Care Conundrum Research Articles

Care conundrum in the emergency department: The gap between clinician awareness and patient expectations surrounding advance directives.

Clinicians in the emergency department (ED) frequently encounter seriously ill patients at a time when advance directives may be pivotal in improved clinician decision-making. The objectives of this study were to identify the prevalence of advanced directives in ED patients, as well as patterns of advance care discussions between patients and providers. This study describes patients' perceptions and expectations of such serious illness discussions in an emergency care setting with the expectation of including patients as strategic members of the care team. Trained research assistants in two emergency departments surveyed patients over age 65, or their caregivers, from July 2016 to August 2018. Patients were verbally administered a standard survey tool related to advance directives and advance care planning. 497 out of 877 patients completed surveys (59.4%). 50% of patients reported having an advance care planning document. The large majority (92%) of patients with an advance directive had not been asked about it during their ED visit. When questioned about their personal preferences, 79% of patients thought emergency physicians should be aware of their wishes regarding life-sustaining treatments and end-of-life care. Paradoxically, only 38% expressed a desire to discuss advance care plans with an ED clinician. Older patients expect emergency clinicians to be aware of their care preferences, yet most are not asked about these care preferences in the ED. The large gap between patient preference and reality suggests the need for more targeted discussion by ED clinicians and translation of patient perspectives into system healthcare improvements. Future studies should explore barriers to advance care planning in the ED as well as patient preferences for these conversations to support a true healthcare learning system.

Confronting Conundrums of Care in College Student Advising

At colleges and universities throughout the United States, academic advisors play a central role in stemming the tide of declining student enrollment and academic underachievement—especially in the wake of academic, physical, emotional, and interpersonal setbacks incurred during the COVID-19 pandemic. For many undergraduates, the mentoring relationship with their academic advisor provides the longest lasting and deepest connection with a faculty or staff member throughout their college experience. Increasingly, the expectations that institutions and students place on academic advisors have escalated far beyond simply guiding course selection and checking fulfillment of graduation requirements. While this more holistic approach to advising can cultivate a greater sense of belonging, it also places the advisors in a precarious position as the parameters of their responsibilities and the extent of caregiving continue to broaden. The ever-expanding expectations of caregiving placed on college academic advisors exemplify how pandemic-informed labor practices across many workplaces inadequately acknowledge caregivers while the care recipients may become overly dependent. This study investigates how advising evolves to become an extrapolation of the caregiving demands socially placed upon women in traditional, patriarchally structured families and workplaces. Using methods derived from critical incident theory that identify systemic crisis points and opportunities for intervention, the authors examine narratives of two women who serve as the lead advisors for their departments in southeastern United States universities. Their narratives delineate two double binds. First, the presumably bottomless reservoir of care demanded from women places nurturance of students in tension with career advancement and other care responsibilities (e.g., self and family). Second, setting boundaries to caregiving may generate accusations of insensitivity, but boundless care can accommodate and encourage learned helplessness among students. The investigation concludes with suggestions to reform institutional policies and build student resilience that equips them to learn independently.

S2090 Underrecognized Risk of Severe Acute Necrotizing Pancreatitis in Metastatic Colorectal Adenocarcinoma Patients After Percutaneous Transhepatic Biliary Intervention: A Palliative Care Conundrum

S2090 Underrecognized Risk of Severe Acute Necrotizing Pancreatitis in Metastatic Colorectal Adenocarcinoma Patients After Percutaneous Transhepatic Biliary Intervention: A Palliative Care Conundrum

Exposing the Care Conundrum of Low-Energy Pelvic Ring Fractures in Older Adults: A Review of 322 Patients.

A care conundrum for low-energy pelvic ring fracture patients in which they face financial burden after not qualifying for an inpatient stay of 3days or more has been noted in the literature. The purpose of this study was to identify factors that lead to inpatient length of stay (IP LOS) ≥3days in older adults with nonoperative pelvic ring fragility fractures and to highlight the challenging financial decision-making of those with IP LOS <3days in the context of the Medicare 3-day rule. This was a retrospective review of 322 patients aged ≥65 presenting from March 2016 and February 2019 to either of 2 emergency departments (EDs) after a ground-level fall resulting in a pelvic ring fracture. Patient demographic, IP LOS, and mortality data were extracted. Case management notes were analyzed to summarize financial decision-making for patients with IP LOS <3days. Multivariate logistic regression analysis was conducted to identify factors that predicted IP LOS ≥3days and mortality. IP LOS ≥3days was associated with presentation to level I hospital (OR .30 [.19, 0.50]) and being single (OR 2.50 [1.10, 5.68]). 70.3% required a post-acute skilled nursing facility (SNF) stay. Of patients with LOS <3days, 25.0% were financially responsible for their SNF stay, while 7.9% elected home care due to financial reasons. Overall 30-day, 90-day, and 1-year mortality were 2.5%, 8.1%, and 20.8%, respectively. For patients with LOS <3days, returning to assisted living compared to discharging to a SNF increased 90-day mortality risk (HR 8.529, P = .0451). Having Medicare trended towards increased 90-day mortality risk compared to commercial insurance (HR 4.556, P = .0544). The current system is failing older adult patients who sustain nonoperative low-energy pelvic ring fractures in terms of financial coverage of necessary post-acute treatment. This care conundrum has yet to be solved.

Moral Economies of Care and Women Who Use Drugs in Ukraine

This article analyzes interviews with women who use drugs in Ukraine to understand the care conundrum they face as members of a stigmatized group. In the interviews, the women sought to position themselves as deserving and needing care as members of a vulnerable category—sometimes as women who use drugs or people living with HIV, but also as mothers—yet also themselves capable of providing care for others. We examine how women who use drugs in Ukraine navigate a moral economy of care involving judgments about deservedness and social worth, the obligatory nature of care, and expectations for reciprocity. For programs for women who use drugs to be successful, they must acknowledge and engage with the moral economies of care in which these women operate. We offer recommendations for how health and social service providers can better meet the unique needs of women who use drugs.

Dyspneic and dizzy.

Journal of Hospital MedicineEarly View CLINICAL CARE CONUNDRUMS Dyspneic and dizzy Sahityasri Thapi MD, Sahityasri Thapi MD Icahn School of Medicine at Mount Sinai, New York, New York, USASearch for more papers by this authorSurafel Tsega MD, Corresponding Author Surafel Tsega MD surafel.tsega@mountsinai.org orcid.org/0000-0002-0814-3984 @drtsega Icahn School of Medicine at Mount Sinai, New York, New York, USA Division of Hospital Medicine, Department of Medicine, The Mount Sinai Hospital, New York, New York, USA Correspondence Surafel Tsega, MD, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Email: surafel.tsega@mountsinai.org; Twitter: @drtsegaSearch for more papers by this authorConnie Zhao MD, Connie Zhao MD Department of Medicine, The Mount Sinai Hospital, New York, New York, USASearch for more papers by this authorAndrew P. J. Olson MD, Andrew P. J. Olson MD @andrewolsonMD Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USASearch for more papers by this authorStephanie V. Sherman MD, Stephanie V. Sherman MD orcid.org/0000-0002-9726-500X @StephVSherman Department of Medicine, Baylor College of Medicine, Houston, Texas, USASearch for more papers by this author Sahityasri Thapi MD, Sahityasri Thapi MD Icahn School of Medicine at Mount Sinai, New York, New York, USASearch for more papers by this authorSurafel Tsega MD, Corresponding Author Surafel Tsega MD surafel.tsega@mountsinai.org orcid.org/0000-0002-0814-3984 @drtsega Icahn School of Medicine at Mount Sinai, New York, New York, USA Division of Hospital Medicine, Department of Medicine, The Mount Sinai Hospital, New York, New York, USA Correspondence Surafel Tsega, MD, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Email: surafel.tsega@mountsinai.org; Twitter: @drtsegaSearch for more papers by this authorConnie Zhao MD, Connie Zhao MD Department of Medicine, The Mount Sinai Hospital, New York, New York, USASearch for more papers by this authorAndrew P. J. Olson MD, Andrew P. J. Olson MD @andrewolsonMD Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USASearch for more papers by this authorStephanie V. Sherman MD, Stephanie V. Sherman MD orcid.org/0000-0002-9726-500X @StephVSherman Department of Medicine, Baylor College of Medicine, Houston, Texas, USASearch for more papers by this author First published: 30 March 2022 https://doi.org/10.1002/jhm.12815 This icon represents the patient's case. Each paragraph that follows represents the discussant's thoughts. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Low-Energy Pelvic Ring Fractures: A Care Conundrum.

Introduction:A need exists for improved care pathways for patients experiencing low-energy pelvic ring fractures. A review of the current literature was performed to understand the typical patient care and post-acute rehabilitation pathway within the US healthcare system. We also sought to summarize reported clinical outcomes worldwide. Significance: Low-energy pelvic ring fracture patients usually do not qualify for inpatient admission, yet they often require post-acute rehabilitative care. The Center for Medicare and Medicaid Services’ (CMS) 3-day rule is a barrier to obtaining financial coverage of this rehabilitative care.Results:Direct admission of some patients to post-acute care facilities has shown promise with decreased cost, improved patient outcomes, and increased patient satisfaction. Secondary fracture prevention programs may also improve outcomes for this patient population.Conclusions:Post-acute care innovation and secondary fracture prevention should be prioritized in the low-energy pelvic fragility fracture patient population. To demonstrate the effect and feasibility of these improved care pathways, further studies are necessary.

Egad!

Journal of Hospital MedicineVolume 14, Issue 3 p. 181-185 Clinical Care Conundrum Egad! Laura Platt MD, Laura Platt MD Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this authorScott R DeBoer MD, PhD, Scott R DeBoer MD, PhD Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this authorKevin Shenderov MD, PhD, Kevin Shenderov MD, PhD Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this authorJohn C Probasco MD, John C Probasco MD Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this authorElan L Guterman MD, Elan L Guterman MD Department of Neurology, University of California, San Francisco School of Medicine, San Francisco, CaliforniaSearch for more papers by this authorReza Manesh MD, Corresponding Author Reza Manesh MD rsedigh1@jhmi.edu Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandCorresponding Author: Reza Manesh, MD; E-mail: rsedigh1@jhmi.edu Telephone: 412-708-6944;Search for more papers by this authorC John Sperati MD, MHS, C John Sperati MD, MHS Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this author Laura Platt MD, Laura Platt MD Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this authorScott R DeBoer MD, PhD, Scott R DeBoer MD, PhD Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this authorKevin Shenderov MD, PhD, Kevin Shenderov MD, PhD Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this authorJohn C Probasco MD, John C Probasco MD Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this authorElan L Guterman MD, Elan L Guterman MD Department of Neurology, University of California, San Francisco School of Medicine, San Francisco, CaliforniaSearch for more papers by this authorReza Manesh MD, Corresponding Author Reza Manesh MD rsedigh1@jhmi.edu Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandCorresponding Author: Reza Manesh, MD; E-mail: rsedigh1@jhmi.edu Telephone: 412-708-6944;Search for more papers by this authorC John Sperati MD, MHS, C John Sperati MD, MHS Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandSearch for more papers by this author First published: 01 March 2019 https://doi.org/10.12788/jhm.3103Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume14, Issue3March 2019Pages 181-185 RelatedInformation

Elusive “Doc Fix”: Groundhog Day 2015 for Sustainable Growth Rate (SGR)

In summary, the SGR continues to hang like Damocles sword over physicians. To understand health care needs, we need to separate basic health care needs from economic mandates, and health insurance from health care coverage. The SGR flux represents another meaningful uncertainty to this health care conundrum.

P060 Amputations complicating major burns: the critical care conundrum. A 3D mathematical model for fluid and TBSA assessment: the Birmingham approach

P060 Amputations complicating major burns: the critical care conundrum. A 3D mathematical model for fluid and TBSA assessment: the Birmingham approach

Flatlined: resuscitating American medicine

ON JUNE 1, 2009, GENERAL MOTORS DECLARED BANKruptcy. Some blame management, others blame labor. But 39% of a 2005 GM employee’s hourly wage was related to health care costs—costs that management and labor were powerless to control. Two trillion dollars a year—16.5% of the gross national product—is spent on health care in the United States. Medicare and Medicaid expenditures account for 23% of the federal budget and are increasing faster than suspected global temperatures. If trends continue, polar bears are likely to stay afloat longer than the current health care system. Expense is not the only problem. Eighty-two million nonelderly US individuals have “insufficient, unstable, or no insurance coverage” (p xii). With an abundance of raw statistics such as these, Guy Clifton is able to draw readers into his treatise on the health care conundrum. Clifton argues that the US health care system is inefficient and expensive, providing limited access and variable quality. While somewhat overambitious, Clifton’s solutions offer insight into the complexity of a system in urgent need of change. Clifton combines his bedside experience as a professor of neurosurgery with his recent exposure as the 2006-2007 Robert Wood Johnson Foundation Health Policy Fellow to offer a broad perspective on health care reform. Clear, concise, well organized, and well researched, the book could be a quick read, but the statistics are so compelling and the issues are so complex that readers will be hard-pressed not to pause to attack the margins of each page with their own comments. The 274 pages of narrative are divided into 3 parts: “Why the Uninsured Should Be Covered,” “Why Health Care Is So Expensive,” and “Reforming American Health Care.” There is no question where Clifton stands on these issues. The 22 chapters have similarly unambiguous titles, with well-placed, practical subtitles, allowing one to put down or pick up the book at a moment’s notice. Following the narrative are 37 pages of “Notes,” arranged chapter by chapter. These notes reflect Clifton’s personal involvement as a Senate staffer, with varied sources relating to testimony before US Senate committees, press releases, and commission reports. The quality of these statistical sources adds legitimacy to Clifton’s call for urgent health care reform. While Clifton’s statistics on why to cover the uninsured and why health care is so expensive may be informative and insightful, his statistics on how much US health care reform will cost and where money will come from range from an informed estimate to anyone’s best “guesstimate.” Clifton cites the article “Covering the Uninsured: How Much Will It Cost?” in Health Affairs Web Exclusive (June 4, 2003), by Hadley and Holahan, which estimates a cost of $73 to $100 billion in addition to what is already being spent on the uninsured. Clifton puts that cost at 4% to 5% of a $2 trillion health care system, a system replete with wasteful spending. How much waste? In his “30 Percent Waste—or 50?” chapter, Clifton estimates that at least $700 billion dollars is being wasted on inefficient and unnecessary health care. Accordingly, Clifton proposes a federal solution. First, cover the uninsured as well as Medicaid and State Children’s Health Insurance Program patients with a private insurance equivalent to stop the cost shifting that leads to increased premiums. Next, Clifton proposes federal regulation of insurance companies mandating that insurers provide coverage equal to that provided to federal employees and disconnecting insurance from employment, thereby creating a competitive insurance market for the 247 million individuals in the non-Medicare population. Furthermore, Clifton proposes eliminating fee-for-service care and reducing costs by bundling payments to hospitals and specialists together. Pointing out that 10% of the population accounts for 70% of health care costs and that one-fourth of Medicare spending goes to costs incurred in the last year of life, Clifton argues for better coordination of care, using the “medical home” concept. Clifton’s most ambitious proposal is the creation of an American Medical Quality System (AMQS). Modeled after the Federal Reserve, with a board in Washington and state or regional boards, the AMQS would have more responsibilities than the guardians in Plato’s Republic. The AMQS would “develop standards for the application of procedures, the treatment and prevention of diseases and workups” by funding “research to generate the missing information needed to create guidelines and protocols” (p 224). The AMQS would also evaluate the effectiveness of medical technology and make its findings public as well as make specific recommendations on payment policy to BOOK AND MEDIA REVIEWS

The Canadian Health Care Conundrum

The Canadian Health Care Conundrum

Health care technology assessment and transfer

Health care technology assessment and transfer

New Governance and Soft Law in Health Care Reform

A contemporary health care reform is underway, associated with a set of reformers who are active nationally and locally at the doctor/patient level, the health care institution level, and the policy level. This reformist energy is associated with processes in law and policy that can be called new governance and soft law. These processes are different from previous understandings of how health care can be governed, such as self-regulation, market forces, and new deal command and control regulation. These processes are taking hold and are visible in the public and private sectors and through out the health care industry. The paper discusses the relationship between resolving health care conundrums, such as universal access, eliminating racial and ethnic disparities and embedding information technology, and the new processes. There are six innovations that derive from the interaction between new governance, soft law, and reform processes: alternative sites for deliberation, consumer and patient participation, different roles for government, redesigned organizational forms, and new tools for regulation and resolving disputes. Each of these innovations is discussed in the context of the health care reform stories. The paper discusses the variety of interactions between new governance and the older systems and how they coexist. It describes three ways in which the older processes are maintained, or could be maintained while utilizing the newer more effective processes. One type is the dynamic interaction between the old and new, a second is orchestrating a multi-pronged strategy that incorporates new governance techniques with more traditional incentives. The third interaction is the integration of traditional legal values, such as transparency, inclusion, and equity into the new processes.

New Governance and Soft Law in Health Care Reform

A contemporary health care reform is underway, associated with a set of reformers who are active nationally and locally at the doctor/patient level, the health care institution level, and the policy level. This reformist energy is associated with processes in law and policy that can be called new governance and soft law. These processes are different from previous understandings of how health care can be governed, such as self-regulation, market forces, and new deal command and control regulation. These processes are taking hold and are visible in the public and private sectors and through out the health care industry. The paper discusses the relationship between resolving health care conundrums, such as universal access, eliminating racial and ethnic disparities and embedding information technology, and the new processes. There are six innovations that derive from the interaction between new governance, soft law, and reform processes: alternative sites for deliberation, consumer and patient participation, different roles for government, redesigned organizational forms, and new tools for regulation and resolving disputes. Each of these innovations is discussed in the context of the health care reform stories. The paper discusses the variety of interactions between new governance and the older systems and how they coexist. It describes three ways in which the older processes are maintained, or could be maintained while utilizing the newer more effective processes. One type is the dynamic interaction between the old and new, a second is orchestrating a multi-pronged strategy that incorporates new governance techniques with more traditional incentives. The third interaction is the integration of traditional legal values, such as transparency, inclusion, and equity into the new processes.

New Governance Practices in U.S. Health Care

The problems of the uninsured, cost escalation, and improving quality in United States health care are once again on the front pages. There is a sense that these problems can be resolved despite the magnitude of the issues. This optimism is related to techniques and approaches to governance. This approach is called new and includes devolution, public-private partnerships, stakeholder collaboratives, network creation, coordinated date collection, benchmarking and monitoring. This paper examines the way governance tools are being incorporated in resolving health care problems. The first section discusses stakeholder collaborations, the arenas in which leading actors are developing ways of dealing with three health care conundrums: how to embed technology, how to eliminate racial and ethnic disparities, and how to achieve universal coverage. The paper then describes how the effort to resolve these problem areas moves from traditional regulation to a different set of strategies. The first shift is in the strategy for embedding technology from command and control to standard setting and local collaborations. The second example is the shift in eliminating racial and ethnic disparities from anti-discrimination litigation to quality assurance tools. The final example is the shift to envision universal coverage from a centralized single system to linked state experimentation. The paper concludes with a discussion of how regulation and governance must be rethought to allow these emerging practices to resolve the health care conundrums.

Teasing apart the child care conundrum: A factorial survey analysis of perceptions of child care quality, fair market price and willingness to pay by low-income, African American parents

Child care quality plays a crucial role in children's social and cognitive development. While child care quality is a critical issue for all children, it matters more for low-income children. Policy makers have increased the emphasis on allowing parents, not government, to make decisions about the type of care they want for their children. Yet most research on child care quality has focused on how child care professionals, not parents define high quality care. This study investigates how low-income families evaluate child care quality by examining the child care preferences of a sample of low-income African American parents. We employ the factorial survey method, a method used in sociological research to assess people's perceptions and rankings of individual attributes associated with complex multidimensional phenomena. The factorial survey method permits a simultaneous assessment of how respondents evaluate and make tradeoffs among multiple child care characteristics. We assess the impact of child care characteristics on respondents’ perceptions of child care desirability, fair market value, and willingness to pay. Findings indicate that parents’ definition of quality focused squarely on the care giving environment, specifically the qualifications, experience, training and behavior associated with the child care provider. The type of care facility—family, center, relative or neighbor care was largely irrelevant to this sample of parents. Parents believed that the characteristics they defined as desirable child care situations were worth more, and parents were willing to pay more for these characteristics. These parents also defined quality in terms of race and class, and they wanted racial and economic diversity. This research suggests parents may choose lower quality care, not because they do not know what quality is or because they define quality care differently, but because such care may be neither available nor affordable in their communities.

Newhouse, J. P.: Pricing the Priceless – A Health Care Conundrum.

Newhouse, J. P.: Pricing the Priceless – A Health Care Conundrum.

Pricing the Priceless: A Health Care Conundrum

Pricing the Priceless: A Health Care Conundrum

Rethinking Los Angeles

Folio - Robbert Flick On Pico Boulevard Looking North Rethinking Los Angeles - Greg Hise, Michael J Dear and H Eric Schockman Los Angeles in the 21st Century - Steven B Sample Representing Los Angeles - Robbert Flick in conversation with Michael J Dear The Inner City 'Problem' - Paul C Hudson Remaking the Los Angeles Economy - Stuart A Gabriel Cyclical Fluctuations and Structural Evolution Economic Referendum - Jacquelyn Dupont-Walker Financing the Future in Los Angeles - Gary A Dymski and John M Veitch From Depression to the 21st Century Accountability and Responsiveness - Abby J Liebman Is Los Angeles Governable? - H Eric Schockman Revisiting the City Charter Community Policing - Mark Kroeker Los Angeles and the Future - Harlan Hahn Uprisings, Identity and New Institutions Hollywood, USA - Leo Braudy Lakewood, California - Alida Brill 'Tomorroland' at 40 Folio - ADOBE LA Bordergraphies A Small Introduction to the 'G' Funk Era - Todd Boyd Gangsta Rap and Black Masculinity in Contemporary Los Angeles Milagros - Ruben Martinez Our LA? Korean Americans in Los Angeles after the Civil Unrest - Edward J W Park Payment - Eloise Klein Hardy Multiracial Organizing Among Environmental Justice Activists in Los Angeles - Laura Pulido Environment, Economy, Equality - Lilian Kawasaki Radical Reform versus Professional Reform in American Schools - Guilbert C Hentschke The View from Southern California The Health Care Crisis - William Loos The Health Care Conundrum - Robert E Tranquada Remaking the City - Margaret Crawford Transporting Los Angeles - Genevieve Giuliano 'Can't We All Get Along?' - The Reverend Cecil Murray Re-Imagining Los Angeles - Robert Fishman