Dr. Flea Blogged His Malpractice Trial, Settles When Outed

Dr. Flea and His Blog

Dr. Flea was the alias of a pediatrician who blogged anonymously on Blogger.com. I have visited the site occasionally following links from Grand Rounds but his writing was a bit too bitter for me to become a regular reader. Recently, Dr. Flea started to blog extensively about his malpractice trial and then suddenly, all his blog entries were deleted although the placeholder URL still remains in place.

It turns out the plaintiff's attorney used Dr. Flea's blog against him in court. When outed, the pediatric pulmonologist decided to settle the case within 24 hours. New York Personal Injury Law Blog points out that the Flea story was printed on the front page of the Boston Globe, above the fold. "Which is to say, his patients and colleagues will all see it." This is regrettable. I am sure many of us feel sorry for Dr Flea as well as for the patient and his/her family, of course.

Blogging and Your Career

Blogging can be a dangerous business. If it is done right and in a positive way, it can help advance your career. If blogging involves poor judgment, it can have undesirable consequences. Just ask Mark Jen, reportedly the first employee to be fired for blogging. He worked for Google and was blogging about the company's upcoming products. It did not take long for Google, famous for its somewhat secretive corporate culture, to decide that Mark Jen was not the best fit. Since then, Google teams and employees have launched multiple blogs (both work-related and personal) and I have not heard of anybody running into problems because of what they have written online.

I would encourage anybody to write a blog if they have something interesting to say and add value to the online conversation. Just be smart about it. Write to share and educate not to blow off steam. We live in a Google world. What you post online today can come back tomorrow to haunt you. According to LifeHacker:

"A new study shows that one fourth of human resources people have decided against hiring a job candidate based on information they found online about that person. Luckily, you can have a say in what Google says about you."

Some Advice for Medical Bloggers

- Write as if your boss and your patients are reading your blog every day
- Comply with HIPAA
- Do not blog anonymously. List your name and contact information
- If your blog is work-related, it is probably better to let your employer know
- Use a disclaimer, e.g. " All opinions expressed here are those of their authors and not of their employer. Information provided here is for medical education only. It is not intended as and does not substitute for medical advice."

Updated in November 2010: Interview with Dr. Flea. ScienceRoll, 2010.

References:
Blogger unmasked, court case upended. BostonGlobe.
Doctor Blogs Own Malpractice Trial, Settles When Outed. WSJ Health Blog.
Flea. Kevin, M.D.
Make Yourself Google-able
Flea's fall sobering for other bloggers. White Coat Notes.
Simply Fired - How NOT to Blog About Your Job. Especially If You Are a Doctor
A new study shows that... LifeHacker.com.
Case Reports and HIPAA Rules
Anonymous Medical Blogger? Not Anymore
Guide to Winning Your Malpractice Lawsuit - Medscape http://buff.ly/UTaWOq

Image source: Boston Globe.

SHM Annual Meeting and Cleveland Clinic Hospitalist Section

The Society of Hospital Medicine (SHM) was founded 10 years ago and the Section of Hospital Medicine at the Cleveland Clinic was established 7 years ago. We launched a new web site for the section last year.

During the last annual meeting of SHM in Dallas, Texas, members of our section presented 18 innovations, research, and clinical abstracts out of 133 accepted (14%). With the Cleveland Clinic logo present on so many posters, this was clearly the largest display of any single academic institution.

My small contribution consisted of 6 abstracts/posters which is 33% of the Clinic abstracts and 4.5% of the total accepted (not that anybody is counting). One of the abstracts was featured by Medscape: "Mini-Rounds" May Help Improve Physician-Patient Communication and Satisfaction (a free registration is required to see the web page). Laurie Barclay, M.D. of Medscape interviewed me and our Section Head, Frank Michota 2 weeks ago. All accepted abstracts were published in a supplement of the Journal of Hospital Medicine.

Former alumni of the Cleveland Clinic hospital medicine program continued to have a strong SHM presence as well:

- Shaun Frost, the regional director for Cogent Healthcare and director of the SHM perioperative pre-course
- Jim Pile, the director of the Division of Hospital Medicine at MetroHealth Medical Center and an annual meeting speaker
- Daniel Brotman, the director of Hospital Medicine at Johns Hopkins and a clinical vignette reviewer

References:
What I Learned from Making the Website of the Cleveland Clinic Hospitalists
Research Abstracts. Journal of Hospital Medicine, Volume 2, Issue S2 , Pages 1 - 39, published online: 4 Jun 2007.

Updated: 09/28/2007

Emded Procedure Slideshows from Google Photos

Google Photos (currently named Picasa Web Albums) added Flash slideshows which can be embedded in web sites. This new feature is demonstrated with some of our procedure guides below. You can choose the photo size: from small (144 px) to extra-extra large (800 px).


Thoracentesis: A Step-by-Step Procedure Guide with Photos


Central Line Placement: A Step-by-Step Procedure Guide with Photos


Central Line Placement with Ultrasound Guidance: A Step-by-Step Procedure Guide with Photos

Update 06/26/2007:
Picasa Web has a mobile version and map locations.


Online Photo Sharing in Plain English

References:
Picasa Web Albums introduces embeddable Flash slideshows. DownloadSquad.com.
Put your photos on a map, and Picasa on your phone. Official Google Blog, 06/2007.

Updated: 02/02/2008

Self-plagiarism of a Case Report in NEJM and Salami Publications

Self-plagiarism is the reuse of significant, identical, or nearly identical portions of one’s own work without acknowledging that one is doing so or without citing the original work (source: Wikipedia).

Last week, I updated the references of my post about complications of central line placement with another image from NEJM. Clicking through an old NEJM reference, I noticed something interesting -- the author has retracted his NEJM publication due to self-plagiarism. The same case was published twice in 2006 before being accepted to NEJM in 2007. The first publication was just an abstract in Circulation and one can probably argue that this does not impact the publication of the full case report. The second publication however features the complete report with the same striking images shown later in the NEJM.

This is an example of self-plagiarism -- a practice which should be strongly discouraged.

Another "academic trick" is publishing so-called "salami papers." For example, one large project is split ("sliced) in 2-4 smaller articles published in different journals and finally, the full manuscript is submitted at the end of the process. "Salami slicing" refers to the practice of creating several publications out of material that could have been published in a single journal or review (source: Wikipedia).

"Self-plagiarism: unintentional, harmless, or fraud?" was a recent commentary in the Lancet. Journals increasingly seeing submissions in which large parts of text have been copied from previously published papers by the same author. Lancet (http://bit.ly/4B0DO).

The Lancet Editor-in-Chief tweets his dark view of contemporary medicine, related to the salami publication conflict between NEJM and Lancet  - Forbes, 2012.

References:

Something you have never seen before -- a rare central line complication in NEJM
Complications of Central Line Placement - Pneumothorax, Arrhythmia, Hematoma
Retraction: Guo H. Complication of Central Venous Catheterization. N Engl J Med 2007;356:e2
Academic Plagiarism. Irving Hexham, Department of Religious Studies, University of Calgary.
Plagiarism, from Wikipedia, the free encyclopedia.
Dealing With Salami Publication. The World Association of Medical Editors.
Odd Ghostwriting Offer Raises Researcher’s Blood Pressure. WSJ’s Health Blog, 11/2007.
Fight against plagiarism continues http://bit.ly/cAzJcN one npublisher rejected 23% of submitted papers after using CrossCheck. Nature News, 2010.
Image source: Wikipedia, a Creative Commons license.

Google Maps Street View

Google Maps launched a new very detailed views at street level of several cities on the U.S. with plans to expand to more locations in the future. Currently, Google can put in you in the driver seat for 5 cities: San Francisco, Las Vegas, Denver, New York and Miami.

You have to feel sorry for Microsoft. They paid a lot of money to fly planes to provide detailed aerial views of the major U.S. cities. Google outdid them simply by having people drive around and take pictures...


This is a video showing Street View in action.

Update 5/30/07: Google Street View and Personal Privacy

Robert Scoble writes that "a BoingBoing reader is worried that Google is infringing on his privacy by taking pictures of his cat in a window in his house.

No, sorry, it’s not spying and it’s not creepy. If you can see it from a public street it’s not private and you should not expect ANY privacy."

References:
Introducing... Street View! LatLong Blog.
The Earth is Closer: Street Views in Google Maps. Google Operating System.
Google Maps Street View invades privacy, exposes alien life. DownloadSquad.com.
BoingBoing reader demonstrates misunderstanding of privacy. Scobleizer.com.
The Google 'ick' factor. CNN, 6/2007.

Related:
Video: Getting around your neighborhood with Google Maps. Official Google Blog, 10/2008.

Updated: 10/14/2008

Lion vs. Buffalo vs. Crocodile at Kruger National Park

The Animal of the Day links to a rare video showing buffalo hunting gone wrong for a pack of lions at Kruger National Park. The excited tourists narrate the 8-minute-long video very well. Unbelievably, everything seems to end fine for the buffalo calf...


Battle at Kruger

Related:
You’ve Seen the YouTube Video; Now Try the Documentary. NYTimes, 05/2008.

Updated: 05/10/2008

$ 30 Million Lawsuit for Complications of Pressors Use in Septic Shock

A 47 yo female was awarded $30 million to recover past and future medical costs, lost wages and pain and suffering for complications of treatment of septic shock by a Florida court.

A plastic surgeon performed a "tummy tuck" (abdominoplasty) in 2001, soon after that the patient began to to have fever. According to the newspaper story, she went to the ER and the on-call surgeon "removed some fluid from her stomach area and... she was given medicine that focused blood flow to the inner part of her body to protect her vital organs.

Yerrid said this medicine can be given only after fluids have been administered; otherwise, the flesh in the extremities will die. Haedicke never ordered fluids for Lucia.

Haedicke's attorney said Lucia's kidneys were shutting down. Had he administered fluids, she could have died.

The lack of blood flow to her extremities had caused severe damage to her hands and legs. Doctors at Tampa General were forced to amputate fingers from both hands and her legs below both knees."

Of course, it is difficult to impossible to comment on a medical case without examining the patient and reviewing the chart but we usually give IV fluids (IVF) before and during pressors administration.

The rationale of "filling the tank" before using pressors (which can cause peripheral ischemia) is well-illustrated in this clinical case: Pneumonia and Septic Shock. As you can see from the labs, this patient also had acute renal failure which actually improved with IVF.

Early rapid and appropriate treatment of septic shock is extremely important in order to decrease morbidly and mortality in this very sick patient population.

References:
Patient Wins $30 Million. The Tampa Tribune, 5/2007.
Pneumonia and Septic Shock. ClinicalCases.org.
Link via Kevin, M.D.
Image source: CDC, public domain.

Avandia Heart Risks and a World Which Never Sleeps

The NEJM meta-analysis revealing possible cardiovascular risks associated with Avandia was one of the top news 2 days ago.

Within minutes, a new search trends tool by Google called Hot Trends showed a "volcanic" activity: millions of new search queries for "Avandia" (see the screenshots). One of the related posts from this blog made both the first search result on Google and Hot Trends.


Screenshots of Google Hot Trends and Google search results for "Avandia Cardiovascular Risk"

Physician bloggers are not the only ones who follow the medical news. Lawyers do the same thing.

Within hours, Avandia malpractice ads started to appear on this blog surrounding a post about the possible heart risks of the medication (see the screenshot).


A screenshot of malpractice AdSense ads within hours of the news about Avandia heart risks

The Internet world never sleeps and the news spreads fast.

References:
Avandia (Rosiglitazone) May Increase Risk of Cardiovascular Death
Video: Dr. Nissen Discusses Heart Risks of Avandia
Screenshot of Google Hot Trends from Google Operating System. Licensed as Creative Commons Attribution.

Related:
Doctor Accused of Leak to Drug Maker. NYTimes, 01/2008.

Updated: 01/31/2008

Video: Dr. Nissen Discusses Heart Risks of Avandia

This WSJ video gives you the chance to hear the rational behind the Avandia warning from the study author.

Related:
Doctor Accused of Leak to Drug Maker. NYTimes, 01/2008.

Updated: 01/31/2008

Avandia (Rosiglitazone) May Increase Risk of Cardiovascular Death

According to a meta-analysis by Steven Nissen, the chief of cardiology at the Cleveland Clinic, published in NEJM:

"Rosiglitazone was associated with a significant increase in the risk of myocardial infarction (MI) and with an increase in the risk of death from cardiovascular causes that had borderline significance. The study was limited by a lack of access to original source data, which would have enabled time-to-event analysis."

Avandia seemed to increase the risk of MI by 43 percent and cardiovascular death by 64 percent. Despite the limitations of the study, the findings are significant and there seems to be little rationale for prescribing rosiglitazone anymore.

A video recap from the WSJ health blog summarizes today's events:



Steven Nissen has a long track record as an early critic of the following medications:

- Merck’s Vioxx
- Bristol-Myers Squibb and Merck's Pargluva
- Johnson & Johnson’s Natrecor
- ADHD drugs

He wasn't named one of the 100 People Who Shape Our World by TIME for nothing.

For the record, I was never a big fan of Avandia, especially since I saw a small study in a 2003 issue of the Mayo Clinic Proceedings which showed that "thiazolidinediones can cause or exacerbate heart failure and pulmonary edema and should be avoided in patients with left ventricular dysfunction or chronic renal insufficiency."

In 2005, investigators from the Cleveland Clinic published their experience with using EMR to notify 11,699 patients on Vioxx within 24 hours of the medication withdrawal: Responding to the Rofecoxib Withdrawal Crisis: A New Model for Notifying Patients at Risk and Their Health Care Providers, Annals of Int Med. A similar system will likely be used to notify patients of the increased risk with Avandia.

There has been some discussion recently about the value of wikis for medical information. The Wikipedia entry about Avandia was updated with the new safety concerns about the drug at 4:48 PM and the full reference was added 2 hours later, as you can see from the revisions/history page. That was reasonably fast, I think.

As it has become customary, the medical blogosphere reviewed the news from a professional perspective in a timely fashion:

Not So Rosy. Medviews.

Rosiglitazone (Avandia) in perspective. Notes from Dr. RW.

Avandia and heart attack. Kevin, M.D.

References:
Effect of Rosiglitazone on the Risk of Myocardial Infarction and Death from Cardiovascular Causes, NEJM.
Avandia: Video Recap, Jacob Goldstein, WSJ.
Cardiologist: Glaxo’s Diabetes Drug Raises Heart Risks, Jacob Goldstein, WSJ.
Thiazolidinedione-Associated Congestive Heart Failure and Pulmonary Edema. Mayo Clinic Proceedings, 2003.
Responding to the Rofecoxib Withdrawal Crisis: A New Model for Notifying Patients at Risk and Their Health Care Providers, Annals of Int Med, 2005.
Interview with Dr. C. Martin Harris on PHRs. eHealth, John Sharp, 06/2007.

Related:
Doctor Accused of Leak to Drug Maker. NYTimes, 01/2008.

The long Avandia endgame - The Lancet, 2011 http://goo.gl/qcMzN

How to read 600 web feeds per day (and why)

Robert Scoble is probably the most famous blogger in the world. He is also a power web feeds reader which seems to be a prerequisite for being a popular blogger nowadays. Robert shares his tips on reading more than 600 feeds per day in real time in the video below. He is interviewed by the author of the best-selling book The 4-Hour Workweek which was recently reviewed by Steve Rubel of Micro Persuasion.



A web feeds reader, like Google Reader, is a true "inbox for the web." If you have not given the web feeds a try yet, check out this neat little video which explains how easy and fun the whole process is:

Click To Play

There are two types of Internet users, those that use RSS and those that don't. This video is for the people who could save time using RSS, but don't know where to start.

Author: The Common Craft Show. Get the HTML code to embed in your web site.

References:
Best Web Feeds Reader for Medical and General Information
RSS in Plain English -- The Best Video Explanation in 3 Minutes
Link via Go 2 Web2.0.

Free Ophthalmology Atlases

The RedAtlas.org is a free online atlas of ophthalmic disorders, in existence since 2002.

The atlas has sections for Anterior Segment, Glaucoma, Neuro-Ophthalmology, Oculoplastics, Pathology, Retina and Uveitis. It is case-based but almost all cases lack the history part and only the images are shown, which is the most important feature of an atlas after all.

I found several more free online atlases of ophthalmology and they are listed below:

- EyeRounds Online Atlas of Ophthalmology, University of Iowa

- The Robert Bendheim Digital Atlas of Ophthalmology

- Atlas of Ophthalmology by the International Council of Ophthalmology

- Video: Eye Trauma according to Dr Root http://goo.gl/KIEC and http://www.rootatlas.com

The EyeRounds Online Atlas of Ophthalmology by the University of Iowa has the significant advantage of a very relaxed copyright policy for educational use: "The material belongs to the contributing author. The contributing authors allow visitors (including health care professionals who wish to distribute materials to patients) to duplicate portions of this site for personal or educational use without seeking permission from the authors."

Related:

Ophthalmology Self-Guided Study Activity - ACP 2011 .

Fundoscopy. CETL Learning, Queen Mary University of London.
Image source: RedAtlas.org.

NEJM Images: Adult-Onset Eosinophilic Esophagitis

The case description and pictures are available on the NEJM web site:

"Adult onset of eosinophilic esophagitis is still not recognized by many practitioners. This condition is often confused with gastroesophageal reflux disease and is associated with esophageal strictures. The presence of more than 20 eosinophils per high-power field in an esophageal biopsy specimen is strongly suggestive of this diagnosis."


"Multi-ring esophagus" in eosinophilic esophagitis (left), infiltration of eosinophils (right). Source: Wikipedia.

Although eosinophilic esophagitis is well-recognized entity in children, it is still underdiagnosed in adults.

A few months ago, I saw an adult patient with a multitude of unexplained gastrointestinal complaints who was referred to our tertiary care center as a diagnostic dilemma. She was diagnosed with an adult-onset eosinophilic esophagitis by us and did very well with swallowed Fluticasone. The full case description will be posted on ClinicalCases.org in the future.

I would like to point out the remarkable contributions to medical Wikipedia by Samir, a Canadian gastroenterologist. He has published a multitude of EGD, colonoscopy and biopsy images on Wikipedia under a GNU free license and in strict compliance with HIPAA. The NEJM holds a copyright of its text and images and having a free alternative via Wikipedia is an excellent addition.

References:
Eosinophilic Esophagitis. NEJM, 2007.
Eosinophilic esophagitis, from Wikipedia, the free encyclopedia. Images under the terms of the GNU Free Documentation License.
Esophagus - Eosinophilic Esophagitis. The DAVE Project - Gastroenterology.
Eosinophilic microabscess in eosinophilic esophagitis. JACI, Volume 119, Issue 6, Page A6 (June 2007)
Eosinophilic disorders. Current reviews of allergy and clinical immunology/Series. JACI, Volume 119, Issue 6, Pages 1291-1300 (June 2007).

Columbus Zoo: Manatees, Gorillas and More

Columbus Zoo is one of the 6 great Ohio Zoos. Currently, I have photos and videos from 4 of them: Cleveland, Akron, Toledo and Columbus.

Click to play the video below:


Manatee Coast at Columbus Zoo

This video was shot with a Canon SD 450, a nice little camera which is almost the size of a credit card (only thicker). The background music was added using the new AudioSwap feature of YouTube. I especially like the turtle swimming right in front of the camera every minute or so. The video was edited with Windows Movie Maker, a free program included with every recent Windows version. I would like to point out to my readers that such videos are easy to make and I am looking forward to seeing your own educational or entertaining (preferably both) videos soon.

See more photos and videos here.

How to Study

LifeHack.org offers a few tips on making studying more enjoyable and productive. I have used several of them when preparing for USMLE and ABIM and it worked for me -- I consistently scored above the 95th percentile on most exams and was invited to talk to medical residents on how to score well on the boards. The key is to make studying more fun.

LifeHack advises to:

Use Flashcards
Create the Right Environment
Use Acronyms to Remember Information (mnemonics)
Listen to music
Rewrite your notes.
Engage Your Emotions
Make Associations (mind maps)

Writing your own notes, mind maps and mnemonics may be especially useful. Joshua of KidneyNotes posted some interesting experiments with mind maps:

Workup of Hypertension (Primary and Secondary)

Treatment of High Potassium (Hyperkalemia) and Protein in the Urine (Proteinuria)

There are more examples of mind maps on Flickr. If you choose the creative commons search, you can use the images to illustrate your own blog posts.

References:
How To Study. LifeHack.org, 2007.
How to Score Well on the Boards? Clinical Notes.
Medical Mnemonics
Image source: KidneyNotes.com, creative commons license.

Related:
How I Study. The Island Med Student, 02/2008.

How to start a medical blog in 2 minutes

This Google video shows that it takes about 2 minutes to start a blog on Blogger.com. Creating a web site has never been easier.



The video length is 1:58 minutes from start to finish and this includes writing your first post illustrated with a photo.

There are many medical blogs out there but we can always use a few new good ones. I do not have a blogroll in the sidebar but I subscribe to at least 40 medical blogs in Google Reader.

ScienceRoll points to an integrated feed of several genetics blogs. This is an interesting idea. I tested something similar with our hospitalist group and members generally liked it. We used the "RSS-to-web page" feature of iGoogle and the approval rate was nearly 90%.

It would be nice to have feed "pipes" (similar to Yahoo Pipes) of blogs in different specialties:

- A feed pipe with general medicine blogs
- A feed pipe with hospitalist blogs
- A feed pipe with cardiology blogs
- A feed pipe with nephrology blogs, etc.

It would be interesting to see if students, residents, fellows and specialists find these feed pipes useful.

Update 5/15/2007:

David Rothman links to a directory of medical blogs categorized by subspecialty on MedWorm.

References:
Best Web Feeds Reader for Medical and General Information
Make Your Own "Medical Journal" with Google Personalized Page
The DNA Network: the best idea of the last months. ScienceRoll, 05/2007.
Image source: ScienceRoll, CreativeCommons license.
Link via Googlified.

Water: Bulgarian Entry in Eurovision 2007 Song Contest

From Wikipedia:

"Water" is a song by Elitsa Todorova & Stoyan Yankoulov which represents Bulgaria and opened the Eurovision Song Contest on 10th May, 2007. The song has drum beats, and two percussionists sing and play their percussion instruments at the same time. Elitsa's deep-toned voice is telling the dramatic story of Bulgarian folklore.

The singers explain the title: "Our folklore is like water. We've chosen this title "Water", because in Bulgarian folklore there are very slow beautiful songs, which are like a lake. But we also have songs, with very fast rhythm which are like a waterfall. And my wish is this song to be like "Water", a gasp of fresh air, for the human spirit and soul. When we recorded the promo video of this song, they poured lots of rain on us, and I felt purified. I want everyone, who hears this song to feel the same way - liberated. This is a very positive song! I'm sure that people will feel it!"

Elitsa Todorova and Stoyan Yankoulov in 2012:



References:

Voda, from Wikipedia, the free encyclopedia.

StudentBMJ Mentions ClinicalCases.org in an Article About Online Medical Information

Our project Clinical Cases and Images - A Case-Based Curriculum of Clinical Medicine (ClinicalCases.org ) was mentioned in the May 2007 issue of StudentBMJ: Trust me; trust me not. The article discusses trustworthiness of online medical information including new Web 2.0 tools such as wikis and blogs.

Dean Giustini, who is one of the best Web 2.0 experts among librarians, was very kind to mention our project in his interview with the author:

"...the main boon of Web 2.0 is how it allows medical practitioners to communicate more effectively with each other. When doctors talk to each other, he says, "The discussions that they have together actually create knowledge-they're continually teaching each other."The technologies of Web 2.0 can allow these conversations to become more fluid, resulting in a "continual process of sharing, information, and repurposing information."Such a process might be facilitated by a wiki, by a medical blog containing clinical information, such as Clinical Cases and Images (http://clinicalcases.blogspot.com), or by a blog recording the thoughts and activities of an individual clinician, such as the popular NHS Blog Doctor (http://nhsblogdoc.blogspot.com)."

The StudentBMJ has a RSS feed with an additional nifty feature: a mash-up box which allows you to create a custom RSS feed from the journal content which fits your search criteria.

References:
Trust me; trust me not. Christopher Hands, studentBMJ 2007;15:169-212 May.
Librarianship and Handling the Media. Dean Giustini, UBC Academic Search - Google Scholar Blog.

Image source:
StudentBMJ.

Shapiro's syndrome: Excessive sweating may cause renal failure

A 55-year-old male is admitted to the hospital with acute renal failure (ARF). He complains of generalized weakness, chills and excessive sweating.

His past medical history includes AFib, obesity, mild mental retardation and HTN.

During physical examination, all skin surfaces are wet and he is shivering under 4 blankets which are wet.

What is the cause for his ARF?

What are the typical finding seen on the MRI of the brain?

Read more on ClinicalCases.org: Acute renal failure due to hyperhidrosis secondary to Shapiro's syndrome.

Image source: Sweat, Shaylor's photostream, Creative Commons license. The image is not related and does not show the patient.