Блог Анкара

In This Chapter

^ Seeking certainty about solubility ^ Keeping tabs on concentrations ^ Making dilutions

Compounds can form mixtures. When compounds mix completely, right down to the level of individual molecules, we call the mixture a Solution. Each type of compound in a solution is called a Component. The component of which there is the most is usually called the Solvent. The other components are called Solutes. Although most people think "liquid" when they think of solutions, a solution can be a solid, liquid, or gas. The only criterion is that the components are completely intermixed. We explain what you need to know in this chapter.

Seeing Different Forces at Work in Solubility

For gases, forming a solution is a straightforward process. Gases simply diffuse into a common volume (see Chapter 11 for more about diffusion). Things are a bit more complicated for condensed states like liquids and solids. In liquids and solids, molecules or ions are crammed so closely together that Intermolecular forces Are very important. Examples of these kinds of forces include ion-dipole, dipole-dipole, hydrogen bonding, and London (dispersion) forces. We touch on the physical underpinnings of these forces in Chapter 5.

Introducing a solute into a solvent initiates a tournament of forces. Attractive forces between solute and solvent compete with attractive solute-solute and solvent-solvent forces. A solution forms only to the extent that solute-solvent forces dominate over the others. The process in which solvent molecules compete and win in the tournament of forces is called Solvation Or, in the specific case where water is the solvent, Hydration. Solvated solutes are surrounded by solvent molecules. When solute ions or molecules become separated from one another and surrounded in this way, we say they’re Dissolved.

Imagine that the members of a ridiculously popular "boy band" exit their hotel to be greeted by an assembled throng of fans and the media. The band members attempt to cling to each other, but are soon overwhelmed by the crowd’s ceaseless, repeated attempts to get closer. Soon, each member of the band is surrounded by his own attending shell of reporters and hyperventilating teenage girls. So it is with dissolution.

A.

The tournament of forces plays out differently among different combinations of components. In mixtures where solute and solvent are strongly attracted to one another, more solute can be dissolved. One factor that always tends to favor dissolution is Entropy, A kind of disorder or "randomness" within a system. Dissolved solutes are less ordered than undissolved solutes. Beyond a certain point, however, adding more solute to a solution doesn’t result in a greater amount of solvation. At this point, the solution is in dynamic equilibrium; the rate at which solute becomes solvated equals the rate at which dissolved solute Crystallizes, Or falls out of solution. A solution in this state is Saturated. By contrast, an Unsaturated Solution is one that can accommodate more solute. A Supersaturated Solution is one in which more solute is dissolved than is necessary to make a saturated solution. A supersaturated solution is unstable; solute molecules may crash out of solution given the slightest perturbation. The situation is like that of Wile E. Coyote who runs off a cliff and remains suspended in the air until he looks down — at which point he inevitably falls.

The concentration of solute required to make a saturated solution is the Solubility Of that solute. Solubility varies with the conditions of the solution. The same solute may have different solubility in different solvents, and at different temperatures, and so on.

When one liquid is added to another, the extent to which they intermix is called Miscibility. Typically, liquids that have similar properties mix well — they are Miscible. Liquids with dissimilar properties often don’t mix well — they are Immiscible. This pattern is summarized by the phrase, "like dissolves like." Alternately, you may understand miscibility in terms of the Italian Salad Dressing Principle. Inspect a bottle of Italian salad dressing that has been sitting in your refrigerator. Observe the following: The dressing consists of two distinct layers, an oily layer and a watery layer. Before using, you must shake the bottle to temporarily mix the layers. Eventually, they’ll separate again because water is polar and oil is nonpolar. (See Chapter 5 if the distinction between polar and nonpolar is lost on you.) Polar and nonpolar liquids mix poorly, though occasionally with positive gastronomic consequences.

Similarity or difference in polarity between components is often a good predictor of solubility, regardless of whether those components are liquid, solid, or gas. Why is polarity such a good predictor? Because polarity is central to the tournament of forces that underlies solubility. So, solids held together by ionic bonds (the most polar type of bond) or polar covalent bonds tend to dissolve well in polar solvents, like water. For a refresher on ionic and covalent bonding, visit Chapter 5.

Sodium chloride dissolves more than 25 times better in water than in methanol. Explain this difference, referring to the structure and properties of water, methanol, and sodium chloride.

Sodium chloride (NaCl) is an ionic solid, a lattice composed of sodium cations (atoms with positive charge) alternating with chlorine anions (atoms with negative charge). The lattice has a highly regular, idealized geometry and is held together by ionic bonds, the most polar

Type of bond. To dissolve NaCl, a solvent must be able to engage in very polar interactions with these ions and do so with near-ideal geometry. The structure and properties of water (which is polar) are better suited to this task than are those of methanol (see the following figure). The two O-H bonds of water (on the left) partially sum to produce a strong dipole along the mirror image plane of the molecule that runs between the two hydrogen atoms. Methanol (on the right) is also polar, due largely to its

Own O-H bond, but is less polar than water. In solution, water molecules can orient their dipoles cleanly and in either of two directions to interact favorably with Na+ or Cl – ions. Methanol molecules can engage in favorable interactions with these ions too, but not nearly as well as water.

A)

H H

B)

H

H

H

1. Lattice energy Is a measure of the strength of the interactions between ions in the lattice of an ionic solid. The larger the lattice energy, the stronger the ion-ion interactions. Here is a table of ionic solids and their associated lattice energies. Predict the rank order of solubility in water of these ionic solids.

Sodium Salt Lattice Energy, kJ mol"1

NaBr 747

NaCl

NaF

NaI

787 923 704

Solve It

2. Ethanol, CH3CH2OH, is miscible with water. Octanol, CH3(CH2)7OH, isn’t miscible in water. Is sucrose (as in table sugar) likely to be more soluble in ethanol or octanol? Why?

Solve It

Altering Solubility with Temperature

Increasing temperature magnifies the effects of entropy on a system. Because the entropy of a solute is usually increased when it dissolves, increasing temperature usually increases solubility — for solid and liquid solutes, anyway. Another way to understand the effect of temperature on solubility is to think about heat as a reactant in the dissolution reaction:

Solid solute + Water + Heat — Dissolved solute

Heat is usually absorbed when a solute dissolves. Increasing temperature corresponds to added heat. So, by increasing temperature you supply a needed reactant in the dissolution reaction. (In those rare cases where dissolution releases heat, increasing temperature can decrease solubility.)

A.

Gaseous solutes behave differently than do solid or liquid solutes with respect to temperature. Increasing the temperature tends to decrease the solubility of gas in liquid. To understand this pattern, check out the concept of vapor pressure. (If creaking sounds emanate from your skull as you try to remember what vapor pressure is about, take a peek at Chapter 11.) Increasing temperature increases vapor pressure because added heat increases the kinetic energy of the particles in solution. With added energy, these particles stand a greater chance of breaking free from the intermolecular forces that hold them in solution. A classic, real-life example of temperature’s effect on gas solubility is carbonated soda. Which goes flat (loses its dissolved carbon dioxide gas) more quickly: warm soda or cold soda?

The comparison of gas solubility in liquids with the concept of vapor pressure highlights another important pattern: Increasing pressure increases the solubility of a gas in liquid. Just as high pressures make it more difficult for surface-dwelling liquid molecules to escape into vapor phase, high pressures inhibit the escape of gases dissolved in solvent. The relationship between pressure and gas solubility is summarized by Henry’s Law:

Solubility = Constant x Pressure

The "constant" is Henry’s Constant, And its value depends on the gas, solvent, and temperature. A particularly useful form of Henry’s Law relates the change in solubility (S) that accompanies a change in pressure (P) Between two different states:

S1 / P1 = S2 / P2

According to this relationship, tripling the pressure triples the gas solubility, for example.

Henry’s Constant for dinitrogen gas in water at 293K is 0.69 x 10-3 mol L-1 atm-1. The partial pressure of dinitrogen in air at sea level is 0.78 atm. What is the solubility of N2 in a glass of water at 20°C sitting on a coffee table within a beach house?

0.54 X 10"3 mol L"1. This problem requires the direct application of Henry’s Law.

The glass of water is at 20°C, which is equivalent to 293K (just add 273 to any Celsius temperature to get the Kelvin equivalent). Because the glass sits within a beach house, we can assume the glass is at sea level. So, we can use the provided values for Henry’s Constant and the partial pressure of N2.

Solubility = (0.69 x 10-3 mol L-1 atm-1) x (0.78 atm) = 0.54 x 10-3 mol L-1

3. A chemist prepares an aqueous solution of cesium sulfate, Ce2(SO4)3, swirling the beaker in her gloved hand to promote dissolution. She notices something, momentarily furrows her brow, and then smiles knowingly. She nestles the beaker into a bed of crushed ice within a bucket. What did the chemist notice, why was she briefly confused, and why did she place the dissolving cesium sulfate on ice?

Solve It

Deep-sea divers routinely operate under pressures of multiple atm. One malady these divers must be concerned with is "the bends," a dangerous condition that occurs when divers rise too quickly from the depths, resulting in the over-rapid release of gas from blood and tissues. Why do the bends occur?

Solve It

5. Reefus readies himself for a highly productive Sunday afternoon of football watching, arranging bags of cheesy poofs and a six-pack of grape soda around his beanbag chair. At kickoff, Reefus cracks open his first grape soda and settles in for the long haul. Three hours later, covered in cheesy crumbs, Reefus marks the end of the fourth quarter by cracking open the last of the six-pack. The soda fizzes violently all over Reefus and the beanbag chair. What happened?

6. The grape soda preferred by Reefus (the

Gentleman introduced in Question 5) is bottled under 3.5 atm of pressure. Reefus lives on a bayou at sea level (hint: 1 atm). The temperature at which the soda is bottled is the same as the temperature in Reefus’s living room. Assuming that the concentration of carbon dioxide in an unopened grape soda is 0.15 mol L-1, what is the concentration of carbon dioxide in an opened soda that has gone flat while Reefus naps after the game?

Solve It

Solve It

Concentrating on Molarity and Percent Solutions

It seems that different solutes dissolve to different extents in different solvents in different conditions. How can anybody keep track of all these differences? Chemists do so by measuring Concentration. Qualitatively, a solution with a large amount of solute is said to be Concentrated. A solution with only a small amount of solute is said to be Dilute. As you may suspect, simply describing a solution as concentrated or dilute is usually about as useful as calling it "pretty" or naming it "Fifi." We need numbers. Two important ways to measure concentration are Molar-.ctABEfl Ity And Percent solution.

Molarity relates the amount of solute to the volume of the solution:

Molarity = (moles of solute) / (liters of solution)

To calculate molarity, you may have to use conversion factors to move between units. For example, if you’re given the mass of a solute in grams, use the molar mass of that solute to convert the given mass into moles. If you’re given the volume of solution in cm3 or some other unit, you need to convert that volume into liters.

The units of molarity are always mol L-1. These units are often abbreviated as M And referred to as "molar." Thus, 0.25M KOH(aq) is described as "Point two-five molar potassium hydroxide" and contains 0.25 moles of KOH per liter of solution. Note that this does Not Mean that there are 0.25 moles KOH per liter of Solvent (water, in this case) — only the final volume of the solution (solute plus solvent) is important in molarity.

Like other units, the unit of molarity can be modified by standard prefixes, as in millimolar (mM, 10-3 mol L-1) and micromolar (uM, 10-6 mol L-1).

Percent solution is another common way to express concentration. The precise units of per-jljjjl ) cent solution typically depend on the phase of each component. For solids dissolved in liquids, mass percent is usually used:

Mass % = 100% x-mass °fs°lute -

Total mass of solution

^ This kind of measurement is sometimes called a mass-mass percent solution because one mass is divided by another. Very dilute concentrations (as in the concentration of a contaminant in drinking water) are sometimes expressed as a special mass percent called Parts per million (ppm) Or Parts per billion (ppb). In these metrics, the mass of the solute is divided by the total mass of the solution, and the resulting fraction is multiplied by 106 (ppm) or by 109 (ppb).

Sometimes, the term Percent solution Is used to describe concentration in terms of the final volume of solution, instead of the final mass. For example:

"5% Mg(OH)2" can mean 5g magnesium hydroxide in 100 mL final volume. This is a mass-volume percent solution.

"2% H2O2" can mean 2 mL hydrogen peroxide in 100 mL final volume. This is a volume-volume percent solution.

Clearly, it’s important to pay attention to units when working with concentration. Only by observing which units are attached to a measurement can you determine whether you are working with molarity, mass percent, or with mass-mass, mass-volume, or volume-volume percent solution.

Q. Calculate the molarity and the mass-volume percent solution obtained by dissolving 102.9g H3PO4 into 642 mL final volume of solution. Be sure to use proper units. (Hint: 642 mL = 0.642L)

A. First, calculate the molarity:

102.9gH2PO4 0.642L

Mol H 3PO 4 98.0g H3PO4

= 1.64M H3PO4

Next, calculate the mass-volume percent solution: 102.9gH2PO

642 mL

- x 100% = 16.0% mass/volume, or

16.0g H3PO

100 mL

Note that the convention in molarity is to divide moles by Liters, But the convention in mass percent is to divide grams by Milliliters. If you prefer to think only in terms of liters (not mil-liliters), then simply consider mass percent as kilograms divided by liters.

7. Calculate the molarity of these solutions:

A. 2.0 mol NaCl in 0.872L solution

B. 93g CuSO4 in 390 mL of solution

C. 22g NaNO3 in 777 mL of solution

Solve It

8. How many grams of solute are in each of these solutions?

A. 671 mL of 2.0MNaOH

B. 299 mL of 0.85MHCl

C. 2.74L of 258 mMCa(NO3)2

Solve It

9. A 15.0MSolution of ammonia, NH3, has density 0.90g mL-1. What is the mass percent of this solution?

Solve It

10. A chemist dissolves 2.5g of glucose, C6H12O6, into 375 mL of water. What is the mass percent of this solution? Assuming negligible change in volume upon addition of glucose, what is the molarity of the solution?

Solve It

Changing Concentrations by Making Dilutions

Real-life chemists in real-life labs don’t make every solution from scratch. Instead, they make concentrated Stock solutions And then make Dilutions Of those stocks as necessary for a given experiment.

To make a dilution, you simply add a small quantity of a concentrated stock solution to an amount of pure solvent. The resulting solution contains the amount of solute originally taken from the stock solution, but disperses that solute throughout a greater volume. So, the final concentration is lower; the final solution is less concentrated and more dilute.

But how do you know how much of the stock solution to use and how much of the pure solvent to use? It depends on the concentration of the stock and on the concentration and volume of the final solution you want. You can answer these kinds of pressing questions by using the dilution equation, which relates concentration (C) And volume (V) Between initial and final states:

C1 X V1 = C2 X V2

This equation can be used with any units of concentration, provided the same units are used throughout the calculation. Because molarity is such a common way to express concentration, the dilution equation is sometimes expressed in the following way, where M1 and M2 refer to the initial and final molarity, respectively:

M1 X V1 = M2 X V2

Q. How would you prepare 500 mL of

200 mM NaOH(aq), given a stock solution of 1.5M NaOH?

A. Add 67 mL 1.5M NaOH stock solution to 433 mL water.

Use the dilution equation: M1 x V1 = M2 x V2

The initial molarity, M1, derives from the stock solution, and so is 1.5M. The final molarity is the one you want in your final solution, 200 mM, Which is equivalent to 0.200M. The final volume is the one you want for your final solution, 500 mL,

Which is equivalent to 0.500L. Using these known values, you can calculate for the initial volume, V1:

V1 = (0.200MX 0.500L) / 1.5M= 6.7 x 10-2L

The calculated volume is equivalent to 67 mL. The final volume of the aqueous solution is to be 500 mL. 67 mL of this volume derives from the stock solution. The remainder, 500 mL – 67 mL = 433 mL, derives from pure solvent (water, in this case). So, to prepare the solution, add 67 mL 1.5MStock solution to 433 mL water. Mix and enjoy.

11. What is the final concentration of a solution prepared by diluting 2.50 mL of 3.00M KCl(aq) up to 0.175L final volume?

Solve It

12. A certain mass of ammonium sulfate,

(NH4)2SO4, is dissolved in water to produce 1.65L of solution. 80.0 mL of this solution is diluted with 120 mL of water to produce 200 mL of 200 mM(NH4)2SO4. What mass of ammonium sulfate was originally dissolved?

Solve It

Answers to Questions on Solutions

By this point in the chapter, your brain may feel as if it has itself dissolved. Check your answers, boiling away that confusion to reveal crystalline bits of hard-earned knowledge. In other words, make sure you know what you’re doing. Solutions are critically important. Really.

D The rank order from most to least soluble is: Nal, NaBr, NaCl, NaF. As the question indicates, the larger the lattice energy is, the stronger the forces holding together the ions. Dissolving those ions means outcompeting those forces; a solution forms when attractive solute-solvent forces dominate over others (such as solute-solute bonds). So, salts with lower lattice energy are typically more soluble than those with higher lattice energy.

CM Sugar should be more soluble in ethanol than in octanol. Like dissolves like. Chemists know from experience that sugar dissolves well in water. Therefore, we expect sugar to dissolve best in solvents that are most similar to water. Because ethanol is more miscible with water than is octanol, we expect that ethanol has solvent properties (especially polarity) more like water than does octanol.

CM The chemist noticed as she swirled the beaker of dissolving cesium sulfate that the beaker

Was becoming noticeably warmer. This observation momentarily confused her, because it suggested that the dissolution of cesium sulfate released heat, a state of affairs opposite to that usually observed with dissolving salts. Having diagnosed the situation, she cleverly turned it to her advantage. With typical salts, increasing temperature increases solubility in water, so heating a dissolving mixture can promote dissolution. In the case of cesium sulfate, however, the reverse is true: By cooling the dissolving mixture, the chemist promoted solubility of the cesium sulfate.

MM At the high pressures to which deep-sea divers are exposed during their dives, gases become more soluble in the blood and tissue fluids due to Henry’s Law (Solubility = Constant X Pressure). So, when the divers do their thing at great depth, high concentrations of these gases dissolve into the blood. If the divers rise to the surface too quickly at the end of a dive, the solubility of these dissolved gases changes too quickly in response to the diminished pressure. This situation can lead to the formation of tiny gas bubbles in the blood and tissues. These bubbles can be deadly.

MM Nothing dramatically fizzy happened when Reefus opened the first soda because that soda was still cold from the refrigerator. As the game progressed, however, the remaining sodas warmed to room temperature as they sat beside Reefus’s beanbag chair. Gases (like carbon dioxide) are less soluble in warmer liquids. So, when Reefus opened the warm, fourth-quarter soda, a reservoir of undissolved gas burst forth from the can.

CM 4.3 X 10"2 mol L"1. To solve this problem, use the two-state form of Henry’s Law:

51 / P1 = S2 / P2

The initial solubility and pressure are 0.15 mol L-1 and 3.5 atm, respectively. The final pressure is 1.0 atm. Using these known values, solve for the final solubility:

52 = (0.15 mol L-1 / 3.5 atm) X 1.0 atm = 4.3 X 10-2 mol L-1

MM Solve these kinds of problems by using the definition of molarity and conversion factors: A. 2.3MNaCl

2.0Am0o’NaCl = 2.3M NaCl 0.872L

B. 1.5M CuSO4

93gCuSO4 103 mL molCuSO

390 mL

^ = 1-5M CuSO4 160gCuSO4 4

C. 0.33M NaNO3

22iNaN, O3 X L°^mL X J??^ = 0.33M NaNO3 777 mL L 85.0gNaNO3

Efl Again, conversion factors are the way to approach these kinds of problems. Each problem features a certain volume of solution that contains a certain solute at a certain concentration. Begin each calculation with the given volume. Then convert to moles by multiplying the volume by the concentration. Finally, convert from moles to grams by multiplying by the molar mass of the solute.

A. 54g NaOH

671 mL x L x 2.0 mol NaOH x 40.0gNaOH = 54gNaOH 1 10 3 mL L mol NaOH

B. 9.3g HCl

299 mL x L x 0.85 mol HCl x 36.5gHCl = 9 3gHCl 1 103 mL L mol HCl

C. 116g Ca(NO3)2

2 74L 258 mmol Ca (NO3 )2

Mol x 164gCa (NO3 )2

10

Mmol mol Ca(NO3 )2

= 116gCa (NO3 )2

H 28%. To calculate mass percent, you must know the mass of solute and the mass of solution. The molarity of the solution tells you the moles of solute per volume of solution. Starting with this information, you can convert to mass of solute by means of the gram formula mass (see Chapter 7 for details on calculating the gram formula mass):

15.0 mol L-1 X 17.0g mol-1 = 255g L-1

So, each liter of 15.0M NH3 contains 255g NH3 solute. But how much mass does each liter of solution possess? Calculate the mass of the solution by using the density. Note that the problem lists the density in units of milliliters, so be sure to convert to the proper units:

1.0L solution X (0.90g / 1.0 X 10-3L) = 9.0 X 102g solution

So, 255g NH3 occur in every 900g of 15.0MNH3. Now you can calculate the mass percent:

Mass percent = 100% X (255g / 900g) = 28%

1

L

IfiJ The mass percent is 0.66%; the molarity is 3.7 X 10-2M To calculate the mass percent, you

Must use the estimate that 1.0 mL of water has 1.0g mass. This is a very good approximation at room temperature, and one with which you should be familiar. So, 375 mL water has 375g mass. Adding 2.5g glucose increases that mass to 377.5g for the final solution. Calculate the mass percent as follows:

Mass % = 100% (2.5g / 377.5g) = 0.66%

To calculate the molarity, you must know the final volume of the solution. Although adding 2.5g to 375 mL water increases the volume from 375 mL, the increase is very small compared to the volume of the water. So, 375 mL is a good approximation of the final volume of the solution. Next, convert from grams of glucose to moles of glucose by means of the gram formula mass:

Moles glucose = 2.5g glucose (1 mol / 180.2g) = 1.4 10-2 mol glucose

Now that you know the moles of glucose and the final volume of solution, calculating molarity is easy:

Molarity = (1.4 10-2 mol glucose) / (0.375L solution) = 3.7 10-2M

IF| 4.29 X 10-2M Use the dilution equation: M1 X V1= M2 X V2

In this problem, the initial molarity is 3.00M, the initial volume is 2.50 mL (or 2.50 X 103L), and the final volume is 0.175L. Use these known values to calculate the final molarity, M2:

M2 = (3.00 mol L-1 2.50 10-3L) / 0.175L = 4.29 10-2M

U 109g (NH4)2SO4. First, use the dilution equation to find the concentration of the original solution:

M1 = (200 X 10-3 mol L-1 X 200 X 10-3L) / (80.0 X 10-3L) = 0.500M

This calculation means that the original solution contained 0.500 mol (NH4)2SO4 per liter of solution. The question indicates that 1.65L of this original solution were prepared, so:

I65i 0.500 mmol (NH4) SO4 132g(NH4) SO4 , .

I^k X–i-^–x-^— = 109g (NH4) SO4

1 L mol (NH4)2 SO4 2

In This Chapter

^ Finding out what chiropractic is all about

^ Understanding how it works

^ Discovering what chiropractic can be good for

^ Knowing what to expect in a typical consultation

^ Knowing how to find a safe and effective chiropractor

Chiropractic is one of the most widely practised forms of complementary medicine in the West. In fact, even for many traditional doctors it is now one of the treatments of choice for bad backs and neck problems.

In this chapter, I tell you how chiropractic started as a therapy back in 19th-century America with its founder, Daniel D. Palmer, and how it developed into a popular and effective modern therapy today.

You find out about the types of assessments that chiropractors carry out to determine what’s wrong with you. I also tell you about the moves chiropractors may make to put things right and the types of positions you may find yourself in during therapy!

Many chiropractors are also skilled in treating animals. So I let you know how even your dog, cat, racehorse, or bunny rabbit can have joint problems eased by chiropractic.

Finding Out about Chiropractic

Chiropractic diagnoses, treats, and prevents problems with the spine, joints, and muscles and is also concerned with their effects on the nervous system, internal organs, and general health. Chiropractors may use x-rays and other tests as part of their diagnosis.

The aim of treatment is to identify areas of restriction and muscle tightness or pain and to then free the restricted joints and relax the muscles. Treatment consists mainly of adjustments (also called manipulations) to restore normal movement to the joints, bring the body back into alignment and balance and to facilitate the body’s own healing. These adjustments are usually performed with the hands but occasionally special hand-held devices are used.

Daniel David Palmer had already been a beekeeper and a grocer before he began to develop his interest in healing. He read widely on metaphysical ideas about healing that were popular at the time and probably read the works of Andrew Taylor Still, the founder of osteopathy. Whether the two ever met though isn’t known.

The caretaker in Palmer’s office, Harvey Lillard, had been nearly deaf for 17 years after hearing a ‘pop’ in his back one day after having been in a cramped position for a long time. Palmer claims to have manipulated Lillard’s spine and that almost immediately Lillard could hear carriages in the street down below and regained his hearing. Palmer argued that there was nothing chance about this development but that it had been the careful application of his ideas in practice. Lillard’s relatives dispute this story, saying that actually Palmer slapped Lillard heartily on the back one day, after he told a good joke, and then became interested in how his hearing miraculously returned!

Later, Palmer came to stress more strongly his belief in the religious and spiritual aspects of

Chiropractic and claimed that he’d been given the ideas of chiropractic from a deceased doctor during a seance and that he’d ‘received chiropractic from the other world’. He later even likened himself to a spiritual leader who’d searched for and found the cause of all disease.

However, by this time chiropractors had organised themselves as a profession under the leadership of his son and successor, B. J. Palmer, and other prominent chiropractors, and Daniel Palmer became increasingly sidelined.

Palmer was fond of saying, ‘The best physicians are Dr Diet, Dr Quiet, and Dr Merryman’, but I don’t know how merry he was himself. He was unhappy at being sidelined and in constant dispute with his son after selling him his chiropractic college. Palmer died controversially in 1913. The official cause of death was typhoid, but his widow later filed an unsuccessful lawsuit claiming his death was the result of injuries from being knocked down by a car driven at him by his son.

Chiropractic is most commonly used for back and neck problems but can also be used to treat headaches, sciatica (nerve pain from the lower back down into the legs), other types of joint pain, Repetitive Strain Injuries (RSIs), sports injuries, poor posture, and everyday wear and tear.

Chiropractors may also give advice on posture, exercise, lifestyle, and general nutrition.

A (very) brief history of chiropractic

Chiropractic’s founder was Daniel D. Palmer, a Canadian, who moved to America with his family in 1865. He held several jobs and eventually worked as a Magnetic healer. After using spinal manipulation to heal someone with deafness and another with heart problems, Palmer developed his theory of ‘the science (knowledge) and art (adjusting) of chiropractic’. Together with a friend he came up with the term by combining the Greek words Cheir Meaning ‘hand’ and Praxis Meaning ‘action’, thus describing his manipulations done by hand.

In 1896, Palmer added a school of chiropractic to his magnetic healing practice and began to educate others. One of his first graduates, Solon Langworthy, later opened a second college and incorporated ideas from naturopathy and osteopathy in his practice. He also first coined the word Subluxation To describe how malpositioned bones in the spine (vertebrae) can interfere with the surrounding nerves.

With the growth of the medical profession in the US, chiropractors became hounded and Palmer was thrown into jail twice for practising medicine without a licence. His son took over the development of chiropractic education and expanded it considerably. It was later successfully argued that chiropractic was a profession separate from medicine and the path to the development of modern, scientific chiropractic began.

Chiropractic was brought to the UK in the 1900s, and the British Chiropractic Association was formed in 1925. Several schools of chiropractic now operate in the UK, and since an Act of Parliament in 1994, all chiropractors must be registered with the General Chiropractic Council, which regulates training and standards.

Modern day chiropractic has long dropped the more metaphysical elements of Palmer’s ideas and is now more firmly rooted in scientific theory and evidence-based medicine. However, research findings on chiropractic have been mixed (see ‘Evidence that it works’ later on in this chapter).

Grasping the idea behind chiropractic

Daniel Palmer believed that the body has an ‘innate intelligence’, enabling it to organise and heal itself if the right conditions are provided. He believed that the nervous system played an important part in this process and that interference with the nerve supply, due to spinal misalignment or other joint imbalance, was the basic cause of disease.

His theories developed over time. Originally he argued that displacements in the spine caused friction on the nerves leading to inflammation and disease. He later favoured the idea of nerve Impingement, Whereby pressure on the nerves caused by imbalance of spinal bones can affect internal organ function. He also adopted Langworthy’s term, subluxation, and at one time argued that ‘A subluxated vertebrae. . . is the cause of 95 per cent of all diseases. The other five per cent is caused by displaced joints other than those of the vertebral column.’

However, the concept of subluxation has remained very controversial in chiropractic, with it coming to have different meanings for different practitioners while others have opted to drop it altogether.

Palmer’s idea was that if spinal and other joint imbalance can be corrected, and normal nerve function restored, then nerve irritation, inflammation, discomfort, and pain can be eased and related ailments relieved.

Resolving restriction and restoring normal function are still central to chiropractic today, but many of Palmer’s original theories about how chiropractic works have been abandoned in favour of more scientific explanations based on an understanding of the physiological mechanisms of pain and pain relief.

Chiropractic today

Chiropractic was one of the first complementary therapies to be regulated and licensed in the UK, with the Chiropractor’s Act of 1994.

As part of the Act, the General Chiropractic Council (GCC; Www. gcc-uk. org) was established as an independent body to regulate the profession. The GCC sets standards for education and training in chiropractic and for professional practice.

Since 2001, it is illegal for anyone to call themselves a chiropractor unless they’ve completed a recognised training course and are registered with the GCC. Modern training is comprehensive and generally consists of a four – or five-year degree course incorporating clinical training.

Currently, the UK has three approved chiropractic colleges and more than 2,000 practitioners. In the US, where chiropractic is widespread, more than 50,000 chiropractors practise. Chiropractic is also established in Australia and New Zealand and elsewhere in Europe.

Modern treatment remains almost entirely based on manual therapy techniques. Chiropractors don’t perform surgery or prescribe medicines (apart from some US chiropractors who are licensed to perform certain types of minor surgery).

Understanding How Chiropractic Works

The neuro-musculo-skeletal system is made up of the bones, joints, muscles, tendons, ligaments, soft-tissues, and nerves. It provides structural support for the body and the mechanics for our daily movements.

Accident, trauma, poor posture, stress, illness, or wear and tear can all cause damage to the neuro-musculo-skeletal system leading to loss of normal movement, misalignment and nerve inflammation. Nerve irritation can in turn lead to discomfort and pain, manifesting as back pain, neck pain, headache, or even organ dysfunction or it can contribute to Referred pain, That is, pain in other areas of the body away from the site of injury or trauma.

Chiropractic adjustments open up the spaces between the spinal bones (vertebrae) and loosen up other joints, thereby increasing flexibility and range of motion. Adjustments also improve circulation through muscle tissue and help to reduce inflammation.

Chiropractic techniques also stimulate what are known as Joint movement receptors, Which can alter the messages sent to the brain about the joint’s position and movement and can affect nervous system function.

As the nerve irritation is calmed and normal alignment and mobility are regained, then pain and discomfort may be relieved and normal function restored.

Discovering Whom and What Chiropractic Is Good For

Most people associate chiropractic with the treatment of bad backs and necks, and this certainly makes up a large proportion of the average chiropractor’s daily practice. However, most chiropractors also treat a range of other conditions.

Conditions that chiropractic can treat

Today’s chiropractors most commonly treat the following:

Back, neck, and shoulder problems Joint and muscle problems and poor posture Nerve pain, including sciatica Headaches Whiplash injuries Sports injuries

Benefits have also been seen in the treatment of the following:

Infant colic Digestive problems Respiratory problems such as asthma Repetitive strain injuries Menstrual pain Arthritis Migraines

Many years ago I was invited to speak at a conference organised by the McTimoney Chiropractic Association. At that time I hadn’t yet experienced chiropractic myself, although I had had osteopathy many times. As luck would have it I got stuck in a motorway traffic jam due to an accident and had spent almost six hours cramped in a car by the time I arrived at the conference. The cramped conditions, plus the stress of worrying that I might be late for my presentation (thankfully I wasn’t), must have combined so that by the time I arrived I had a pretty bad backache. The organiser noticed that

I was moving painfully and laughingly gestured towards the conference hall saying, ‘Here are 200 people who can resolve the problem for you – you’ve come to the right place!’ Right after my presentation one of the practitioners gave me some treatment. I was amazed at how gentle and effective it was. I felt better almost immediately and had a trouble-free and pain-free return home. Since that time I have worked regularly with chiropractors in my clinical practice and have found that the treatments have helped large numbers of my patients.

Evidence that it works

Studies in the UK, US, and Australia have shown benefits from chiropractic in the treatment of low back pain. In particular, a Medical Research Council clinical trial and its follow-up, reported in the British Medical Journal In 1990 and 1995, found that chiropractic treatment for back pain was more effective than hospital outpatient treatment.

Other trials have shown no specific benefits compared to orthodox or other treatments, and certain large scale review studies have concluded that overall the evidence is weak. However, some of these negative studies have been criticised because they don’t take into account how multi-faceted back pain can be or because they analyse the effects of chiropractic manipulation alone, whereas in practice chiropractic often includes more than just manipulation.

Research on other conditions has also been inconclusive. Some have shown good results for infant colic and headaches whereas others for these conditions, and also asthma, carpal tunnel syndrome (nerve compression in the wrist), and painful menstruation, have not. However, many of these studies have had design flaws and more good research is needed.

For more information about chiropractic research, check out the Cochrane Library (Www. cochrane. org/reviews/clibintro. htm), the NHS Complementary and Alternative Medicine Specialist Library (Www. library. nhs. uk/cam), or the PubMed database, which can be accessed via Www. nlm. Nih. gov/nccam/camonpubmed. html. Further information on US and Canadian trials can be found at Www. clinicaltrials. gov.

When not to use chiropractic

With care and experience, gentle chiropractic techniques can be used for most conditions, but don’t use vigorous manipulations with the following conditions:

Osteoporosis (brittle bones)

Severe rheumatoid arthritis (bone inflammation)

Unstable osteoarthritis (that is, serious bone degeneration as opposed to the mild osteoarthritic changes that are a normal part of ageing)

\^ Tumours

Neck adjustments should only be performed with great care in people with a history of stroke or high blood pressure. Particular care should also be taken with the elderly and young children or infants.

Chiropractic has a good safety record and the risk of serious complications from it is very low, although a very slight risk of complications with neck manipulations does exist.

What to Expect in a Typical Consultation

Chiropractic consultations usually begin with questions about your medical history and general health, as well as your current symptoms. You may also be asked questions about your diet and lifestyle.

Diagnostic methods

The questions are followed by a physical examination, for which you’re given privacy to undress down to your underwear. Female patients are given a gown to wear, which is open at the back to allow the chiropractor to examine the spine.

The examination focuses on the spine, with the chiropractor checking which joints are moving freely and which may be restricted. Other joints and posture may also be checked. The chiropractor often manoeuvres you into different positions, while you are sitting or lying on the treatment couch, to check the range and ease of movement of your spine and joints and the functioning of your muscles.

You may be asked to bend forward or sideways to check your range of movement or to march on the spot to observe pelvic balance. Different muscle tests may be used to test for pain or immobility. Your skin may be palpated to assess levels of inflammation or muscle tension.

The chiropractor may also perform the following:

Measure your blood pressure and pulse Test your reflexes

Check your heart and lung functions by listening to your chest with a stethoscope, or by means of other tests

Take x-rays if clinically necessary or recommend you for an x-ray or clinical scan elsewhere. If you already have recent x-rays of the affected joint or bone, take these with you to show your chiropractor.

McTimoney chiropractic was developed by engineer John McTimoney, an Irish chiropractor, during the 1950s. After receiving successful chiropractic treatment himself, he studied with an American chiropractor, Dr Mary Ward, in England and went on to open his own school in 1972. He developed many of his own gentle techniques as well as specialised techniques for use with animals.

The key to McTimoney’s techniques is using just the wrist to make the adjustment and then

Removing the hand immediately afterwards to allow the body to adjust itself appropriately, rather than having an adjustment imposed upon it. For more information, see www. mctimoney-chiropractic. org.

One of McTimoney’s graduates, Hugh Corley also developed his own gentle Whole body Techniques and specialised treatments for animals, calling his method McTimoney-Corley chiropractic. For more information, see www. mctimoney-corley. com.

The chiropractor uses these methods to assess the nature of your symptoms and to identify or rule out any serious underlying disease. Treatment may be delayed until the second visit if diagnostic test results are required.

The chiropractor should explain to you the results of the examination and any test results, the proposed treatment plan, and outline any risks associated with your condition or the treatment.

Getting to grips with chiropractic techniques

Chiropractic treatment consists mainly of Adjustments, Carefully controlled movements, with the quick application of slight force, designed to increase the quality and range of movement in the area, or joint, being treated. The aim is to loosen and mobilise any areas that are locked or restricted.

Often the whole spine and other joints are treated, not just the affected part of the body, because each part is seen to have an effect on the other.

Chiropractors have many techniques in common with other manual therapists, such as osteopaths and physiotherapists but tend to focus on these adjustments.

Sometimes you hear a Crack Or Pop When the joint is released. This may sound alarming, but is harmless and simply due to pressure changes causing the release of tiny gas bubbles around the joint. The treatment is usually painless. If the area is very inflamed or sore, treatment can be modified accordingly. Other techniques used may include the following:

U Joint mobilisation: Rhythmical moving of the joint and the application of gentle stretches to the surrounding tissue to release tension and ease restriction.

U Direct pressure: Direct pressure to certain Trigger-points In order to release tension and pain.

U Massage: Different types of massage may be used to ease muscle tension, stretch the tissues, and promote circulation.

Most chiropractors also use other non-manual treatments. These may include the following:

U Heat and ice U Ultrasound U Electrical stimulation U Exercise therapy

U Dry needle therapy (a type of trigger-point acupuncture used to relieve pain)

U Magnetic therapy

Chiropractors may also give nutritional, ergonomic and general lifestyle advice.

At the end of your treatment, you may receive the following additional tips and advice:

U You may be shown certain exercises for you to practise between sessions.

U You may be advised on the after-effects of your treatment. Some people experience mild aching, headache, or fatigue, but these are usually minor and ease after a day or so.

U You can discuss the need for further treatments and the time in between appointments.

U You’ll be advised to avoid vigorous exercise, heavy lifting, and longdistance travel right after treatment to allow your tissues time to settle down.

Duration and frequency

The first chiropractic session generally lasts 30 to 60 minutes, while follow-up visits are typically 15 to 20 minutes (depending on the practitioner’s choice of techniques). In the first week, you may be advised to have two or three sessions. Thereafter, sessions are usually once a week, according to need.

For recent conditions, three to six treatments are common, whereas more chronic conditions often require six to twelve treatments. Maintenance treatments at regular intervals to prevent recurrence are also often advised.

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Exploring Chiropractic Approaches

Chiropractors use a variety of techniques and different chiropractors may go about your treatment in different ways. Their choice of technique depends on where they qualified, any special interests they have, and what type of additional courses they’ve attended.

Pronto was a horse used for dressage (a series of complex manoeuvres through which the horse is guided by slight movements of the rider’s hands, legs, and weight to test the horse’s physique and ability and the rider’s skill). He’d won many competitions but had become over-bent after repeated practice with head carriage. As a result, the muscles of his neck and shoulders had become stiff and painful and movement of his forelimbs was becoming restricted. He was also becoming uncharacteristically temperamental and refusing to co-operate during practise sessions.

A chiropractor, specialised in dealing with horses, was recommended by the local vet and worked with Pronto, making adjustments to his neck and shoulders and massaging the

Muscles. She then showed Pronto’s owner how to give him a series of stretches to loosen his muscles and joints, using a carrot as an incentive. (Nicknamed Carrot-practics, Examples of these exercises have been published in Natural Horse Magazine, And you can find them on Www. todayshorse. com/Articles/ HorseCarrotPractics. htm.)

After three treatments, a few days’ rest, and daily Carrot-practics, Pronto was performing better than ever, back to his usually happy disposition and soon in competition-winning form once more. His owner has maintained his exercise regime and occasional maintenance chiropractic treatments and the problem hasn’t recurred.

Certain individual chiropractors have become known for particular styles of treatment that they have pioneered. The most well known of these is John McTimoney who developed what has become known as McTimoney chiropractic.

However, the common goal for all chiropractors is the same: To get your joints, muscles, and nervous system working properly, so that your body can recover and heal as quickly as possible.

Knowing whether your chiropractic treatment is working

Although you may experience immediate benefits from chiropractic treatment, symptoms do sometimes flare-up before they get better. You may feel a bit stiff or sore for a couple of days or feel more tired than usual. However, these effects normally pass after a day or so.

Here are some tips for successful chiropractic treatment:

U If you experience a marked increase in pain, or deterioration in your symptoms, contact your chiropractor for advice.

U Ask your chiropractor what improvements you can realistically expect over what sort of timescale.

U For best results, attend regularly and follow the exercise and lifestyle advice given to you by your chiropractor. Daily practise of the rehabilitation exercises can speed up healing.

U If you have no improvement after a course of treatment, then chiropractic may not be effective for your condition and you may need to consider another form of therapy. Discuss this situation with your practitioner.

Common questions about chiropractic treatment

Here are some questions that I’m often asked about chiropractic:

U Will it hurt? Not usually, no. You may feel a slight click or hear a pop during manipulations, but these are just signs that the manipulation has been successful.

U Do I have to take my clothes off? You’re normally required to strip down to your underwear, but you may wear a robe during treatment if you feel uncomfortable.

U Will I be lying down or sitting up? Treatment may be given while you are sitting, standing, or lying down. Chiropractors use a specially designed treatment couch to maintain comfort during adjustments.

U Will other equipment be used? Some chiropractors use small devices to exert a measured thrust on a particular joint in place of their hands.

U How does the chiropractor know what techniques to use?

Chiropractors are thoroughly trained in diagnosis, assessment, reading x-rays, and clinical practice to enable them to select the safest and most effective techniques for your particular ailment.

U What happens if I’m scared of vigorous manipulations? Discuss your anxiety with your chiropractor, who can modify your treatment if necessary.

Finding a Good Chiropractor

To find a qualified chiropractor in your area, contact the General Chiropractic Council (GCC) (Tel: 020 7713 5155; Www. gcc-uk. org).

Anyone using the name chiropractor must now be registered with this professional body.

McTimoney chiropractors are also members of the McTimoney Chiropractic Association (MCA) (Tel: 01491 829211; Www. mctimoney-Chiropractic. org).

Look for the letters after the person’s name. These will depend on when and where the person qualified but graduates of approved colleges currently have the following: Undergraduate MChiro (Anglo-European College of Chiropractic (AECC)); BSc(Hons) Chiropractic (McTimoney College of Chiropractic); and BSc(Hons) Chiropractic (University of Glamorgan).

American-trained chiropractors have the letters DC (Doctor of Chiropractic) after their names.

Here are some other recommendations for finding a chiropractor:

U Ask friends, family, and colleagues for personal recommendations. U Some sports and leisure clubs offer chiropractic treatment.

W Many GPs have contact with their local chiropractor and may be happy to refer you.

U Consider visiting the teaching clinics at chiropractic colleges (listed below). All students practise under close supervision from experienced practitioners and fees are low compared to private practice.

• Anglo-European College of Chiropractic (Tel: 01202 436200;

Www. aecc. ac. uk).

• University of Glamorgan (Tel: 01443 482287; Www. glam. ac. uk).

• McTimoney College of Chiropractic (Tel: 01235 523336; www. Mctimoney-college. ac. uk).

Questions to ask your chiropractor

You may want to ask your chiropractor about the following:

U Qualifications: Most practitioners are happy to give details of their training and qualifications. If you have any doubt as to their validity, then check them with the General Chiropractic Council (Www. gcc-uk. org).

U Insurance: To be a registered chiropractor, your practitioner must have appropriate indemnity insurance.

U Experience: Ask your practitioner about their experience in treating your particular ailment and their usual degree of success!

U Treatment: Ask about the likely frequency and duration of treatment that you may need and the cost involved.

Counting the cost of chiropractic

Initial chiropractic consultations usually cost around Ј40 to Ј65, while follow-up sessions are in the region of Ј25 to Ј35.

Some GP practices offer chiropractic treatment on the NHS. Ask your doctor for details. Some private health insurances cover chiropractic treatment. Check with your provider for advice.

Some chiropractors offer concessions for retired persons or those on benefits. Ask your chiropractor for details.

Chiropractors trained in animal manipulation, and able to treat animals with veterinary approval, hold a PGDip in Animal Manipulation from either the McTimoney College of Chiropractic (see the earlier sidebar about McTimoney chiropractic) or the Oxford College

Of Equine Physical Therapy (more information is available from Www. mctimoney-corley. comor education@ocept. info). They may be located through either of these organisations or by logging on to Www. natural-animal-Health. co. uk/find-therapist. html.

Ensuring satisfaction

If you’re dissatisfied with your treatment, first talk things over with your practitioner.

If you think that the practitioner has been negligent or unethical in any way, including incompetent treatment and inappropriate touching, you should contact the General Chiropractic Council, which has a formal complaints procedure.

Helping Yourself with Chiropractic

Chiropractors advise many self-help exercises to aid posture and strengthen muscles. Here’s a good one for stretching the lower back and toning the muscles:

1. Lie flat on the floor in a relaxed position with legs outstretched together.

2. Bend your right knee and bring it up towards your chest.

3. Place your hands around the knee and slowly and gently pull it down towards your chest. Don’t strain; simply pull down as far as is comfortable. Keep the left leg straight and flat on the floor while you do this.

4. Hold this position for three to five seconds, breathing normally.

Release any tension and relax as you hold the position.

5. Gently release and lower your leg.

6. Repeat the movement with the opposite leg. Make sure that you keep the outstretched leg flat on the floor and straight out.

7. If you want, you can develop the exercise by bringing both knees up to the chest together and holding as before.

I use this exercise every day to help to prevent back problems that can be triggered by spending hours sitting at the computer writing books! It can be especially helpful to do this exercise first thing in the mornings.

If you have, or have had, any sort of lower back problem or injury, consult your chiropractor, doctor, or other manual therapist before performing this or any other back exercise.

In This Chapter

^ Grasping the fundamentals of the coverage gap

^ Predicting whether you’ll tumble into the coverage gap

^ Sidestepping or narrowing the gap with other benefits

Ust imagine. For months you’ve been filling a prescription for $30 a month. Then one day, you go for a refill and the pharmacist says, "That’ll be $185, please." You shriek, you’re outraged, you think it’s a mistake. But no — you just fell into the doughnut hole. Suddenly, you’re paying full price.

It’s no wonder that this Doughnut hole — the universal nickname for what is officially called the Coverage gap — is the most criticized and unpopular part of the Medicare drug benefit. Unlike almost any other kind of insurance, Part D gives some coverage for your first slice of drug costs and, if your out-of-pocket expenses for drugs are high enough, another chunk of coverage later in the year. But in the middle, there’s this gap, and falling into it means having to pay every cent of drug costs out of your own pocket, unless you have other insurance that picks up any of it.

The doughnut hole doesn’t affect everybody. You won’t fall into it if

Your total drug costs (what you and your plan pay) aren’t high enough to reach the limit of initial coverage over the whole year

You receive Extra Help, which has no gap, as explained in Chapter 5

You have additional benefits that cover your expenses through the gap

You’re enrolled in a Medicare drug plan that covers all of your drugs in the gap

Even if none of these apply to you, you may still be able to avoid the gap or lessen its impact. But the gap exists, and it’s wise not to ignore it. This chapter explains how the doughnut hole works, how to tell whether you’ll

J

Fall into it, and how you may be able to cover some of your costs in the gap with additional benefits. Chapter 16 describes additional methods of bringing down your drug costs.

I use "doughnut hole" or "coverage gap" or just "the gap" interchangeably in this chapter — they all mean the same thing.

Understanding the Basics of the Coverage Gap

It may be hard to get your head around an insurance concept you’ve never met before. After all, car insurance doesn’t suddenly stop sometime through the year after you’ve clocked a certain number of miles. And home insurance doesn’t come with a clause saying you’ll be covered all year except, say, for July and August. But it’s amazing how quickly folks catch on to the idea of the Part D doughnut hole when their pocketbooks are at stake. You will too — I guarantee it!

In the following sections, I walk you through the mechanics of the doughnut hole in some detail so you can grasp exactly how it works. I also explain what drops you into the gap, what gets you out of it, and certain Medicare rules about the gap that you need to know.

The yawning gap in the middle of coverage

As I explain in Chapter 2, Medicare drug coverage has four phases over the course of a calendar year. The doughnut hole is the third phase. But whether you go through only one phase, two, three, or all four depends mainly on the overall cost of the drugs you take during the year.

Phase 1, the deductible: In this phase, you may pay full price for your drugs until the cost reaches a limit set by law ($275 in 2008, $295 in 2009) and drug coverage actually begins. If your plan has a deductible (many plans don’t), this period begins on January 1, or whenever you start using Medicare drug coverage.

Phase 2, the initial coverage period: This phase begins when you’ve met the deductible, if there is one. Otherwise, it begins on January 1, or whenever you start using Medicare drug coverage. In this phase, you pay the co-pays required by your plan for each prescription; the plan

Takes care of the rest of each drug’s price. Phase 2 ends when the total cost of your drugs — what you’ve paid Plus What your plan has paid — reaches a certain amount set each year by law ($2,510 in 2008, $2,700

In 2009).

Phase 3, the coverage gap: This phase begins if and when you reach the dollar limit of Phase 2. Unless you have other insurance that helps fill in the gap (see the later section "Avoiding or Narrowing the Coverage Gap with Other Benefits" for more information), you pay 100 percent of your drug costs until your total out-of-pocket expenses (except for premiums) reach another dollar amount set by law ($4,050 in 2008, $4,350 in 2009).

Phase 4, catastrophic coverage: If your drug costs are high enough to take you through the gap, coverage begins again at a greatly reduced cost. In this period, you pay the standard catastrophic co-pay ($2.25 per prescription for generics or $5.60 for brand-names in 2008; $2.40 and $6.00 respectively in 2009) or 5 percent of the cost of your drugs, whichever is higher. Medicare picks up the remaining cost. Catastrophic coverage ends on December 31. The following day, January 1, you return to Phase 1 (or Phase 2 if your plan has no deductible), and the whole cycle starts over again.

Look again at the last sentence in the preceding paragraph — On January 1, the whole cycle begins all over again. In other words, the four phases repeat every calendar year. I want to be sure you understand this, because some folks think that after they’ve struggled through the doughnut hole and emerged into the rarified air of catastrophic coverage, this last phase goes on forever. Sorry — it doesn’t. But then, the doughnut hole doesn’t go on forever, either. Even if you ended the year paying full price in the gap, you’ll get back to Phase 2 coverage again next year as soon as you’ve met the deductible, or as early as January 1 if your plan has no deductible.

To make more sense of this annual progression, take a look at Table 15-1. It shows how one Medicare beneficiary (Anna) with high drug costs — $800 a month for several prescriptions — went through all four phases and what she and her plan paid each month in 2008.

This example is based on the standard benefit for minimum drug coverage that Congress designed and that many plans stick to (as I explain in Chapters 2 and 3). In other words, Anna is in a plan that charges her a full deductible and 25 percent of the cost of her drugs in the initial coverage period, and offers no coverage in the gap. If she were in a plan that varied the standard design, her costs would be different. Note: The calculations are based on the deductible and dollar limits for the initial coverage period and coverage gap that applied in 2008. These amounts are raised each year.

Table 15-1 One Woman’s Dollar Journey In and _Out of the Doughnut Hole in 2008

Month Anna Pays Anna’s Plan Total Cost of

Pays Her Drugs

January (before Meeting $275 $0 $275 deductible)

January (after Meeting $131.25 $393.75 $525 deductible)

February $200 $600 $800

March $200 $600 $800

April (before Reaching $27.50 $82.50 $110

Coverage gap)

August (after Reaching $33.70 $640.05 $673.75

Catastrophic coverage)

September $40 $760 $800

October $40 $760 $800

November $40 $760 $800

December $40 $760 $800

Total costs in 2008 $4,243.70 $5,356.30 $9,600

In Table 15-1, you can see that Anna paid the deductible (Phase 1) and then 25 percent of her costs in the initial coverage period (Phase 2). She hit the doughnut hole (Phase 3) in the first few days of April, as soon as her total drug costs reached $2,510. She then paid full price until early August, when her out-of-pocket spending since the beginning of the year reached the $4,050 limit. (The shaded rows in the table indicate her total time in the doughnut hole.) Then she came out of the gap and started receiving coverage again at the catastrophic level (Phase 4), paying only 5 percent of the cost of her drugs until the end of December.

Over the entire year, Anna paid less than half (44 percent) of what her drugs actually cost. But a full three-quarters (75 percent) of her expenses came right in the middle, in the doughnut hole. Note that this example focuses on Anna’s payments and savings in buying her drugs under Part D. But, in addition, Anna must pay her plan a monthly premium to receive Part D coverage. A premium of $26 a month, for example, would add $312 to her annual expenses.

What drops you into the doughnut hole

BEH You reach the limit of the initial coverage period (Phase 2 in the previous section’s list) when the money Both you and your plan Pay for your drugs reaches the dollar amount set by law ($2,510 in 2008, $2,700 in 2009). It isn’t just what You Have paid. This point is often overlooked, or misunderstood, with the result that folks fall into the gap a lot sooner than they expect to. I don’t want this to happen to you.

So say, for example, that your co-pay for one of your prescriptions is $25. During the initial coverage period (Phase 2), your plan pays the rest of the price it has negotiated for the drug — say $75. The full price of the drug is $25 + $75 = $100. The $100, not the $25, counts toward the limit. And what you’ve paid to the plan each month in premiums just to receive drug coverage doesn’t count at all.

What lifts you out of the doughnut hole

Ii$jAB£W You get out of the gap as soon as your Own Out-of-pocket spending on drugs since the beginning of the year reaches the limit set by law ($4,050 in 2008, $4,350 in 2009). In this case, what your Plan Has paid doesn’t count. And other rules (no surprise here) outline what counts as "out-of-pocket" spending and what doesn’t.

These payments count toward the coverage gap limit:

Your initial deductible (if your plan has one) during Phase 1.

Your co-pays (or coinsurance) in the initial coverage period (Phase 2) or in the doughnut hole if your plan covers any of your drugs in the gap.

Out-of-pocket payments that you’ve made in the doughnut hole for drugs bought through your plan at a pharmacy in your plan’s network

(Phase 3).

Payments for your drugs bought through your plan and made by a family member, a friend, a charitable group, or a State Pharmacy Assistance Program (any phase). (I cover State Pharmacy Assistance Programs later in this chapter and charities in Chapter 16.)

I Any payment you make toward the cost of your drugs in the coverage gap when a third party (such as an employer or union plan or a pharmaceutical company’s assistance program) picks up the rest of the tab. (I describe these types of extra coverage in the later section "Avoiding

Or Narrowing the Coverage Gap with Other Benefits.") These payments do Not Count toward the limit:

I The monthly premiums you pay to the plan.

I Payments made by your plan for your drugs during the initial coverage period or in the doughnut hole. (Some plans, as you see later in this chapter, cover some drugs in the gap.)

I Payments you make for any drugs not covered by your plan (unless, for medical reasons, the plan has agreed to pay for a drug that it doesn’t normally cover; see Chapter 4 for more on this).

I Payments you make for drugs at pharmacies outside your plan’s network of pharmacies.

I Payments made for your drugs by a current or former employer or union, a government program (such as Veterans Affairs, TriCare, Indian Health Services, or Black Lung), or any other group insurer.

I Payments for drugs made under workers’ compensation or automobile or liability insurance.

I Payments made by AIDS drug assistance programs.

I Payments for drugs bought from Canada or other foreign countries.

I Payments for low-cost drugs (or the value of free ones) received from a drug manufacturer’s patient assistance program.

I The value of free samples your doctor has given you.

Rules for buying your drugs in the doughnut hole

As you may notice from the lists in the previous section, Medicare has some strict rules to persuade you to continue buying your drugs through your plan in the gap. Part D allows Only Payments for drugs covered by your plan And

Purchased from a pharmacy within your plan’s network to count toward the out-of-pocket limit that gets you out of the doughnut hole. The following sections detail what these mean and factors to keep in mind.

Using drugs covered by your plan

Drugs covered by your plan generally are the ones that are on your plan’s Formulary (the list of drugs the plan helps pay for). The full cost of these drugs counts toward your out-of-pocket limit in getting out of the coverage gap. So does the cost of any nonformulary drugs that your plan agrees to cover if you’ve won an exception to its policy (as explained in Chapter 4). Any other drugs Don’t Count toward your out-of-pocket limit.

For example, say that you’re taking four meds — W, X, Y, and Z — but your plan covers only the first three. In the coverage gap, when you’re paying full price, these three drugs cost a total of $200 a month, every cent of which counts toward your out-of-pocket limit. So do your co-pays for them in the initial coverage period (Phase 2) that precedes the gap. In contrast, you pay the full price (say $100 a month) of the fourth drug, Z, throughout the year because your plan doesn’t cover it. For the same reason, none of your payments for Drug Z count toward your out-of-pocket limit.

If you start using a new medication when you’re in the gap, check to see whether the new drug — or a similar one that would work just as well for you — is on your plan’s formulary. If it is, the money you spend on it will count toward getting you out of the doughnut hole. (To find out, call your plan or look at the formulary on its Web site.) Also, remember that if the new drug isn’t on the formulary, you can still ask for an exception to get it covered, even while you’re in the doughnut hole.

Buying drugs from pharmacies in your plan’s network

Pharmacies in your plan’s network are those that accept your plan’s membership card. If you buy your drugs from any of these pharmacies (or from your plan’s mail-order service) during the gap, your payments Will Count toward your out-of-pocket limit. Otherwise, they won’t. So if you find a lower price outside the network, you have to decide whether the savings are worth not having the payments counted.

Deciding whether you should stick to the rules

If your overall drug costs are high, you need all your payments in the gap to count in order to reach catastrophic coverage as quickly as possible. But if your costs are in the medium range, and you’re pretty sure you won’t get out of the gap before the end of the year — or you can’t afford the money it takes to get out of the gap — you may feel you have nothing to lose by getting lower-cost drugs elsewhere. (You can find ways to do this in Chapter 16.)

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Keep in mind, though, that this choice can be a bit of a gamble. You can’t be entirely sure that you won’t develop a new medical condition that requires more drugs, and maybe expensive ones, later in the year — all of which, if bought through your plan, will move you faster through the doughnut hole.

Making sure your gap purchases count

Ii$jAB£W If you continue to get your drugs at any of your plan’s in-network pharmacies during the gap, be sure to show your plan’s card to the pharmacist. Even though the plan doesn’t pay anything toward your drugs during this phase, your payment is logged into the computer system and counts toward your out-of-pocket limit. You may also want to keep the pharmacy receipts as a record of these payments, just in case you and your plan later disagree about the date when you emerge from the gap and become entitled to catastrophic coverage.

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The consequences of stopping premium payments in the doughnut hole

You’re expected to pay monthly premiums through the gap. This rule bugs many people, which isn’t surprising. In the doughnut hole, you’re basically paying good money for no coverage. Medicare officials argue that your premiums cover the cost of coverage over the whole year, including the generous catastrophic period. But what if your drug costs are enough to land you in the gap but nowhere near high enough to get you to the catastrophic level before the end of the year? Or what if you simply can’t afford the amount it takes to get out of the gap? Why continue paying premiums?

If you stop paying premiums, you’ll likely be thrown out of your plan and lose coverage. Here’s why that may not be a good idea:

I If you want to go back into Part D at a later date, you’ll pay a late penalty — an amount that adds to your premiums and increases over time, as explained in Chapter 8.

I You may be required to repay the premiums you owed before enrolling in a Part D plan again.

I The plan you dropped out of may go after you for the premiums you didn’t pay, arguing that you broke your contract.

I And — you never know — you may need coverage later in the year if you come down with some unforeseen health problem that requires treatment with expensive drugs.

What were they thinking. . . when

They created the doughnut hole?

In designing the Medicare drug benefit in 2003, coverage to everybody else too. It was impos-

Congress decided to give comprehensive cov- sible to cover everyone comprehensively within

Erage to people with low incomes (Extra Help) the $400 billion originally budgeted for the pro-

Or high drug expenses (catastrophic coverage). gram, so something had to give. Inventing the

But to sell the program politically — as well as doughnut hole solved the problem for the gov-

To attract wealthier and healthier enrollees to ernment’s purse strings, but created one for

Spread the cost burden — Congress had to give many enrollees’ pocketbooks.

Determining Whether You’ll Fall into the Coverage Gap

Nobody likes nasty surprises — and, as many folks have found out, falling into the doughnut hole unexpectedly can be a real shock. So it’s worth finding out in advance if and when you’ll face the coverage gap. Calculating this isn’t easy to do on your own, but the following sections explain ways to find out how close you are.

Reviewing statements from your plan

Your Medicare drug plan is required to send you regular statements showing

I How much you and the plan have spent to date for your drugs

How close (or not) you are to the end of the initial coverage period and the beginning of the doughnut hole

If you go into the gap, the statements also show how much more you have to spend to get out of it before you can start receiving catastrophic coverage. Statements are normally sent monthly, unless you haven’t filled any prescriptions in a particular month. You can also request a statement at any time by calling your plan. Some plans offer personalized access to their Web sites so enrollees can keep track of their status online.

Using charts on the Medicare Web site

The Web site for comparing Medicare drug plans at Www. medicare. gov has a convenient tool you can use to see at a glance whether the doughnut hole will affect you and, if so, when it will hit. This is a very cool tool that creates personalized bar charts showing your likely out-of-pocket costs under different plans, according to the drugs you take, month by month through the year.

The charts on the Medicare Web site are so useful in estimating how your expenses may rise and fall during the year that going to some trouble to look at them is well worth it. (If you don’t have access to the Internet, you can ask someone else to do it for you.)

To have a personalized chart created for you, you must first enter the names of each of your drugs (plus their dosages and how often you take them) on Medicare’s online Prescription Drug Plan Finder. (For a step-by-step guide on how to do this quickly, go to Chapter 10.) Your costs under different plans are then automatically calculated. Ideally, you’d do this search when you’re comparing Medicare drug plans to decide which one to pick. You can then look at the charts included with each plan’s details. Or, if you’re already in a plan, you can go directly to that plan’s details to see your chart.

You’ll find your personalized chart at the bottom of the plan details page — so be sure to scroll down so you don’t miss it. The chart displayed there calculates your out-of-pocket costs (including premiums) on the basis of drugs bought from a retail pharmacy in the plan’s network. To see a chart showing your costs if you buy your drugs from the plan’s mail-order pharmacy (if the plan offers this option), click the "Show" button next to the heading Total Monthly Cost Estimator for Mail Order Pharmacy. To see details of how each month’s costs are calculated, click "Show Explanation of These Costs" alongside either chart.

Every chart varies according to the drugs you take and the plan’s overall design. Figures 15-1 and 15-2 are two examples of what the charts look like.

Figure 15-1 shows the monthly out-of-pocket profile of a person in a plan with a deductible and no coverage in the gap, but this person’s costs aren’t high enough to take her through the doughnut hole to the catastrophic coverage level.

I Figure 15-2 shows the monthly out-of-pocket profile of a person in a plan with no deductible and no coverage in the gap, but this person’s costs are high enough to move him through the doughnut hole so he receives catastrophic coverage until the end of the year.

Source: Medicare Prescription Drug Plan Finder Atwww. medicare. gov.

Figure 15-2:

A cost profile for someone who will reach catastrophic coverage.

Costs

Month

$317.50

1st

$317.50

2nd

$317.50

3rd

$611.44

4th

$773.52

5th

$773.52

6th

$773.52

7th

$376.31

8th

$70.95

9th

$70.95

10th

$70.95

11th

$70.95

12th

Source: Medicare Prescription Drug Plan Finder at Www. medicare. gov.

Each chart shows a profile of the user’s out-of-pocket costs under that particular plan — one with a deductible and one without — month by month throughout the year. The dollar amounts at the top of each bar are the total of what the user pays each month, including premiums.

The bar charts in Figures 15-1 and 15-2 come in many variations, according to each plan’s charges and benefit design. For example, if you’re in a plan with no deductible and your drug costs aren’t high enough to reach the doughnut hole, the payments for each month, January through December, will be the same. If you’re in a plan with no deductible that covers all of your drugs through the doughnut hole, that too will show the same flat payments each month.

The examples in Figures 15-1 and 15-2 show cost profiles over the whole year — typically the kind of bar chart you’d see during the annual open enrollment period (November 15 to December 31) when you’re comparing plans to pick one for next year. But what if you come into Part D partway

Through the year? Or change your medications during the year — dropping some or adding some? Here’s how the charts work in those circumstances:

If you join Medicare Part D partway through the year: You’ll still see a profile of your projected costs over the whole year, but the Dark shaded Bars will show your actual monthly costs for the rest of the year. Say that you turn 65 and enroll in the program in November. Your cycle of coverage then begins in December, starting with the deductible (if any) and the initial coverage period. You’ll see a dark shaded bar in Month 1 that shows your costs in December. The other months (2 through 12) are shown in light shading, but are irrelevant because, in this example, after December you’ll be into a new cycle of coverage. If you start coverage in June, say, the dark bars also begin in Month 1 (representing June), and continue through Month 7 (representing December). Again, the light-shaded bars in Months 8 through 12 are irrelevant because after December you’ll be in next year’s cycle of coverage.

I If your drugs change during the year: In this case, you can update your drug list on the plan finder to see how your cost profile will change. You must revise your list of drugs (omitting any you’ve stopped taking and adding any new ones) and then click the plan you’re Currently Enrolled in to see your new cost profile on the bar chart. Again, as explained in the preceding bullet, the dark bars on the chart indicate what you’ll pay for the rest of the year.

Avoiding or Narrowing the Coverage Gap with Other Benefits

In Medicare as a whole, you’ve always had the right to purchase extra insurance that’s specifically designed to pay for out-of-pocket expenses, like Part A and Part B deductibles and co-pays. (This is known as Medigap supplementary insurance, which I explain in Chapter 1.) You’d expect this type of insurance to also cover out-of-pocket expenses in Part D — especially those in the doughnut hole. But no, it doesn’t. The law specifically forbids it. (See the nearby sidebar "What were they thinking. . . when they didn’t allow Medigap to cover prescription drugs?" for more information.)

However, you may be able to get other benefits that help fill in the doughnut hole, either completely or partially. In the following sections, I consider help given through employer or union health plans, State Pharmacy Assistance Programs, and the few Medicare drug plans that offer some coverage in the gap. (I outline other ways of reducing your drug costs, which may also help you avoid the doughnut hole or lessen its impact, in Chapter 16.)

What were they thinking. . . when they didn’t allow Medigap to cover prescription drugs?

In designing Part D, Congress specifically prohibited Medigap insurance from covering prescription drugs in all policies sold after Part D began. The law allowed people who already had such policies to continue using them — but barred those folks from having Medicare drug coverage at the same time. The law also decreed that those folks would be hit with a late penalty if they were to drop drug coverage from Medigap and join Part D in the future.

Consumer advocates vigorously opposed this clause in the law, arguing that buying additional

Benefits should be a personal decision, as it is in other forms of insurance. Lawmakers who supported the clause argued that Medicare beneficiaries needed to remain "aware" of the real cost of prescription drugs (as in, presumably, "feeling the pain").

But there was also strong political pressure to get as many people as possible into Part D and to keep the program firmly within the control of Medicare’s private health and drug plans.

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Leaning on employer benefits

Some employer or union health benefits provide drug coverage that Wraps around Part D — in other words, it pays for some or all of enrollees’ out-of-pocket costs in a Medicare drug plan. Sometimes this wrap-around drug coverage includes paying for drugs in the doughnut hole, either wholly or in part. (You can find more information in Chapter 6 on how employer and union drug benefits fit in with Part D.)

Any money your employer or union pays toward your drugs during the gap does Not Count toward your out-of-pocket limit, and therefore delays or eliminates your chances of qualifying for catastrophic coverage later on. (Not that this matters, because you’re saving money anyway.) But anything You Pay does count. Employers are expected to coordinate benefits with Medicare drug plans. Still, keeping the receipts for your share of these payments in the gap is a good idea, just in case you need to give proof to your drug plan.

Filling in with veterans benefits

If you’re enrolled in the healthcare program run by the Department of Veterans Affairs, And You’re in a Part D plan, you have the right to use either the VA or your drug plan to obtain medications, on a prescription-by-prescription basis, as explained in Chapter 6. So you can use your VA benefits to cover prescriptions in the Part D coverage gap. These payments don’t count toward the out-of-pocket limit to get out of the gap, but your co-pays count.

For more information or help on VA health and pharmacy benefits, go to Www. va. gov/healtheligibility, visit a local VA medical facility, or call the VA Health Benefits Service Center toll-free at 877-222-8387. For CHAMPVA info, go to Www. va. gov/hac or call 800-733-8387.

Seeking additional coverage from a State Pharmacy Assistance Program

In 2008, ten State Pharmacy Assistant Programs (SPAPs) provide some coverage in the doughnut hole for residents with incomes under a certain level who are enrolled in Medicare drug plans. They are Connecticut, Delaware, Illinois, Maine, Massachusetts, Nevada, New Jersey, New York, Pennsylvania, and South Carolina. Help in the gap varies a great deal among these programs, from quite limited assistance to full coverage. (For more on how SPAPs fit together with Part D, see Chapter 6.)

^jjftBEfl Any payments an SPAP makes for your drugs in the gap Do Count toward your $y^j$\ Out-of-pocket limit — as long as the program is "qualified" under Medicare Part D rules (as those listed previously are; see Chapter 6 for an explanation of "qualified"). So these payments do Not Delay or erase your chances of qualifying for catastrophic coverage later on if your drug costs go that high.

Getting lucky with a Medicare drug plan that covers your drugs in the gap

Most Part D plans stick to the basic plan designed by Congress — that is, they don’t give any coverage in the doughnut hole. But some do, in one of two ways:

Plans that cover only generic drugs in the gap: Generics have the same active ingredients as the brand-name drugs they are copying but cost far less, as explained in Chapter 16. In 2008, every beneficiary in every state has access to at least 14 plans that offer generic coverage in the gap. Most of these plans have higher-than-average premiums.

Plans that cover generics And Brand-name drugs in the gap: These plans have become much scarcer since Part D began in 2006. In that year, people in 46 states had access to at least one stand-alone prescription drug plan (the kind that most people in Medicare have, to complement the traditional Medicare health program), which offered full coverage of generics and brand-name drugs in the gap. In 2007, such plans were available in 39 states. In 2008, only one stand-alone plan in one state gave any brand-name coverage in the gap, covering only about 30 drugs.

Among Medicare Advantage plans that provide both healthcare and drugs (see Chapter 9), gap coverage for brand-name drugs has also gotten scarcer. MA plans that covered all the drugs on their formularies in the gap were available only in a few counties across the nation in 2008, mainly in large urban areas in California and Florida.

If you have one of these Fill-in plans, The money your plan pays toward your drugs during the gap does Not Count toward your out-of-pocket limit, but your co-pays Do Count.

How do you know whether a fill-in plan is worth it?

If you’re considering a plan that offers any coverage in the gap, think about these points before signing up for one:

I Will the plan give you any benefit in the gap? If you use a lot of generic drugs, you may assume that a plan offering gap coverage for generics is your best bet. Well, it might be — but not necessarily. Most generics are so inexpensive that you’d need to use a very large number of them to rack up enough costs to even reach the gap. So why pay a higher premium for one of these fill-in plans if you’ll never hit the gap anyway? A plan that covers all your brand-name drugs as well as generics may well be a good deal if the drugs are costly enough to take you into the gap. But you generally can find such plans only in a few Medicare Advantage plans in local areas — which means considering their health benefits as well as their drug coverage before you sign up, as explained in Chapter 9.

I Will the plan cover all of your drugs in the gap? In the first two years of Part D, the fill-in plans usually offered full coverage in the gap for all drugs on their formularies. By 2008, only a very few Medicare Advantage plans did. The rest use much vaguer terms to describe their gap coverage: for example, "some generics and some brands" or "some generics" or "all preferred generics." These terms often conceal a very limited range of drugs, often the least pricey ones on a plan’s formulary.

I What will you be charged for your drugs in the gap? Most fill-in plans charge the same co-pays for drugs in the gap as they charge during the initial coverage period. But some charge more. One plan in 2008 charged a $15 co-pay in the gap for the same generic drug that cost $2 in the initial coverage period — in other words, more than seven times as much. Some other plans charge three or five times as much. At the other end of the generosity spectrum, some plans don’t charge anything for generics, either in the initial coverage period or in the gap.

So how do you avoid these traps? In every case, you need to compare plans to find out whether a fill-in plan is actually worth it, according to the drugs you take. The only effective way to do this is to run the names of your drugs (plus their dosages and how often you take them) through Medicare’s online plan finder. Doing so automatically shows you the plans that cover your

Drugs at the least expense — including whether the plans offer any coverage in the gap. (I explain how to use the plan finder, or get someone else to use it for you, in detail in Chapter 10.)

Will there be more gap coverage in the future?

It’s always possible that more plans will offer full coverage in the gap in future years. You’d expect them to, because there’s obviously a demand. But don’t hold your breath. Private insurers are in this business to turn a profit, and they’re leery of offering full-coverage plans that attract people who need the most drugs and make the most claims — and therefore cost insurers the most money. In 2006 and 2007, full gap coverage was offered consecutively by two insurers, and each eliminated it at the end of one year, citing financial problems. Many people saved a lot of money when enrolled in these plans — while they lasted. Their disappearance was bad news for people with high drug costs who most need coverage in the gap, especially those taking brand-name drugs that don’t have a comparable generic yet.

When open enrollment (November 15 to December 31) comes round each year, check to see whether any new plans are offering gap coverage for the following year. To find out, look in the plan listings at the end of your Medicare & You Handbook, which Medicare mails to you in mid-October, or go to www. Medicare. gov and click "Learn more about plans in your area." Still, as I suggested earlier in this section, the only way to find out whether any fill-in plan would benefit you is to use Medicare’s online plan finder, either yourself or by getting someone else to do it for you, as suggested in Chapter 10.

Chapter 16