, overseen by social workers and lawyers, who sit ready to assist patients in addressing these social determinants of health. Volunteers provide a variety of services including helping patients apply for food stamps and paratransit, finding affordable childcare or legal services to prevent an eviction, and paying utility bills. The help desk is perhaps the purest expression of what social emergency medicine is all about.

The idea of the help desk, and using college student volunteers, originated in Boston in the late 1990’s, with Rebecca Onie and Health Leads. The aim of Health Leads, which now offers proprietary consulting services (in essence, ready-made help desk solutions), is to “operationalize equity” and “create sustainable, high-impact and cost-effective social needs interventions that connect patients to the community-based resources they need to be healthy.”

The help desk origin story at our ED goes like this. One day in 2012, a patient arrived on a psychiatric hold, restrained and hysterical, after melting down in the housing authority lobby and threatening to kill herself if her Section 8 housing voucher was taken away. As luck would have it, her ED provider that day was second year resident, Dennis Hsieh. Dennis happened to be a law school graduate and already an expert on medical-legal partnerships to assist the underserved. As the story goes, Dr. Hsieh walked back out of the patient’s room after a few minutes. “That woman doesn’t need a psychiatrist,” he fumed, “She needs a lawyer!” Dr. Hsieh and Dr. Harrison Alter went on to start the ED help desk, called Highland Health Advocates, at our hospital.

Like the other Social Emergency Medicine initiatives on my list, a help desk needs champions, and an investment of resources. Fortunately, the challenge of addressing social determinants of health is not unique to emergency medicine. It is a challenge, and frustration, shared by physicians in many specialties, and their social work colleagues, in every medical center that works primarily with underserved patient populations. These medical centers, through their departments of family practice, pediatrics, geriatrics, etc, can marshal and share resources to create help desks at their individual sites. There are now help desks located at Stanford Medical Center, San Francisco General Hospital and the UCSF Benioff Children’s Hospital pediatric ED. There is even a Bay Area Regional Help Desk Consortium to foster a regional approach, help with implementation, and share lessons learned.

To ED doctors, the idea of a help desk may seem like something more suited to a primary care clinic, the patient’s medical home. Yet we all know that, for many of our patients, the ED is the only point of contact with the healthcare system. If we don’t link them with the services provided by a help desk, it will never happen. And, when the help desk succeeds, say by obtaining a paratransit pass for your disabled patient, it increases the chances that that patient can, and actually will, make it to their primary care appointment. This could mean one less frequent flier for you. Oscar would immediately recognize it as a classic example of helping oneself by helping one’s patients.

Likewise, ED social workers – who are forced to triage their own time and often can only attend to the most immediate crises – recognize that help desks offer a more proactive approach and can focus on patients’ long-term social problems. Ezra, one of our ED social workers, tells the story of a woman whose already sketchy living situation was lost to fire. Living among drug users, and with mental health issues of her own, she had previously come to our ED many times. Ezra was able to find a short-term placement for her, but he then referred her to Highland Health Advocates. There a volunteer spent 3 hours helping her sign up for food stamps, Salvation Army Fire Relief and a Section 8 housing wait list. When Ezra checked on her progress, the patient hugged him and the volunteer and, in tears, said she felt optimistic about her future for the first time in years.

OK, so let’s say you buy this notion that social determinants of health directly underlie many ED visits. And, yeah, you are always willing to try and address your patient’s real problem, even if it’s not life-threatening. Further, let’s suppose some other far more big-hearted and ambitious colleague has actually established a help desk outside your ED. How do you know which patients to refer? Dennis Hseih gives these pointers. The first clue, often, is you find yourself wondering, “WTF? Why is this patient here?” Those are the patients whom you should then ask, “Do you have somewhere safe to stay?” and “Do you have enough money for food and for your medications?”

By making that well-targeted help desk referral, you stand to turn a “waste of your time” into a positive encounter – one that could have a lasting, beneficial effect for your patient.

In my next blog post, I’ll show you how another Social Emergency Medicine initiative, identifying opioid misuse and prescribing buprenorphine from the ED, stands to similarly transform the dreaded “drug seeker” encounter.


Interested in learning more about Social Emergency Medicine, social determinants of health and help desks? Check out these resources:

Bay Area Help Desks

https://www.calhospital.org/general-information/web-forum-registration-bay-area-regional-help-desk

Stanford Health Advocacy and Research in the Emergency Department SHAR(ED)

http://emed.stanford.edu/specialized-programs/sem/shared/help-desk.html

Social Interventions Research and Evaluation Network (SIREN)

https://sirenetwork.ucsf.edu/

Health Leads

https://www.ted.com/talks/rebecca_onie_what_if_our_healthcare_system_kept_us_healthy/transcript#t-259680https://healthleadsusa.org/about-us/vision/

Lynton Scholar Tehreem Rehman Reflects on the SEM Consensus Conference, September 2017

As someone just about to begin training in Emergency Medicine and who entered the profession of medicine invested in advancing health justice, it was an incredibly humbling experience to be included in a discussion with passionate and experienced leaders in the field of Social Emergency Medicine. From the very beginning, I was overwhelmed with the vast knowledge and perspectives being shared and debated, and eagerly reflected long after the sessions themselves ended. It was evident that in order to promote Social Emergency Medicine, physicians would need to look outside of the walls of the hospital in order to advocate for necessary institutional and structural change.

Within the institutions themselves, it would be imperative to garner support at the administrative level in order to create system changes that facilitated addressing structural determinants of health inequity. Additionally, institutions need to engage in curricular reform to ensure that future members of the profession are adequately trained to effectively address structural determinants. As someone who had to navigate numerous institutional barriers while establishing an interdisciplinary course on US Health Justice, the voiced need for greater mentorship and faculty support resonated with me. In order to truly promote cultural change within institutions that promotes the practice of Social Emergency Medicine, it would be particularly important, as one fellow participant noted, to include other members of the team such as nurses, physician assistants, and social workers in the design and implementation of relevant programs and innovation.

However, the work outside of the institutions themselves is arguably even more crucial. Even if system changes are made that facilitate identifying socioeconomic stressors in the clinical setting, the capacity to address them would be limited if adequate community-hospital partnerships are not established. Dr. Khaldun stressed that in the current health policy landscape, non-profit hospitals are mandated to devote a certain amount of resources to conduct a health needs assessment of the community and subsequently are incentivized to take action in order to meet metrics such as patient satisfaction and reduced hospital readmissions. However, the creation of community partnerships takes time and energy as you cannot easily undo the impact of historical institutionalized oppression and the intergenerational structural trauma that it consequently inflicted as Dr. James pointed out.

Outside of the sessions themselves, I benefited from the opportunities to get insight from different leaders in the field on their career trajectories and their different experiences with practicing Social Emergency Medicine. I intend to refer back to these acquired pearls of wisdom as I embark on my own journey of becoming an Emergency Medicine physician who effectively promotes health justice both within and outside of the walls of the hospital. Ultimately, I am grateful for the Lynton Scholarship that enabled me to participate in such an exciting and momentous milestone in the field of Social Emergency Medicine.

Lynton Scholar Rebecca Karb, MD, PhD, Reflects on the SEM Consensus Conference, September 2017

by Rebecca Karb, MD, PhD

It was an honor to attend the Social Emergency Medicine (SEM) Consensus Conference at the American College of Emergency Physician (ACEP) headquarters in Dallas, Texas. What an inspiring experience to get together with such a thoughtful, motivated, and justice-oriented group of EM physicians. The dialogue raised many important questions regarding the priorities for SEM as well as the strategies for pursing our mission. What is the most appropriate and effective strategy for addressing social determinants of health? And where is the most effective space to do so? Addressing SDOH in the ED is, by constraint of necessity, an individual-level intervention. As such, it should certainly be one of the tools that we research and develop as ED physicians; however, it cannot be the only space in which we intervene if we truly wish to address health inequalities.

We must be active and engaged at the community and policy level to change the underlying structures of inequality. For example, we may be able to develop an effective screen for homelessness or housing insecurity in the ED, and as a result provide an individual patient with the resources necessary to obtain secure housing. However, we have not altered the more upstream fundamental causes of disease but rather modified their effect on our individual patient. This is not unimportant and it is what we do as physicians—we treat individual patients. But our SEM mission must extend outside the walls of the ED and into our local communities and government. As ED physicians, we are on the frontlines of healthcare and have a unique window into the health of our communities. We should be systematically gathering information about our communities and using that knowledge in combination with our positions of privilege and power to advocate for fundamental changes at the policy level. I hope that we can continue to build a strong, cohesive movement and that EM can lead the way in the fight to eliminate health disparities.

This Is Not By Chance Alone

First Fridays in downtown Oakland is a monthly event that fills the streets with food and music and dance, brilliant colors, and enticing smells. Full of life. This past Friday, two groups of teenagers reportedly began an argument in the middle of the event.  Shortly, at least one person pulled out a gun and shot dead an 18-year-old boy in the middle of the street fair. His name was Kiante Campbell. Three other people were also shot and wounded: a teenaged friend of Kiante’s, and two young women in their twenties who were not involved in the argument and were simply out to enjoy the art and music. Hit by stray bullets, they were in the wrong place, at the wrong time. But the truth is with so many guns in our city and our country, any place could be the wrong place, any time could be the wrong time. The high prevalence of guns takes heated moments of dispute and turns them into lifetimes of irreversible loss and death.

Witness To Social Emergency Medicine

As we all know 20 children and 6 adults were shot and killed at Sandy Hook Elementary School on December 14th 2012. This horrific tragedy provoked a wide array of responses from leaders and citizens across the world. It prompted murmurs of a real response and dialogue about gun control and mental illness in our country by our elected leaders. Washington Post Associate Editor and presidential biographer David Maraniss called President Obama’s vigil to the victims his “Gettysburg Address”. His comparison is apt – the President’s speech was poetic, mournful, somber, and evoked the gravity and humanity of an evil day. 

Social Emergency Medicine Is A Two-way Street

Like most readers of this blog, I received a lot of calls and emails about Atul Gawande's recent New Yorker piece on high-cost patients (find it here).  The geospatial element, as well on the incorporation of the effects social pressures on ED use, were direct hits onto some of what Jahan Fahimi and I are working on with the Barometer Project, our effort to measure community stress and well-being from the ED. It was great to see these issues laid out so clearly in a very public forum.  

Belated Report From Phoenix: Still Walking On Air

Hard to believe that I never posted after our amazing panel in Phoenix. I was joined by several members of the Levitt Center’s Scientific Advisory Committee for a didactic session at the Society for Academic Emergency Medicine’s annual meeting. It was a bold move on the Program Committee’s part to select our unorthodox proposal.  I think we did not disappoint them.

An Embarrasment Of Riches: A New Fellow, And A Media Spotlight

We have a new Fellow, and a fine fellow he is indeed. The Levitt Center Board agreed to provide seed support for the first year of the first-ever Fellow in Social Emergency Medicine, Dr. Jahan Fahimi. Prior to his position as resident and then Chief Resident in our department, Jahan obtained a Master of Public Health from the Harvard School of Public Health and an MD from New York University, where he was elected into the Alpha Omega Alpha honor society.  Jahan is a Bay Area native, and a graduate of UCSD, summa cum laude.

Saem Faces Advocacy Role In Arizona

The most stimulating emergency medicine specialty meeting of the year, the Society for Academic Emergency Medicine, was greeted this year by many of us with less than the usual enthusiasm.  The same mind-expanding content, the same dear and deep people, but this year in Phoenix.  OK, it's hot.  OK, it's paved.  We can deal with that.  But the passage of the recent immigration law had many of us tied in knots.