Michael Cosimini Uses Visuals to Create Games for Busy Doctors | Episode 135

Listen to this episode on your phone!

Michael Cosimini is an Assistant Professor of Clinical Pediatrics at the Keck School of Medicine of the University of Southern California and an attending physician at Children’s Hospital Los Angeles. He is a contributor and associated producer of the pediatric continuing medical education podcast Pediatrics Reviews and Perspectives and the designer of Empiric Pediatric, a 2-4 player card game used to teach guideline-based antibiotic use for medical students and residents.

Michael’s webpage is EmpiricGame.com and @MichaelCosimini on Twitter is the best way to reach him.

Hey Engagers! We’re testing out new software to fully transcribe the episodes, let us know what you think in the comments below or through any of the below!

There are many ways to get in touch with Professor Game:





Ask a question

Subscribe to Professor Game E-mail Newsletter

Looking forward to reading or hearing from you,



Full episode transcription

Rob    00:39    Engagers welcome! Today we have something interesting. Once again, it seems like we’re in kind of a, I dunno like a rant of talking to people who are in gamification and games, in the medical field because today we have Michael, but Michael, before we get started, are you prepared to engage?

Mike Yes, I am.

Rob Michael Cosimini is an Assistant Professor of Clinical Pediatrics at the Keck School of Medicine of the University of Southern California and an attending physician at Children’s Hospital Los Angeles. He is a contributor and associated producer of the pediatric continuing medical education podcast Pediatrics Reviews and Perspectives and the designer of Empiric Pediatric, a 2-4 player card game used to teach guideline-based antibiotic use for medical students and residents. Is there anything else you know that we’re missing from that intro you’d like to point out?

Mike I think that’s perfect. Thank you.

Rob So Michael, can you tell us like what is a typical schedule for you look like? I know you’re in paternity leave right now, but maybe you know, pre paternity leave and maybe even pre all this madness of the Coronavirus. How does that look like for you?  

Mike    01:51    Yeah, I only know what it was like before. You know, I’m, I’m a clinical faculty, so my primary role is to see patients. So I, I’m lucky to work in a hospital where we’re still allowed to do outpatient work with children as well as inpatient work. So I take care of hospitalized children, both outpatient in our clinic as well as um, when they stay in the hospital. And the bulk of that work is done in an educational setting, either supervising resident doctors, so doctors who have finished their medical school here in the American system or medical students who are still in their medical school at Keck. Um, I do, you know, I have a little bit of time for research and for developing new curriculum and I do a little bit of work in utilization management, so like reviewing authorizations for studies and such too. So I get a nice variety in my day.  

Rob    02:36    Like you have a lot to do and every day, you know, there are quite a few things that you can dig into which is always an interesting position to be at. Where you sort of not get bored but you know, you want to get a little change and you have all these different things to do. So Michael, we would like to know of a time, you know, a situation in which you maybe would like to call your favorite fail or first attempt in learning. A time of course you were maybe creating some sort of educational experience or similar, especially if it involves games or of, and you know at some point you’d had some failure, which of course as usual is not fatal, is not definitive. And of course, we want to be there with you. We want to live that story and learn from those situations with you.  

Mike    03:19    Yeah, I think I’m still kind of midway through my best and first fail for the last two years I’ve been building this card game that I use to teach medical students and residents, you know, appropriate use of antibiotics that they don’t really learn in medical school. Kind of bridging that gap from what they learn about, you know, what the drugs are a bacteria, the drugs kill how the drugs get into the body. That kind of, you know, basic information they learned in medical school and bridging that to like, Hey, how do we really use them in real life? So I’ve been working on a card game to teach that and at first this was something I was just doing for myself and I used it over and over again with my students and felt pretty good about how it worked for me to teach. But I found that I would have, I have like scripts that I would eventually end in and I would say the same thing every time a certain card came up and I would have my own sort of teaching points, my own sort of way of using it as a teaching tool.  

Mike    04:07    And as I started to think about how am I going to get this game to be usable to other people, I thought, well, I’m not going to come in that box and how can I share that information? I was discussing it with someone and they said, well, just put some QR codes on there and you can put as much as you want to online. I’m like, perfect. And I jumped right in when they said that. And at the time, the cards, I think I had 120 cards in the deck and 50 of them were cases which I thought the QR codes would help with. So I jumped right in. I put QR codes on 50 cards. I wrote a couple paragraphs online for each of them with references. I basically wrote a little textbook that came online with the game. And you know, there’s been a lot of iterations since then, but I kept that effort into the game until now. And now that people are getting their own copies and using them themselves, those QR codes are not being used. So I put this, there’s probably lots of people who write little textbooks that no one reads, but I’ve done it and I’m very aware that no one’s reading it because I can see that people are not clicking those links. And I think that’s something that I definitely am learning from right now.  

Rob    05:07    And if you had, of course, the opportunity to do it again and you were kind of there, is there something that you would maybe from the get-go something that you would have done differently in that sense? I dunno for incentivizing people to do to either read those texts or never to create them or do something different. Like would you try something, I was like at least experiment as it as in any good scientist. You certainly are.  

Mike    05:28    Yeah. I think one learning point from it is probably the learning point that many people make as they develop their own games, which is, you know, start simple and do as much testing as you can upfront and get things to users as quickly as possible so you know how people will actually use what you’re making. And I think that’s a very generic lesson that comes from this that people probably hear when anyone talks about how they developed a game. I think that it gives me pause about using a mixture of digital and a physical product in the same time as I reflect on, I think about what games do I play in my real life that use a cell phone and a card game and I can think of only one. I know like the unlocked series is like a escape room game that uses a mixture but it’s not a common combination and perhaps that’s for a good reason and so I think that’s something I would think twice about or certainly test early if I was thinking about using a mixed method on a future game as far as what I’m going to do would probably claw that space back from the QR codes and put whatever I think is most important in that little corner of the card because you know with two and a half by three and a half inches to work with, you don’t have much space.

Rob    06:309    Absolutely, absolutely. There’s not too much to substitute them for, but you know, maybe something else will come and up in that sense, Michael, because I think, I think it’s a very valuable lesson.  You said, it seems kind of generic, but until, until you actually run into that, and you probably will run into that more than once. Like we’ve seen here many guests who have run into things and you say, well, but I had heard this before and I still fell into like my own trap. You know, even people who are teaching these things can even fall into those traps every now and then. So I don’t, it’s, even though it might sound generic as you mentioned, Mike, I do think that it’s important for us to sort of constantly reinforce these kinds of messages and especially so that when you run into that youth, you realize that it’s okay. I mean it’s the kind of thing that can happen to the best of us, but the important thing is to be able to sort of get back up and pick up from your mistakes and you know, do that next iteration, which will definitely improve things in a massive way. And then, you know, continue moving forward. And maybe even moving on to your next thing and, and talk about moving onto the next thing. I’d like to know of a big challenge that you faced and you said, well I’m trying to solve this challenge, this issue. And you of course he used some sort of games, some sort of, you know, gamified strategy or something similar to solve. And at some point eventually, you actually managed to do something that you were happy, satisfied and successful with whatever you want to, you want to go for.  

Mike    07:51    Yeah, I’ve been using some form of game or gamification for teaching as long as I’ve been teaching in the clinical settings. So that’s, you know, five years of faculty life and a couple of years of residency before that. And the challenge that I started with and the challenge that I continue to have is I work in a sort of chaotic setting. So much of our teaching is in these workrooms where there’s going to be six doctors working and phones ringing constantly and you know, all kinds of things that need to be done, you know, that are not emergencies. And then you know the people throw, you know, throw in a couple of real emergencies there too. So teaching in that kind of setting is extremely challenging. And if you just set up with a PowerPoint or even sometimes just at know a lecture at the whiteboard, the first time a doctor gets a phone call that they need to address, the odds are that they’re not going to check back in. They’re going to address that phone call, log into the computer to put that order in and then then they’re gone. Then they start typing their notes, then they start catching up on all the work that they have to do. Cause they do have, they have so much they have to do. So I find that using a game is a good way to, that just little marginal improvement of engagement is enough to draw them back to the table. So they do address that issue. They do address that phone call, but they come back because they want to get their next turn in and they’ve got that card in their hand. They’ve got that thing they’ve been waiting to do that can bring them back to the table even after interruption. So I think that’s something that I found gamification has been really helpful for.  

Rob    09:14    Absolutely. And in fact I would say almost argue that using games or using gamified strategies is, is probably one of the main gears that it works for is bringing back that engagement or bringing it in the first place. You know, if you’re facing some engagement issue or some motivational issue inside, for example, a class as you were mentioning. And again, it’s not because they are entirely disengaged necessarily or because they’re not interested in this case, it’s because, you know they got some interruption that they cannot avoid. And I’m sure that in the medical field especially, this will be more common than we would like. And then they just, as he tell you, they clock off. I mean it’s over for them because coming back in requires a lot of attention and a lot of things. So how do you do it? The massive solution that you’ve realized that you could use is, you know, again, bringing in a game, bringing some sort of gamified strategies to have people have yet another reason to be, you know, sort of present and a hundred percent into your classes. That right?

Mike    10:10    Yeah, I think that works really well.  

Rob    10:12    Fantastic. Fantastic. And when you’re thinking, again, you’re in your class, you’re, you’re designing maybe a new, a new class or a new session or a new program. Imagine you’re doing that right now or maybe, maybe you are, maybe you’re there. What like what are the steps that you do to introduce maybe a game into your classroom or to use these gamified strategies? Like do you have some sort of process, some thought process, some steps? How do you do it? How do you approach it?  

Mike    10:36    I almost always start by just printing things out, getting physical things in my hands and playing with them. For me, a lot of times this means, you know, getting photos out of textbooks and getting them printed at CVS. So I have a bunch of like clinical pictures that I can use for whatever, you know, content. I teach a lot of like derm or like skin conditions. So I think having those physical pictures to arrange and think about, Oh, how could we really play with these? How could we make this engaging? I think that first step, of having something physical in your hands is usually what I do first and not do too much, you know, iteration in your head or on the computer.  

Rob    11:10    Right. So what you mainly do is you start your thinking, you’re using the content that you have, which is already pretty visual. I’m guessing if you’re working with skin, you usually have to take a look at what the, I’m guessing, again, I’m an engineer. I couldn’t be further from understanding medicine in any capacity, but I’m guessing here that it is already very visual. It’s something that you have to visualize to analyze is that, right?  

Mike    11:32    Yeah. I use games a lot for visual content because I want something tactile for that. I want something that they can hold and turn and look at. And so I think getting that physical presence is a much easier way to think about how it can be used in a gamified situation or, or just generally how you can teach it best.  

Rob    11:46    Absolutely. So you’re bringing sort of that physical and visual elements into the classroom. You’re sort of printing out all those things so that can, you know, you can use them for something and what would maybe be the next step, like what do you do once you have all of that information, whether you use it all or just a part of it, like how do you maybe, how do you structure it? Of course there’s a, of course, a logic in the content that you’re delivering. But how do you, how do you put it forth? I mean if, do you try to go for a card game? Like the one that you have? Do you look for a game that’s already existing and bring it into the class and see how to apply? Like what would you do with all that information once you have it there?  

Mike    12:19    So I guess I use games in a lot of different ways, but let’s stay on the pictures like so the visual diagnosis sort of ones I, I almost always end up with some sort of very simple, like I always shoot for things that take like 10 minutes or less, like quick games that we can do and if we get interrupted it’s okay, not too much time is lost or we could probably finish it before an interruption. So for those kinds of things using just, you know, simple games, it’s always getting those pictures together, sorting them into patterns and finding out what pattern do I want the students to identify and how can I have them make that. So either taking, there’s many conditions that affect the skin and another part of the body. So we take pictures of a skin condition and pictures of the x-ray or MRI of the other part of the body and say, Hey, here’s a big pile of pictures. Why don’t you sort them between the ones that are the skin findings with the other part of the body matching. So like a simple matching game like or here’s a picture of kids doing lots of different activities. Why don’t you sort these in the order that a child would be able to do them in normal development? A lot of the visual stuff is not, we’re not talking about very complicated games for these sorts of teaching points.  

Rob    13:21    So you’re, it seems like you’re using them very much both for you know, sort of recall like recalling some sort of information that they probably either already have or already studying so they can sort of practice that muscle of having those things incorporated. Because I’m sure you, I mean you doctors have to have so much information in your heads so you can analyze cases when they come in. And the other one is of course that analysis tool that you’re putting together things and maybe somebody comes up with the combination that you didn’t even think about before. Right?  

Mike    13:49    Yeah. The interesting things happen  

Rob    13:52    That’s always nice. That’s always nice. So that seems like a very interesting approach as well. Like you have all these things coming on and bringing them together. And of course if you’re, if you’re getting people sort of a different way even to just the traditional things that they are probably used to in their education, it’s already being more dynamic. You’re getting people to be active on their learning and this is definitely going to be beneficial in my opinion to their capacity to learning these things.  

Mike    14:20    Yes. And if I can piggyback on that, I think like something I’ve like evolved through the time is the quality of the physical materials is important and I think it does help with engagement. Like at first I would just write things on sticky notes and we would sort and trade and that was engaging and that did help. But you know the, you see the looks on people’s faces and you see in like people that you’re not even supposed to teach. Start coming to the table when you do have like nicely printed pictures or the formal card game. Really it brings in like random people that I’m not even supposed to be teaching to come play, to have something that really looks good on the table. 

Rob    14:51    so they’re actually being drawn into that even though it’s not their thing, at least not at that moment. So that speaks very highly. Exactly of that what you’re doing and the motivation and the engagement that you’re getting from your and even other students as well. Mike, would you say that there is some sort of, and maybe we’ve been dancing around it, but do you think there is some sort of best practice or some sort of you know, idea elements, a strategy that you’d say, well when are you ever thinking about introducing these games, these gamification elements into your classroom that you would probably benefit from doing or you know, be risking possible failure if you’re an at least not thinking about including it again an element and idea, strategies or there’s something along those lines that you would maybe call sort of a best practice.  

Mike    15:49    I think one thing that I’ve learned is people have very specific expectations of what a game is and how a game is played and when your time is limited, it’s best to like be within those expectations of your learners. Like at one point in developing empiric the card game, I had a set of rules that I had developed to make it less stressful to try to like encourage like a feeling of safety amongst the medical students that they could just, Hey there’s a mechanism that you look at the card instead of just guessing. And I could not get people to play by those rules because those rules did not feel like a normal game to them. So I think being as close to people’s expectations for what a game does is a very good practice to kind of make things go quickly and make things go smoothly as you’re introducing a game into like a situation in which games are not typically expected.  

Rob    16:36    So I would say it’s something like, you know, sort of living up to the expectations of, of a game being a game and what that means for, especially for your audience in particular. And there, of course, you have to consider what your audience thinks in that sense, I’m sure that what they were thinking maybe was different from what you were thinking and what others would be thinking. Something along those lines. Right?

Mike Yeah. And keep it simple. I think that’s super important. Yeah.

Rob The kiss principle. Keep it super simple.

Mike Right. Oh, I’m not familiar with that term, but that’s perfect. Thank you.

Rob That’s super is sometimes substituted by stupid simple but, but I like the super simple a lot better myself. So Mike, after, you know, I know you’ve heard some episodes before as well. I mean after having the whole vibe of the podcast, is there somebody that comes to your mind, like when I interviewed your colleague Teresa Chan, she mentioned to you is, is there something or somebody that you would like to have in the podcast as well to listen to, to learn from this, this person in Professor Game?  

Mike    17:32    I’m not sure how far down the medical rabbit hole you’re intending to go, but if you’re, if you’re staying in these circles. Todd Chang is at my institution and has done, it’s, it’s drifting more into, he’s done some video game work, but also a lot of VR and simulation. And of course, simulation is critical in medical education and he’s done, I’ve seen him speak on some of his work with heart rate monitors of the participants and cortisol samples of the participants and you know, talking about how we’re optimizing the right amount of stress and the right amount of engagement in our learners so that they’re not disengaged or not overly stressed so that they’re learning. So I’ve seen him speak and he would be an interesting person to have on the podcast.  

Rob    18:09    Yeah, and even introducing some of the medical terms that are relevant for the field. I mean you don’t talk about the cortisol and all these things and all the chemistry and all the, you know, the, all this, these things that you were mentioning it that I’m not going to try to say again correctly because I’m probably going to fail because it’s definitely far away from my specialty and it sounds like a very interesting guest as well. So that sounds like it’s going to be a recommendation where we’re going to take a look at as well. Definitely. And staying in that field of recommendation’s Mike. Would you say that there is a book that you would recommend an audience like this one? Again, thinking of people who are thinking, considering or even currently using games and gamification, especially for education, but not necessarily. Is there something that you would recommend? Again, direct inspiration from you know, game design or something that is related or not so related. What would you recommend an audience like this one?  

Mike    18:57    I’m embarrassed to admit I pretty much only read fiction at this point. I mean I read a lot of articles, but I don’t read a lot of books, so I am a little bit at a loss of what to recommend as far as the book for your listeners. I live in Southern California here, so I have a lot of commuting, so I try to take a lot of my, my, a lot of my input is audio, so it’s a lot of podcasts and  

Rob    19:16    that’s fantastic. That’s fantastic. You’ll probably want to try the audiobooks as well.  

Mike    19:20    Yeah, that I find audio books very difficult for like educational content.  

Rob    19:24    Hmm, that’s true. I hadn’t thought about it. I to be honest, I, I’m still a sit-down reader. I haven’t gone deeply into the audiobook space, but I kind of explored that quite a while ago. This is going to age me a little bit because it was through cassettes. I still, I think I have it somewhere. No, probably not. My, my old like the house where I lived with my mom is sold right now and I don’t know if she kept that she moved as well. Countries. It’s probably not existing anymore. It was a series of cassettes. But I started doing that because my dad was a very, very strong reader and when he got, he was ill, he was very, very ill from ELA. I’m not sure if those are the, the initials in English or in Spanish. Now that doesn’t mean amyotrophic lateral sclerosis, ALS, sorry, LS ELA is in Spanish.  

Rob    20:14    I always get the wrong side of it, of these initials and he of course he couldn’t hold books at some point. So we kind of went for the audiobooks, see how it worked and that was, I’m trying to remember if there was anything after that for me in audiobooks, but it’s true. I haven’t, haven’t done much of that since. And that was a while ago as you can, as you can probably tell by the technology used. So that’s okay. I mean, is there any maybe fiction, maybe book or article or somewhere you’d like to people to read that has particularly inspired you? Again, it could be from the story we’ve had guests who have recommended just reading fiction to get inspired or maybe something that, you know, the, the way that they approached the book was interesting to you. If there is, if there’s not, we can just move on to the next, to the next thing, which is perfectly fine. 

Mike    21:02    I mean I think there’s some articles, any of this by, um, Landers, I think he’s been on your podcast actually. He had a couple of articles about just like the framework in which we, you know, we, the way we think gamification works, you know, moderating and like mediating factors for how gamification works for education. I think that he has a pair of articles where he did that along with like a leaderboard thing that I think are pretty good ones to read. Um, gosh, I’ve got a whole list on my webpage of articles I’ve been reading along the way just so I won’t forget their names.  

Rob    21:31    You can, you can share with them about that link of that problem as well. Sorry.  

Mike    21:36    And there’s another one by Rutledge at all in academic medicine. That was a pretty good one for gamification and the medical like framed around medical teaching that I thought was pretty helpful. Yeah, those were good at that thing. I would also recommend is, you know, listen to regular game podcasts, not just educational but you know, dive into that sort of body of people making games for whatever reason. Um, and I think a lot of the same principles apply. I listened to a lot of, you know, those sort of podcasts as well.  

Rob    22:03    There you go. That’s a pretty interesting source of inspiration as well. And what would you say, Mike, now you’ve been recommending other people, other books in your case, what would you say is one of those things that makes you sort of special in a way? And yes, you can brag here that’s perfectly acceptable, but what’s maybe your superpower or that sweet spot where you think, you know, this is the core thing that I know I can, you know, very much dig deep into these things when talking again about education games and gamification,  

Mike    22:32    You know, I think that I’m someone that is absolutely having to be making something at all times. So I have that kind of compulsion to be building things that might not be a super unique thing amongst people who are making games. But if I’m not like, you know, if I’m not drafting a game, I have to be painting or I have to be doing something, creating something physically. So I think that’s definitely what’s led me to, you know, dive into this area  

Rob    22:52    Definitely that, that’s, you know, that whole building thing is always super, super important. And you know, of course, this is going to come out as a difficult question for some, but what would you say is your favorite game?  

Mike    23:07    I’ve been dreading this question. It’s too tough. I knew you were going to ask cause you always ask. Right? Um, I think I’m someone who really likes to explore a new game and to, to learn the rules and learn how to apply them. And I’m not someone that dives so deep to like mastery, you know, I like to just play a new game and then a new one and explore a new one. Right? But right now I’m, I’m really enjoying a game called Palm Island, which is this very unique little 17 card solo game that you can play with your hands without even a table. It’s like your perfect buddy for quarantine or for, um, for at home, a solo game. So I think that’s one that I am really into right now. And then, uh, I’ve been playing Patchwork with my wife, which is, uh, a game designed just for two players, which is nice for, you know, the games that are designed just for two players and really work well in that setting. I think that’s a great one.  

Rob    23:53    Fantastic. Those are, those are probably great games. I haven’t seen or played any of the two but it sounds like they could be pretty exciting and we’re going to go, we usually have time for the extra random question. But this time, you know, after having two guests in medical education, I do have myself a question that could be a bit more specific to your field and it has to do with why do you think in particular like gamification and using games in your classroom in medical education has a specific impact? Like why would you say, you know, the medical field has something special that makes gamification and the use of games very, very useful for that field.  

Mike    24:33    I think those of us that are doing it right now have the advantage of not many people are doing it. So the novelty is really helping us for engagement because I think if anything, medical education is behind other fields and use of games and even probably, you know, as, as our students are, as time passes are probably more and more of our students will have used more and more games through their undergraduate and you know, whatever that’s before, um, and their, their school and then their undergraduate education. So I think, um, it’s probably going to be more and more of an expectation and those of us that are doing it now are kind of early on it in medical education games per se. I think medicine uses a lot of simulation and for very good reason, right? We have these very high stakes situations, like rare events that are very serious that we want to practice as much as we can with mannequins and with simulated situations for emergencies. So I think that there’s a lot of simulation going on already, but games not so much.  

Rob    25:23    I think it could also be a given precisely as you were mentioning. It’s not only the digital and the, you know the card games, but even the mannequins that’s a form of simulation as well. But I would say that in that sense you would actually have like a foot forward. Those people who have been doing a lot of simulation in the past as well, have they foot forward versus somebody who was just starting and saying, Oh why don’t we do these things like games and gamification and I do think that the whole experiential sort of situation so to speak would be a good foot forward that you have, which is actually a very positive thing for the field of medical education and I love your answer in that sense of at least for now being the novelty at some point. The good news is that there will be more people doing it. The other good news is that that means that probably things will start getting, you know, the quality will also be constantly improving. The, not bad news, but the difficult news is that we will have to be improving ourselves as well while the field continues to grow. So, you know, that’s exciting news is all I can say about that. For sure. So Mike, do you have any sort of final piece of advice or final words that you want to tell the audience before we move on?  

Mike    26:31    The last thing I think I would leave people with that’s worked very well for me is if you’re thinking about getting into a game for whatever the field that you’re in, I think get started on whatever social media is happening amongst your, the cohort of people that teach what you teach or whoever like your end-user is. I’ve had a Twitter account for my game for about a year and it’s really been a great opportunity to engage with experts in the area of infectious diseases to get their input on the design of the game, the content of the game. And just to kind of hear the chatter of the kind of things that they talk about what they think is important for doctors to know. Um, and that’s really been invaluable in designing the game. So I think there might not be a lot of other people at your institution that are interested in games and especially or interested in games in a very specific area that you are. But there are people more broadly that are, and I think find those people early and start like floating your ideas by them early. And that’s going to be a good way to start.  

Rob    27:27    So talking about connecting with people worldwide and using the internet for these things and finding sort of your tribe and your audience, how can we connect with you? How can we find Michael Cosimini in the world of the internet and their webpages, Twitter, like whatever it is that you want to share with us so he can connect with you.

Mike    27:42    Yeah, I’m definitely, Twitter is the place if you want to engage with me, it’s just my full name. So Michael Cosimini, C, O, S, I, M, I, N. I, I’m at that and on the Twitter platform and then the game itself, well it’s out of print for um, Covid it has its own webpage with a print and play version and that’s empiricgame.com.  

Rob    28:01    Fantastic. Fantastic. Thank you very much for you know, especially in these times when you have your parental leave, your time is particularly valuable. So thank you very much for investing this time that you invested during the interview and of course if you’d had any preparation as well. Thank you very much for all of that, for all the wisdom that you dropped here, all your experience as well. However, at least for now and for today it is time to say that it’s game over. 

End of transcription

Leave a Reply

Your email address will not be published. Required fields are marked *

sixteen + three =

This site uses Akismet to reduce spam. Learn how your comment data is processed.