Jason Beckta
@drbeckta
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Dad/Doctor/Dude. Radiation Medicine faculty with the University of Vermont. I have a 120-pound dog and a second doctorate in Radiation Biology.
Rutland, Vermont
Joined September 2010
Don't wanna be here?
Send us removal request.
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On June 28th, 2023,
#ROCR
was unveiled to 99.99% of the world.
Just two days shy of the one-year anniversary of this event, my "Letter to the Editor" is finally published at PRO.
There will be...much more to follow.
Like my original letter.
Be sure to read the ROCR letter from
@drbeckta
, a topic where Id love to see a lot more conversation.
You should also be aware of ongoing efforts to correct the existing MPFS.
Nice paper from
@RadiologyACR
.
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2022: cancer staging? There's an app for that. Memorizing AJCC manuals harkens from a time of phone booths and Blockbuster. Except for RadOnc! Since I don't believe in brute-force techniques, I created a "Mind Map" for mentally consuming the AJCC 8th edition:
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I'll guess that most people don't find base of skull anatomy easy. Or, maybe they do, and I'm the problem? Who knows. In case I'm not alone though, here's my SKULL MAP (for RadOncs). Supporting
@ParikhSimul
and
@toddscarbrough
's theory that I sit in a dark room drawing on walls.
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The pace of technology makes
#radonc
an interesting place. In the VMAT era of 2022, some amazing atlases were developed (
@eContourRadOnc
etc). Senior folks (AKA test writers) trained on radiographs, and I think spectacular
#meded
material was lost in the pre-internet vortex.
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My letter about the
@ASTRO_org
Workforce was published in
@IJROBP
.
@CShahMD
and I have talked a lot about this and there's a lot of exciting stuff to develop with
@SprakerMDPhD
@ParikhSimul
etc in the future.
But first, some quick hits: mean and median are not the same.
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@uncertainvector
I'm weirdly biased towards trusting the guy who was trusted to fly fighter jets.
Everything else aside, enough with the stigma. There's only one path towards "truth", and it's not the path of eye rolls and snide comments.
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Close to 0% of my breast patients quit radiation because of side effects, but I dedicate significant effort to counseling "5 years of pills" adherence, which has a massive impact on their quality of life.
With FAST/APBI, omission studies need to focus on endocrine therapy.
Can we omit 5 years of pills that give side effects? No, let's omit 5 days of radiation instead.
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Watching someone create a PTV with an isotropic margin expansion and then crop back certain parts because "dose shouldn't go there" without any attempt to rationally minimize uncertainty.
@aapmHQ
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Dirk Rades is easily one of my favorite RadOncs, for many reasons. As perhaps
@sky__john
and
@BenjaminKannMD
can also recall, his name is burned into my brain as a core memory with the Yale resident lectures.
But in practical terms, given the interest in both rural RadOnc,
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It's the time of year when almost-attendings are balls of anxiety. With modern medicolegal/billing,
#radonc
's quirkiness doesn't always mesh with the apprenticeship model of residency. IGRT is one of those quirks. Slide deck to follow...but this stick figure is MAGIC:
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This...this is in the
@nytimes
...? Who fact checked this? First, those aren't MRI images...those are CT scans. As a Radiation Oncologist who treats many patients with rectal cancer, this plan looks nothing like what I do. Is this a belated April Fools piece?
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*sigh* "The resident promised you 11am? Which resident was that again? Ah OK wait right here..."
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I know I'm piling on here, but 2023 has been such a sad year for "unforced errors" in Radiation Oncology.
While I don't agree with specific results of the workforce study, it was performed in good faith, and the article that accompanied the HMA report (the actual "big" one with
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@jryckman3
@NicholasZaorsky
@CunninghamOnc
@JillGunther
@ILROGTeam
For the XRT side, because I refuse to memorize ranges for boards:
24Gy all indolent
30Gy all HL/NHL CR (36 bulky)
45Gy all SBP/SEP and HL/NHL PR
50Gy NKT
Exceptions being Fav HL CR (20) and Gastric MALT (30).
So I guess 2-3-4-5 for me, for all lymphoma.
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Whatever sequence of events happened in my life to spend the morning of New Year's Eve with the larger-than-life CRT
@DHMC_RadOnc
, him in a Dartmouth hoodie, me in a Yale digital camo trucker hat...well, all I can say is I'm glad to be back with
@uvmvermont
on "home turf".
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Just to echo all my
#radonc
colleagues - tremendous job on the remote exam platform,
@ABR_Radiology
. Over the past 15 years of training I have taken standardized medical exams all over the country (once in a hurricane), and this was my favorite!
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My Twitter is almost only
#radonc
. I have grown concerned: is Peloton the 9th section of Oral Boards? Can
@emmacfields
or
@jennamkahn
tell me how to stage the Peloton? Is it the Kadish system? Should I sim arms akimbo? Do I interrogate the leaderboard at first/last treatment?
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If anyone wants to jump on a benign radiotherapy webinar featuring an international panel of experts - your day has come! 12:30PM EST through IORBC, see us jam 6 talks into <90 minutes. Sadly, haven't figured out how to provide digital lunch yet...
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NARRATOR:
"In an alternate universe, in an alternate timeline, Radiation Oncologists advocate for the extreme value of the their practiced art. This summer, only in theaters, join the adventure of those who...CHOOSE WISELY."
Our editorial on radiation omission trials is out in
@JCOOP_ASCO
.
We analyzed 3 RT omission studies (PROSPECT rectal, PRIME II breast, EuroNet-PHL-C1 peds HL) & described separate methodologic considerations for each trial.
@whallradonc
, Chris Booth
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In honor of Doctor's Day, allow me to present my interpretation of "Radiation Oncologist in Vermont".
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Alright let's add this one to the timeline:
1) Anti-Kickback Statute gets added to the Social Security Act in 1972 to prohibit anyone "knowingly and willfully receiving or paying anything of value to influence the referral of federal healthcare program business".
Well...you
Fascinating.
The final FTC rule banning non-competes tries to justify jurisdiction over non-profits.
Pretty interesting and will 10000% be challenged. BIG factor to keep an eye on.
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Treating palliative spine XRT;
@evicorehc
denied the 3D plan. P2P said "complex isodose is fine, you don't need to generate a DVH to assess radiation to nearby organs, it's OK to assume a safe dose". If that was you on the table, do you want me to ASSUME the radiation is safe?
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Hey
@nytimes
, I'm waiting for the article on this.
I'll likely wait a long time. You know what else is a long time? How many YEARS patients can experience without surgery thanks to the radiotherapy/chemo regimen from OPRA.
But - I'm happy to proof image captions if you want!
🚨🚨🚨5-year update of the OPRA Trial
🔥Supports CRT ➡️chemotherapy as the preferred option to best achieve organ preservation for patients with locally advanced rectal cancer
✅ 5-year organ preservation: 54% vs 39%
Fantastic update by
@Jcj84Jeremy
!!
#ASCO23
@OncoAlert
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It's hard to explain to non-Americans, or physicians in different specialties, just how strong the dogma has become in Radiation Medicine.
I know LDRT was not something taught in residency. But 20 years ago, it was part of the Spring Refresher. One of the projects we're working
I’m officially on the believer train for low-dose radiation therapy for arthritis.
I treated a gentleman in his 70s for an aggressive, myeloma relapse in his left orbit, causing massive proptosis & vision loss. Treatment was very effective to the orbital mass, however, he had
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We have received your request for a "Wonderful Holiday". Per our guidelines, we have determined a "Tolerable Holiday" is medically necessary. If you would like to appeal this decision, please fax an appeals letter to "Santa, c/o The North Pole", with all available documentation.
From us here at eviCore to you and yours, we hope you have a wonderful holiday season
#HappyHolidays
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@jryckman3
@JJCaudell
@ParikhSimul
@cd_fuller
@toddscarbrough
@Radformation
@eContourRadOnc
@CarlosMedPhys
@CTerhaard
@medrxivpreprint
@MICCAI_Society
@culbert_md
People who aren't using these apps are making life significantly harder for themselves
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I can't stop reading this PDF.
I'm glad this trial was designed and executed. I'm glad this paper was published. This data adds to our understanding of medicine.
But this paragraph is like saying "the sky is blue, not red, but we'll keep trying to prove it's red".
Who over
@MayoRadOnc
is writing these press releases? This is...not something I would be putting positive spin on.
Unless I don't understand numbers, late toxicity is almost universally worse for proton hypofrac?
Are...who...what?
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After my initial list yesterday, both
@toddscarbrough
and
@JordanJ65544091
showed me additional organizations supporting permanent "Virtual Direct Supervision".
Simultaneously, it came to my attention that individual practices are being told that various organizations "support
In advance of Friday's “Town Hall” (more accurately: “Webinar Presentation”), I took the liberty of creating a list of professional societies/organizations that have written to CMS in support of “Virtual Direct Supervision” becoming permanent.
This list is not comprehensive, of
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With the LUMINA trial published in
@NEJM
today, here's the tradeoff in 2023:
Would you rather have 5 days of adjuvant radiotherapy, or 5 years of endocrine therapy?
Here's the opening paragraph of the study protocol.
65% reduced relative risk, but "only" 20% absolute benefit.
@toddscarbrough
@NEJM
With huge respect for T.Whelan for all he did for RO science, this prospective study has still the same caveat as others for me : the trial should be RT vs Endocrine Therapy in this setting...
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Hey
@ASTRO_org
, just throwing this out there: while ROCR is projected to save CMS $200 million dollars, ending PPS-exempt hospitals would save $500 million dollars and only affect 11 institutions. Seems like an "advocacy win/win", yes?
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Seeing all the Halloween stuff coming out makes me think of ghosts, aliens, myths and...wait. Myths, like normal application of lotion to skin has a bolus effect? What a great Out of the Basement topic! So let's explore just that:
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For years I kept Googling things like “DRR bone atlas” and couldn’t find anything comprehensive, especially since RadOnc likes to silo information by disease site. So I finally made my own (specifically for the pelvis, where there can be subtle differences).
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@rweichselbaum
Challenge: Ralph is my mock oral examiner, all 8 sections. No rules. Livestreamed on Twitch, small fee to watch + donations accepted, all revenue donated to
@ARRO_org
to fund resident research and travel grants. Recording to Spotify by
@SprakerMDPhD
@ParikhSimul
@annalaucis
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@fumikochino
I asked my wife to put chicken on the top rack to "extend the SSD" last weekend, chuckling to myself. Thanks
@dschan02
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21,000 private practices sold in 2020.
2022: 74% of physicians are W2 employees.
The trend won’t reverse.
Given the worsening complexity of Medicine, there are obvious upsides. But the combo of employed + zero business training = $$$ is now a black box to doctors.
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The 3 objects I keep at my desk to survive are the Talismans of the Beam™️.
I'm not quite sure what to do with them, but my senior partner assures me they are essential.
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10/5/50 rule:
Nearly ~10% vs ~1% local failure if no XRT
5 fractions XRT vs 5 years endocrine tx
Up to 50% of non-adherence in completing the multi-year endocrine tx regimen in studies of "what actually happens" vs "clinical trials"
I think the math is pretty clear 🤷♂️
important paper in
@nejm
about omitting XRT in women >65 years of age with breast cancer (Node negative, HR+). curious what radiation therapy colleagues think of the data and its clinical implications.
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Previously denied reimbursement for planning to treat newly diagnosed oligomets patient to primary+met sequentially. Now, denied reimbursement for planning to treat primary+met simultaneously. Told primary needs to be tx'ed before met.
@evicorehc
: "Tails we win, heads you lose."
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Best
@jamesbyu
memory: Dosimetry, circa 2017, reviewing volumes. He takes the mouse and creates a nearly 2cm brush circle.
Right before making some changes, he looks at me and goes: "this is an attending-size brush".
This plays in my head whenever I use the brush to this day.
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I fell down the rabbit hole of America's complicated relationship with radiation. Listen to the OOB episode...and then watch the 22-part series on how the "linear no threshold" model of radiation safety was more about careerism and less about data.
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Who over
@MayoRadOnc
is writing these press releases? This is...not something I would be putting positive spin on.
Unless I don't understand numbers, late toxicity is almost universally worse for proton hypofrac?
Are...who...what?
ABSOLUTELY MIRACULOUS
Proton beam therapy may shorten breast cancer treatment
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Did...did
@jryckman3
just summon
@mcuban
on Twitter? Anyway, I would like to reiterate my love of
@costplusdrugs
for
#radonc
. They have most of my favorite on-treatment medications: Zofran, Tadalafil, Flomax, etc. Seriously, try it out.
@jryckman3
@MCWardMD
@costplusdrugs
Some clinics help them set up accounts and have delivery to the clinic. Many supportive clinics use their own credit cards to pay. Making it super easy for patients.
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It's interesting to note that this paper was published in The Green Journal (
@RadiotherapyOn1
), with the authors residing in Poland and Germany.
It was originally submitted in August of 2023.
I appreciate the leadership that has consistently been demonstrated by our colleagues
Radiotherapy sentiment in
@NYTimes
is eye-opening. Since 2009, over half of articles show negative bias towards RT, while only 1/4 are positive. Despite major advancements in tech like MR-Linac, adaptive RT, & heavy ions, media celebration is scarce.
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This is, without question, RadOnc mouse champion. I have one for my office and one for my home. I would get a third to carry around with me "just in case", but I had to draw the line somewhere.
(Drawing lines with this mouse? Spectacular.)
Tell me you're a rad onc without telling me you're a rad onc.
My department loves us, thankful for these amazing gifts
@RadoncUh
. And they have added weights!!!
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Adventures w/
@evicorehc
, Episode 2. Faxed explanation of denial states my notes had some "boilerplate language". This small narrative was deep within a 4+ page document of almost entirely "boilerplate language". What's next, a denial for a grammatical mistake? Strong work!
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Being a solo RadOnc in the middle of Vermont means doing a Memorial Day software install with
@Radformation
, then a hardware install with a deck gate after my Great Dane broke free to chase a deer this morning.
Do I like...go make maple syrup now or something?
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*reads Quadshot newsletter*
*logs on X*
🫠
*throws phone in ocean*
Happy
#InternationalWomensDay
to our amazing female radiation oncologists, medical physicists, radiation biologists & other specialist members! Thank you for all that you do.
#WomenInScience
#WeWhoCurie
#RadOnc
#MedPhys
#RadBio
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It's not the gray hairs I see sparkling in the mirror that tell me I'm old, it's the exhaustion I feel looking at the pics of the
@ARRO_org
agenda today.
You kids have fun. I'm going to go tell stories about the Scholastic Book Fair and the first time I used a Zip Disk.
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It struck me that the exams were 5 years ago, and a current PGY2 might have no idea what we're talking about. I've often wished we had "documentary"-esque resources for the important "RadOnc cultural" events. So: I made one...with a movie runtime.
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A truer Tweet has never been Tweeted.
50% of my grad school papers are the result of my tendency to go hang out with my friends in their labs. I would randomly be asked to do some confocal microscopy experiments --> co-author.
Don't network, make friends!
Instead of "networking"
make friends.
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My favorite part of LDRT is when people who used to walk with a cane come in for follow-up a few months later without it.
You wanna feel like a wizard? Using invisible beams to take away the need for a cane...it's Merlin-level stuff.
We have had a couple patients have to prematurely stop low-dose radiation therapy due to life circumstances, but they still received benefit to their joint osteoarthritis after a few treatments, weeks after treatment
#radonc
#medtwitter
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RadOnc jobs are like cicada broods: every 17 years you're overwhelmed with the commotion, but the experience is memorable mostly from rarity. I'm going to find every Cali RadOnc job Tweet like I'm collecting Nolan Ryan rookie cards.
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I eagerly await the 2023 "Choosing Wisely" campaign from ASCO which includes items such as "consider hypodosing or omitting pembro", "consider referral to a site in the High Volume Pembro Network", "use APPI" (accelerated partial pembro infusion).
At
#ASCOQLTY22
, we show markups to pembrolizumab by NCI cancer centers have far outpaced inflation from 2016-21. On avg, they charged Medicare >4x reimbursed price. How do we better regulate transparency and special status benefits from PPS/340B? Cc:
@fumikochino
@JordanJ65544091
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@DaniLavelle
@GarryPNolan
Wait...what?
Danny, are you saying that Kirkpatrick's claims are equivalent to God, and it is impossible to find evidence either supporting or refuting Kirkpatrick's claims?
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This is quite an interesting settlement, and I wish it had gone to trial, because I can guess the details but will probably never know.
1) The Relator is anonymous, identified only as the single member "Rad Claim LLC". That's a pro-level move!
2) The Defendants are a couple
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Man, this topic has reinvigorated
#RadOnc
Xeets to a level we haven't seen in FOREVER.
Accompanying the excellent
@AcceleratorsRO
interview of the INFAMOUS figure that started the Supervision Scaries, we have Episode 2 of the OOTB Supervision Trilogy:
Really found this podcast informative. Great job
@SprakerMDPhD
,
@toddscarbrough
@drbeckta
and Simul. At the end of the day, virtual care, whether applied to supervision, OTVs, or E/M visits, is safe, improves access, and decreases costs. Everything else is intrigue. And the
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Here is "real" data to support
@ParikhSimul
's point. I generalized/anonymized this a bit (paranoid/legal). Obviously, we're not making any "new" arguments, but critiques of the math are often 1) it comes from anonymous sources (SDN), 2) it's NCDB/SEER stuff.
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I generally prefer to see, you know, less Grade 4 toxicity in my "new standards of care" if I'm only getting non-inferior efficacy.
I'm weird like that.
Long awaited data from nrg Gu003. Looks like we have a new standard of care! I’m sure confirmatory trials will be forthcoming (including our own).
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@TheUfoJoe
I don't think that's the impact of this interview, rather, Sheehan just openly violated an NDA to plainly state a government official lied in a Congressional report.
That's a big deal.
There's only two ways for Kirkpatrick to respond: do nothing, which is a tacit admission of
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Alright so the headline got fixed -
@nytimes
y'all wanna take a crack at your image caption next?
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Is this journal peer reviewed? This is...I've never seen anything like this.
Are any of these authors on X? Or does anyone know them? Because the foundational justification for this work is wildly flawed (though I like the rest of the paper).
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Overhaul boards? Why change a pathway of exams where I need to know Sn1 vs Sn2, Krebs enzymes, workup of HFpEF, talk to a fake patient in LA, when to use Lasix, NHEJ vs HRR, Mayneord's F factor, pCR on CROSS, and 21.6Gy after tandem SCT...so I can circle prostates on a DICOM?
@RTendulkarMD
@MonaArbabMD
@QatKhanMD
@KenOlivierMD
@Rad_Nation
@NehaVapiwala
Alternatively, we acknowledge the rarity and complexity of certain cases, ie peds and brachy,
Then sending out residents makes more sense
But then we should overhaul oral boards to recognize that not everyone should treat neuroblastoma without help
#radonc
#jc
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Accurate! And I tried to do *all* the things but couldn't hit the ASTRO '22 mark. So:
We had huge interest s/p
@IJROBP
paper on LDRT for OA, with requests for homegrown data/support.
This isn't a REAL launch. But since everyone is mingling: we've got good stuff coming.
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It’s not perfect, and with A LOT of variations depending on what you read. The “nodal patterns of failure” and “surgical vs radiographic anatomy” literature is a DEEP rabbit hole. If you say “prostate ENI” 3 times in a mirror,
@DrSpratticus
is rumored to appear.
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Alright chums, let's do this - LEEEROO...wait.
I mean to say: if you're interested in a podcast aimed at emulating the spontaneous conversations we have during a clinic day with "practical learning", then join us in the sunlight, Out of the Basement.
The Accelerators Podcast Season 2 Preview!
Enhancements and more!
Shorter episodes, a theme song from an Emmy winning composer, a new podcast from
@drbeckta
, and the launch of the Photon Media collaborative.
Hear all about it in this petite teaser ep!
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@BrianBinghamMD
What in the world does
@evicorehc
mean by "peer" in these situations? If we look in the guidelines, is "peer" defined as "fellow bipedal organism who inhales oxygen and exhales carbon dioxide"?
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Inspired by my good friends
@evicorehc
, who are basically wealth managers for
@UHC
: I would remind my fellow RadOncs to ALWAYS appeal, and then appeal the P2P. Don't forget that CMS contracts with Maximus (IRE) - and we have data now. eviCore has ~4x more overturns than average:
#PriorAuthorization
is a common cost-cutting tool used by health insurers. But some say the rules are impacting care.
I spoke with doctors and patients who have turned to social media to publicly shame insurance companies to reverse denials. 1/6
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Friday afternoon medicine PRO-TIP™️:
If a patient has no history of cancer, no pain, no neurological symptoms, no MRI, and just a CT chest with bone lesions and the sentence "no encroachment in spinal canal" in the Radiology report written 3 times...
It's not cord compression.
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Put another way:
"As long as you agree to 5 years of medication, we can skip 5 days of treatment. It's definitely not worth it, radiation only reduces your risk of recurrence 20%."
"Only"
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@nbn426
@jaguaranna27
In the end, the only achievement that matters is the care and compassion we give to the people who trust us with their lives.
Everything else is artificial.
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Just in time for starting as an attending...y'all are awesome.
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Healthcare admin organizations and lobbying groups whenever there's the slightest hint of pro-physician legislation:
Recently, the FTC proposed banning non-compete clauses - a move that could impact many doctors.
Naturally, the AHA claims that the FTC doesn’t have that authority - and even if they did, “now is not the time” for hospitals to have to compete for doctors.
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20 years ago I was hired for my first healthcare job.
❗️Let the record reflect it was to wash dishes - I don't have THAT much gray hair (yet)❗️
I've trial-and-errored my way ever since. With ASTRO looming, here are "hidden curriculum" job tips I wish I could tell Young Jason.
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@henson_md
I ate a bag of mini Oreos for breakfast at 7:46am and jogged down the hall to answer the phone in my office because it was a P2P.
I'm living my best life!
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@ParikhSimul
Did you...retweet your own joke 30 seconds after making the joke?
🥳👏👏🥳🥳SIGNAL BOOST🌟🌟🕶️🕶️🌟🌟🌟
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Wait wait wait.
The authors used Medicare reimbursement to perform this analysis...
Yet they hail from Sloan, Miami, Moffitt, and DFCI...
Four of the 11 PPS-exempt centers?
@fumikochino
, can you guys do a follow up analysis on cost of short course at PPS-exempt compared to
When the vast majority of authors come from PPS exempt ivory tower clad windows to cast stones, this doesn't land well.
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During residency, I moonlighted for 3 years as Medical Staff for a local Hospice practice. I even did house calls! I was originally planning on sitting for those boards through the "practical pathway" only to find out I was a few years too late. It was very disappointing.
@toddscarbrough
Saw this recently👇🏽
Perhaps
#radonc
can also integrate hospice & palliative medicine into formal RO training to be eligible for dual BC?
cc
@ParikhSimul
@drbeckta
@KenOlivierMD
@RTendulkarMD
@henson_md
@jaguaranna27
@tjroycemd
@SprakerMDPhD
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Hmm. This is the first time I've ever been able to point to myself in a paper.
I look good as a dot.
2021 employment outcomes for graduating Radiation Oncology residents:
- 181 clinical jobs, 9 fellowships
- 35.9% academic
Figure 1:
a) Map of where jobs were accepted
b) Map of where graduates did residency
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In advance of Friday's “Town Hall” (more accurately: “Webinar Presentation”), I took the liberty of creating a list of professional societies/organizations that have written to CMS in support of “Virtual Direct Supervision” becoming permanent.
This list is not comprehensive, of
#radonc
colleagues: do you have thoughts re the direct supervision stance of ASTRO?
Pop by the ASTRO Town Hall 4/5/2024 at 5 pm EST and share your thoughts.
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THIS is the Sci-Fi stuff I expected when I decided to get into Radiation Oncology.
Less non-inferiority trials, more technology adapted from CERN for clinical use!
Now someone needs to invent "black hole beam therapy" where we use gravity to kill tumors...
CERN detector could help to improve head tumour radiotherapy | CERN
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Excellent thread. Drilling down on XRT, 8Gy is just the start of individualized treatment. Depending on the situation, I've done 2, 3, 5, and 10 fraction regimens. There's also a 15 fraction sequence I'd consider.
Movie voice: TALK TO YOUR RADONC TODAY!
Radiotherapy is usually given a a single 8Gy fraction.
Some patients may receive 5 fractions on an individual basis after oncology assessment.
Pain can increase initially with radiotherapy, steroid use should continue after radiotherapy to cover this period.
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It's challenging to appropriately evaluate the "quality" of a lung radiotherapy plan without first making sure the PACS viewer has been changed to the "lung" window.
I guess you could use the "pelvis" window, which this appears to be but...I wouldn't.
@JackWestMD
Agree with you Jack. But we do a disservice to skill of our thoracic
#RadOnc
colleagues when we say "don't try surgery at home" but infer that it is ok to do radiation like this ⬇️"at home". Need to balance local strengths and MDT and think about referrals to ⬆️ volume centers.
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Next, I imagine most of us view head and neck staging as challenging. Fortunately, you only need to laser in on the details where management changes, and leave worrying about N2a vs N2b for when you have your iPhone app:
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Have you even lived in Vermont if you haven't tailgated for fireworks in matching flannel with a moose hat capturing ladybugs? Side note I'm announcing my Senate run to replace Sanders.
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Now that I've returned to my Homeland, I am obligated to teach my son about his New England heritage. We start 2023 with matching flannel and his first Dunkin Donuts hat. Tomorrow we learn to say "you can't get there from here".
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