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text: Patient Perceptions of Expression of Empathy From Chinese Medicine Clinicians in a Chinese Population A Cross-Sectional StudyChung, Vincent C.H. PhD; Yip, Benjamin H.K. PhD; Yu, Ellen L.M. MSc; Liu, Siya MPH; Ho, Robin S.T. MPH; Sit, Regina W.S. FHKAM; Leung, Albert W.N. PhD; Wu, Justin C.Y. MD; Wong, Samuel Y.S. MDSection Editor(s): Schaller., Bernhard Medicine: April 2016 - Volume 95 - Issue 17 - p e3316 doi: 10.1097/MD.0000000000003316 Research Article: Observational Study Open Abstract Author InformationAuthors Article OutlineOutline Article MetricsMetrics This study aims to examine the level of empathy perceived by patients receiving care from herbalists, acupuncturists and massage therapists and to investigate the factors that influence levels of perceived empathy. Participants who were 18 years or above; able to provide written informed consent; and able to read and write in Chinese without assistance were included. A total of 514 participants sampled from charity and semipublic Chinese medicine (CM) clinics in Hong Kong were recruited to assess levels of empathy perceived during various length of consultations (1–20 minutes) by the Chinese Consultation and Relational Empathy Measure (Chinese CARE). Multiple linear regressions were conducted to evaluate the associations between perceived levels of empathy and the type of CM practitioner consulted and participants' demographic and health characteristics. The average Chinese CARE total score for participants consulting CM practitioners was 34.3 of a maximum of 50. After adjusting for participants' health and demographic characteristics, acupuncturists received the highest ratings (P < 0.001), whereas massage therapists (P < 0.001) scored the lowest of the 3 modalities. Participants receiving social benefits (P = 0.013), those with longer waiting times (P = 0.002), and those with shorter consultation durations (P = 0.020) scored significantly lower on the Chinese CARE. The level of empathy perceived by participants using CM was similar to results found for those in conventional care, in contrast to findings in other geographical settings, where a high level of perceived empathy was a major motivator for participants to choose complementary medicine. From the Jockey Club School of Public Health and Primary Care (VCHC, BHKY, ELMY, SL, RSTH, RWSS, SYSW), Hong Kong Institute of Integrative Medicine (VCHC, RWSS, JCYW, SYSW), and School of Chinese Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China (AWNL). Correspondence: Samuel Y.S. Wong, Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, Shatin, Hong Kong SAR, China (e-mail: firstname.lastname@example.com). Abbreviations: CCTRCM = Clinical Centres for Teaching and Research in Chinese Medicine, CI = Confidence interval, CM = Chinese medicine, NGOs = Non-govermental organisations, T&CM = Traditional and complementary medicine The authors report no conflicts of interest. This study is supported by Direct Grant for Research, Faculty of Medicine, Chinese University of Hong Kong (Reference number: 2010.2.057) Authors' contribution: VCHC and SYSW conceived the study; RSTH, RWSS, AWNL, JCYW, and SYL designed the study; SYL collected the data; BHKY and ELMY performed data analysis. VCHC and SYSW wrote the manuscript; RSTH, RWSS, AWNL, and JCYW revised the manuscript. All authors have read and approved the final manuscript. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0, where it is permissible to download, share and reproduce the work in any medium, provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/4.0 Received December 22, 2015 Received in revised form March 11, 2016 Accepted March 13, 2016 Abstract INTRODUCTION METHODS Settings Sampling and Data Collection Questionnaire Design Statistical Analysis RESULTS Participants' Characteristics Chinese CARE Scores Across 3 Modalities Multiple Linear Regression Analysis DISCUSSION CONCLUSION Acknowledgments REFERENCES Back to Top | Article Outline INTRODUCTION A recent World Health Organization report proposed that primary care should "put people first, since good care is about people,"2 indicating a global emphasis on patient-centered care. Both technical and interpersonal effectiveness are important elements of high-quality primary care.1 Empathy is a central component of patient-centred care,3 and can be defined as the "competence of a physician to understand the patient's situation, perspective, and feelings; to communicate the understanding and check its accuracy; and to act on that understanding in a helpful therapeutic way,"4 Clinical empathy is a universal value and is highly regarded by patients across cultures.5 Expression of empathy by clinicians was associated with higher enablement and adherence, lower levels of anxiety and distress, and higher patient satisfaction in the context of primary care.4 Additionally, patient perception of higher levels of empathy was related to better clinical outcomes. The clinical outcomes were evaluated among patients with diabetes and common cold. For diabetic patients, their glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels were significant lower if they were managed by a more empathic physician. For common cold, patients with a more empathic clinical encounter had shorter symptom duration, and greater change in nasal wash interleukin-8 and neutrophil level.4 When Chinese patients evaluate the quality of consultation, both human skills and perceived treatment outcomes are regarded as important elements of a high-quality consultation.6 The Chinese version of the Consultation and Relational Empathy Measure (Chinese CARE) is a validated instrument for measuring patients' perceived empathy.7,8 The content of the Chinese CARE questionnaire was highly relevant to Chinese patients' expectations of primary care.6 It has demonstrated good psychometric properties for evaluating patients' perceived empathy during consultation with conventional clinicians.7,8 The high level of empathy perceived by patients during traditional and complementary medicine (T&CM) consultation has been attributed to the popularity of T&CM alongside conventional care.9 In Hong Kong, a statutory regulation for Chinese medicine (CM) practitioners has been implemented, and these practitioners provide approximately 20% of the primary care services in the Hong Kong health system.10 In the ethical doctrine of CM, fostering a strong practitioner–patient relationship is mandatory, and only those who possess skills in fostering this relationship are considered practitioners of high caliber.11 Building a healing relationship with patients was regarded as an essential element in the practice of family medicine, with the goal of promoting trust, hope, and a sense that the clinician knows the patient well.12 This study aims to examine the level of empathy perceived by patients receiving care from herbalists, acupuncturists, and massage therapists and to investigate the factors that influence levels of perceived empathy. Back to Top | Article Outline METHODS Settings This study was conducted in the charity and semipublic CM sector of Hong Kong, in which nongovernmental organizations (NGOs) are the main providers.13 NGOs are actively involved in the provision of semipublic CM services by managing Clinical Centres for Teaching and Research in Chinese Medicine (CCTRCM). CCTRCMs are established under a tripartite collaboration between NGOs, universities providing tertiary CM education, and the tax-funded health system (ie, the Hospital Authority). CCTRCMs are distinct from NGOs and mobile clinics in that they have formal linkages with the Hospital Authority.14 In this tripartite collaboration, the Hong Kong Government provided partial subsidy to the CCTRCM via the Hospital Authority, NGOs served as the operators of CM services, and universities provided research and training expertise. Regardless of their management structure, all clinics provided 3 types of CM services: herbal medicine, acupuncture, and massage therapy. Consultation fees were waived for patients who were receiving social benefits. Back to Top | Article Outline Sampling and Data Collection Participants were recruited at the 3 types of CM clinics. These clinics are managed by an anonymous charitable NGO and included 5 NGO clinics, 18 mobile clinics, and 2 CCTRCMs. There were 3 CM clinicians working in each NGO clinic and 1 CM clinician attending at each mobile clinic. The 2 CCTRCMs employed 18 and 22 CM clinicians. Following the sample size requirement of 20 subjects per independent variable for conducting multiple linear regression analysis,15 we estimated a required sample size of 500. As there were 12 independent variables in the regression, our planned sample size of 500 is more than sufficient to meet the required number. Please refer to the statistical details described by Vittinghoff and McCulloch.15 To ensure representative recruitment of participants, we adopted a disproportionate stratified sampling approach. We sampled 167 participants from each type of clinic. The sampling frame was constituted of participants attending each type of clinic, and these participants formed the target population of this study. Participants who were 18 years or above, able to provide written informed consent, and able to read and write in Chinese without assistance were invited to participate. Specifically, we approached 34 participants from each of the 5 NGO clinics, 10 participants from each of the 18 mobile clinics, and 83 participants from each of 2 CCTRCMs. For each clinic type, we invited consecutive participants to participate until the required sample size was reached. All service users 18 years or older were invited to participate in a face-to-face interview immediately after their consultation. No compensation was given for participation. The interviews were conducted by trained interviewers. Written informed consent was obtained from patients before the interview. Ethical approval was obtained from the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee (Ref no: CRE-2012.113). Although the NGO remained anonymous in this report, its staff members were involved in the application process for ethical approval. Back to Top | Article Outline Questionnaire Design The questionnaire used to conduct the interviews consisted of 2 parts. The first part assessed patients' perceptions of relational empathy during the consultation using the Consultation and Relational Empathy Measure questionnaire, Hong Kong Chinese version. The second part assessed respondents' demographic and health-related characteristics, including their sex, age, employment status, education level, marital status, housing type, payment status, self-perceived health status, reason for consultation, duration of waiting time, and duration of consultation. Previous qualitative study that invited Hong Kong primary care patients to evaluate concepts mentioned in Chinese CARE measure has demonstrated high utility and relevance of this instrument in evaluating patient-perceived empathy.6 Additionally, the Chinese CARE has demonstrated high inter-rater reliability. Factor analysis of the Chinese CARE has supported a single domain solution with a high factor loading, and construct validity has been demonstrated using the association between Chinese CARE scores and patient enablement and satisfaction.7,8 The Chinese CARE consists of 10 items with response options ranging from poor to excellent (scored on a 5-point Likert scale), yielding a maximum score of 50 points. A "not applicable" option was included for each question. For the full questionnaire, please contact the developers of Chinese CARE.7 Up to 2 "not applicable" responses or missing values were considered acceptable, and values for these were imputed by an expectation-maximization algorithm. Questionnaires with ≥3 "not applicable" responses or missing values were excluded from the analysis.16 Two data entry assistants independently input data from the collected questionnaires, and a third assistant was assigned to check electronically for discrepancies. Back to Top | Article Outline Statistical Analysis One-way analysis of variance was used to compare Chinese CARE scores among different types of CM modalities. Multiple linear regression was used to examine the association between the total Chinese CARE score and CM modalities, adjusting for patients' demographic and health-related characteristics. Improvements in nested linear models were assessed by the likelihood ratio test. For non-nested linear models, the Akaike information criterion was used. Multiple imputation was used to handle missing data, and analyses were performed using the R-packages OpenMX (https://cran.r-project.org/web/packages/OpenMx/index.html) and NORM (https://cran.r-project.org/web/packages/norm/index.html) (R version 2.15.2, R Foundation for Statistical Computing; www.r-project.org).17,18P values < 0.05 were regarded as statistically significant. The original Chinese CARE development specified that the questionnaire was constructed as a continuous scale.7,8 Back to Top | Article Outline RESULTS Participants' Characteristics In total, 516 participants were interviewed using the prespecified quota from all 3 types of clinics. Suitable data for analysis was collected from 514 patients. Two participants did not provide complete responses to the questionnaire, and their responses were therefore excluded from the analysis. Table 1 displays the demographic and health-related characteristics of the participants. There were significant differences in sex (P = 0.001), age (P = 0.032), reasons for consultation (P < 0.001), and duration of consultation (P < 0.001) among users of the 3 different CM modalities of Chinese herbal medicine, acupuncture, and therapeutic massage. A higher proportion of male participants consulted massage therapists, whereas more female participants visited acupuncturists and herbalists. Massage therapists were visited by younger participants, and consultation times for acupuncturists were much longer than for the other modalities. TABLE 1 Back to Top | Article Outline Chinese CARE Scores Across 3 Modalities Table 2 presents the Chinese CARE scores of participants visiting different types of CM modalities. The mean total Chinese CARE score was 34.3 (95% confidence interval [CI]: 33.6–35.0) of the maximum of 50 points. The lowest scores were observed on the items "being interested in you as a whole person" and "making a plan of action with you." In these domains, ratings were <65% of the highest possible scores. TABLE 2 The mean total score was significantly higher for participants who consulted herbalists (34.1; 95% CI: 33.3–34.9) than for those who consulted massage therapists (30.1; 95% CI: 28.3–32.0), and those using acupuncture services had a significantly higher total average score (37.7; 95% CI: 35.9–39.5) than did those who visited herbalists (P < 0.001). Similar trends (with scores being highest for those visiting acupuncturists, followed by herbalists and then massage therapists) were observed for each individual Chinese CARE item, with significant differences in mean item scores across the 3 modalities. Table 3 presents the standardized regression coefficients for all 3 CM modalities in each Chinese CARE domain. After controlling for patients' demographic and health-related characteristics using multiple linear regression, massage therapists were rated significantly lower than acupuncturists (P = 0.001) as measured by the mean total Chinese CARE score, as well as on all individual items (P < 0.05) except for "being interested in you as a whole person" and "fully understanding your concerns" as shown in Table 4. There were no significant differences in total scores or individual item ratings between participants who received acupuncture and those who consulted herbalists, except for the items "helping you to take control" (P = 0.044) and "making a plan of action with you" (P = 0.006), on which herbalists were rated significantly lower than were acupuncturists. TABLE 3 TABLE 4 Back to Top | Article Outline Multiple Linear Regression Analysis Table 4 presents the multiple linear regression analysis of the total Chinese CARE score, with participants' socioeconomic and health characteristics as independent variables. Compared with those who sought acupuncture treatment, participants who sought care from massage therapists had significantly lower total Chinese CARE scores. Participants who waited ≥16 minutes before their consultations reported a significantly lower score than did those who waited a shorter time. Participants who received a session lasting 1 to 5 minutes had significantly lower total Chinese CARE scores, compared with those who had a consultation >20 minutes. Participants aged 70 years or older were more likely to score significantly higher when compared with those aged 18 to 29 years. Finally, those who paid for their consultations tended to score a higher on the Chinese CARE. Back to Top | Article Outline DISCUSSION To our knowledge, this is one of the first studies to evaluate Chinese patients' perceptions of empathy during CM consultation. With a mean total Chinese CARE score of 34.3 of a maximum of 50 points, the performance of CM practitioners was similar to that of conventional clinicians in Hong Kong, whose patients' mean total Chinese CARE scores in previous research range from 31 to 34.6.7,8,19 In this study, the Chinese CARE scores were slightly lower on the items "being interested in you as a whole person" and "making a plan of action with you," which are generally considered particular strengths of T&CM practitioners.20 Two studies from the United Kingdom reported overall CARE scores of 42 to 45 among participants receiving acupuncture services25,26 These studies have also shown that the CARE questionnaire is valid for use in complementary medicine setting.25,26 A Japanese study and a Scottish study conducted in primary care settings reported mean scores of 38.439 and 45.6,21 respectively, and a German study conducted in an oncology setting found a mean score of 37.1.40 There are 2 potential reasons for the lower score observed in our findings: (i) Chinese patients' views of CM as a means to achieve good physical health instead of psychosocial health, and holism of CM is interpreted as an appreciation of CM's capacity in addressing effectiveness gaps in conventional care in managing physical diseases;22 or (ii) paternalism in decision making is often accepted, or desired, especially among older patients with lower socioeconomic status.23,24 These possible reasons require further validation. This overall pattern of relatively low CARE score did not fit with results from all 3 CM modalities. The total mean Chinese CARE scores were similar for patients visiting herbalists and conventional clinicians, significantly higher for patients visiting acupuncturists, and much lower for patients visiting massage therapists. Despite similar patient contact time with massage therapists and acupuncturists, the total mean Chinese CARE score from massage therapists was only 30.1, whereas acupuncturists obtained a score of 37.7. The association between CM modality and the overall Chinese CARE mean score remained significant after controlling for demographic and health characteristics of patients: acupuncturists had significantly higher scores than herbalists and massage therapists on empowerment-related items such as "helping you to take control" and "making a plan of action with you." Higher ratings echo findings from the United Kingdom, where overall CARE scores among acupuncturists were higher than 40.25,26 The interaction between acupuncturists and patients is considered to be a major contributor to the nonspecific effects of acupuncture on positive health outcomes,27 such as greater pain reduction and improvement in physical functioning among patients with chronic pain.28 Acupuncturists usually communicate with patients face-to-face before invasive needle procedures. For massage therapists, lower patient perceptions of empathy could be related to CM massage practitioners' focus on manipulative techniques over establishing a therapeutic relationship.29 As CM massage often takes place in communal treatment spaces separated by curtains, a lack of privacy may pose difficulties for massage therapists in terms of communicating effectively with patients.30 Short duration of consultation and long waiting time were associated with lower levels of perceived empathy.31–33 Clinicians usually need to spend more time talking and explaining problems with older participants, and this may provide an explanation for older participants' higher CARE scores.34 In this study, participants who did not pay for their consultations had significantly lower total Chinese CARE scores. In charity and semipublic CM clinics, patients are entitled to receive fee waivers if they are already receiving social benefits. A previous study in Scotland found that those who were socially disadvantaged often received less emotional support and enablement from primary care doctors, despite suffering from more complex health problems.33 One of the possible reasons for the observed lower score for this group is that CM clinicians were less inclined to offer psychosocial support, information, and involvement in treatment decision during consultation with patients from a lower social class. These participants might perceive that clinicians spent less time with them and failed to explain disease and treatment decisions clearly.35 Low socioeconomic status appears to be associated with poorer perceived empathy.36 The observed relationship between socioeconomic status and perceived empathy could be influenced by both the "health literacy" level of patients and the communication skills of the clinicians.35 Especially as the use of CM has been found to be more common among disadvantaged patients in Hong Kong,37 appropriate measures are needed to improve their participation and empowerment during CM consultations.38 In this study, we reduced selection bias by a stratified sampling strategy to recruit a representative sample of charity and semipublic CM users from 3 types of clinics across 3 different CM modalities. The present results should be interpreted only as a description of the level of empathy perceived by 3 groups of participants who consulted different CM modalities. Future research should be attempted to evaluate the performance of CM practitioners at an individual level. By specifying which CM practitioners participants have consulted, researchers will be able to conduct linear mixed model analyses to adjust for potential clustering effects. This study has several limitations. First, attendees were asked to evaluate their perceived empathy within CM clinic settings, and thus an inflation of the Chinese CARE score could be caused by social desirability bias. Second, although we have attempted to compare our findings with results from studies focusing on conventional care, this comparison should be regarded as exploratory because we did not recruit patients who used both CM and conventional services. Future research should focus on determinants of the CARE scores of patients using both services, including professional, contextual and organizational factors that may determine the mode of clinician–patient interactions.31 Back to Top | Article Outline CONCLUSION As measured by the Chinese CARE, the overall level of empathy perceived by patients consulting CM practitioners in charity and semipublic CM primary care settings was similar to that of patients consulting conventional clinicians in Hong Kong. As higher empathy score is associated with objective clinical outcomes,4 empathic practice should be encouraged in both conventional and Chinese medicine clinicians. In fact, the CARE measure score is now endorsed by the General Medical Council for revalidation purpose among General Practitioner in the UK.16 In Hong Kong, all Chinese medicine practitioners are formally regulated under the 3 streams of herbalism, acupuncture, and therapeutic massage (bone setting).39 As the Chinese Medicine hospital is yet to be established locally,40 majority of Chinese medicine practitioners provide care at outpatient level. Therefore, they should be considered as primary health care providers. From the UK experience, similar evaluation of empathy maybe considered in the auditing of quality of care provided by Chinese and western medicine clinicians in Hong Kong. Back to Top | Article Outline Acknowledgments The authors thank the anonymous NGO, Ms Polly Ma, and Ms Michelle Tsang who facilitated the implementation of this study.Back to Top | Article Outline REFERENCES 1. The World Health Report 2008. Primary health care: now more than ever. Available at: http://www.who.int/whr/2008/en/ Cited Here... 2. Howie JGR, Heaney D, Maxwell M. Quality, core values and the general practice consultation: issues of definition, measurement and delivery. Fam Pract 2004; 21:458–468. Cited Here... | View Full Text | PubMed | CrossRef 3. Mercer SW, Reynolds WJ. Empathy and quality of care. Brit J Gen Pract 2002; 52:S9–S12. Cited Here... | PubMed 4. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Brit J Gen Pract 2013; 63 (606.): Cited Here... 5. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. Jama-J Am Med Assoc 2005; 293:1100–1106. Cited Here... | View Full Text | PubMed | CrossRef 6. Fung CSC, Mercer SW. A qualitative study of patients' views on quality of primary care consultations in Hong Kong and comparison with the UK CARE Measure. BMC Fam Pract 2009; 10:1. Cited Here... 7. Fung CSC, Hua A, Tam L, et al. Reliability and validity of the Chinese version of the CARE Measure in a primary care setting in Hong Kong. Fam Pract 2009; 26:398–406. Cited Here... | View Full Text | PubMed | CrossRef 8. Mercer SW, Fung CSC, Chan FWK, et al. The Chinese-version of the CARE Measure reliably differentiates between doctors in primary care: a cross-sectional study in Hong Kong. Bmc Fam Pract 2011; 12: Cited Here... 9. Bikker AP, Mercer SW, Reilly D. A pilot prospective study on the consultation and relational empathy, patient enablement, and health changes over 12 months in patients going to the Glasgow homoeopathic hospital. J Altern Complem Med 2005; 11:591–600. Cited Here... 10. Chung VCH, Lau CH, Yeoh EK, et al. Age, chronic non-communicable disease and choice of traditional Chinese and western medicine outpatient services in a Chinese population. BMC Health Serv Res 2009; 9:207. Cited Here... | PubMed | CrossRef 11. Quah SR. Traditional healing systems and the ethos of science. Soc Sci Med 2003; 57:1997–2012. Cited Here... | PubMed | CrossRef 12. Scott JG, Cohen D, DiCicco-Bloom B, et al. Understanding Healing Relationships in Primary Care. Ann Fam Med 2008; 6:315–322. Cited Here... | PubMed | CrossRef 13. Information Services Department, Hong Kong: The Facts. Hong Kong: Hong Kong Special Administrative Region Government 2013. Available at: http://www.gov.hk/en/about/abouthk/factsheets/docs/public_health.pdf. Accessed on August 6, 2014). Cited Here... 14. Hospital Authority Chinese Medicine Service Website. Introduction to HA Chinese Medicine Service. 2012. Available at: http://www.ha.org.hk/chinesemedicine/intro.asp?lan=en. Accessed August 6, 2014. Cited Here... 15. Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and cox regression. Am J Epidemiol 2007; 165:710–718. Cited Here... | View Full Text | PubMed | CrossRef 16. The Consultation and Relational Empathy (CARE) Measure Offical Website. Available at: http://www.caremeasure.org/about.php. Cited Here... 17. Boker SM, Neale MC, Maes HH, et al. OpenMx: an open source extended structural equation modeling framework. Psychometrika 2011; 76:306–317. Cited Here... | PubMed | CrossRef 18. 2015; Boker SM, Neale MC, Maes HH, et al. OpenMx 1 3 User Guide. Available at: http://openmx.psyc.virginia.edu/docs/OpenMx/2.3.1/OpenMxUserGuide.pdf. Accessed April 15, 2015. Cited Here... 19. Wong CKM, Yip BHK, Mercer S, et al. Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. BMC Fam Pract 2013; 14:1. Cited Here... 20. Bishop FL, Yardley L, Lewith GT. A systematic review of beliefs involved in the use of complementary and alternative medicine. J Health Psychol 2007; 12:851–867. Cited Here... | PubMed | CrossRef 21. Mercer SW, Neumann M, Wirtz M, et al. General practitioner empathy, patient enablement, and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland: a pilot prospective study using structural equation modeling. Patient Educ Counsel 2008; 73:240–245. Cited Here... | PubMed | CrossRef 22. Chung VC, Ma PH, Lau CH, et al. Views on traditional Chinese medicine amongst Chinese population: a systematic review of qualitative and quantitative studies. Health Expect 2014; 17:622–636. Cited Here... | View Full Text | PubMed | CrossRef 23. Bowman KW, Hui EC. Bioethics for clinicians: 20. Chinese bioethics. Canad Med Assoc J 2000; 163:1481–1485. Cited Here... 24. Cong Y. Doctor-family-patient relationship: the Chinese paradigm of informed consent. J Med Philos 2004; 29:149–178. Cited Here... | PubMed | CrossRef 25. Price S, Mercer SW, MacPherson H. Practitioner empathy, patient enablement and health outcomes: a prospective study of acupuncture patients. Patient Educ Counsel 2006; 63:239–245. Cited Here... | PubMed | CrossRef 26. MacPherson H, Mercer SW, Scullion T, et al. Empathy, enablement, and outcome: an exploratory study on acupuncture patients' perceptions. J Altern Complement Med 2003; 9:869–876. Cited Here... | PubMed | CrossRef 27. Kaptchuk TJ, Kelley JM, Conboy LA, et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. Brit Med J 2008; 336:999–1003. Cited Here... | View Full Text | PubMed | CrossRef 28. Witt CM, Martins F, Willich SN, et al. Can I help you? Physicians' expectations as predictor for treatment outcome. Eur J Pain 2012; 16:1455–1466. Cited Here... | View Full Text | PubMed 29. Wright CK. Massage by nurses in the United States and the People's Republic of China: a comparison. J Transcult Nurs 1995; 7:24–27. Cited Here... | PubMed | CrossRef 30. Witt CM, Ludtke R, Wegscheider K, et al. Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture? J Pain 2010; 11:431–435. Cited Here... | PubMed | CrossRef 31. Pedersen R. Empirical research on empathy in medicine-A critical review. Patient Educ Counsel 2009; 76:307–322. Cited Here... | PubMed | CrossRef 32. Camacho F, Anderson R, Safrit A, et al. The relationship between patient's perceived waiting time and office-based practice satisfaction. N C Med J 2006; 67:409. Cited Here... | PubMed 33. Mercer SW, Watt GCM. The inverse care law: Clinical primary care encounters in deprived and affluent areas of Scotland. Ann Fam Med 2007; 5:503–510. Cited Here... 34. DeVoe JE, Wallace LS, Fryer GE. Measuring patients' perceptions of communication with healthcare providers: Do differences in demographic and socioeconomic characteristics matter? Health Expect 2009; 12:70–80. Cited Here... | View Full Text | PubMed | CrossRef 35. Verlinde E, De Laender N, De Maesschalck S, et al. The social gradient in doctor-patient communication. Int J Equity Health 2012; 11:12. Cited Here... 36. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989; 27:S110–S127. Cited Here... | View Full Text | PubMed | CrossRef 37. Chung V, Wong E, Woo J, et al. Use of Traditional Chinese Medicine in the Hong Kong special administrative region of China. J Altern Complem Med 2007; 13:361–367. Cited Here... 38. McKinstry B. Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. Brit Med J 2000; 321:867–871. Cited Here... | View Full Text | PubMed | CrossRef 39. Section 74 of the Hong Kong Chinese Medicine Oridance, Title of registered Chinese Medicine Practitioner. Available at: http://www.legislation.gov.hk/blis_ind.nsf/e1bf50c09a33d3dc482564840019d2f4/7e7732463d909c1f482567fa00292a03?OpenDocument Cited Here... 40. Section 234 of the 2016 Hong Kong Policy Address. Available at: http://www.policyaddress.gov.hk/2016/eng/p232.html Cited Here... Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. Health, Inc. All rights reserved. Article Outline Abstract INTRODUCTION METHODS Settings Sampling and Data Collection Questionnaire Design Statistical Analysis RESULTS Participants' Characteristics Chinese CARE Scores Across 3 Modalities Multiple Linear Regression Analysis DISCUSSION CONCLUSION Acknowledgments REFERENCES Source Patient Perceptions of Expression of Empathy From Chinese Medicine Clinicians in a Chinese Population: A Cross-Sectional Study Medicine95(17):e3316, April 2016. 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Private In-Home and Online Finance Tutoring in Bradenton, FL
Receive personally tailored Finance lessons from exceptional tutors in a one-on-one setting. We help you connect with in-home and online tutoring that offers flexible scheduling and your choice of locations.
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The study of finance is not a requirement for most people, but the subject can be very helpful for many levels of education. Whether you're taking your first finance course in high school, or pursuing a degree in graduate school, finance courses could prepare you for the job market ahead. You could understand the national and global stock markets, personal investing, and the fundamental rules of a capitalist economy. However, finance can be a complicated subject, and you may feel, right now, that you haven't grasped all the fundamental knowledge that you need to try to succeed on your tests or exams. Contact us to find you an experienced finance tutor in Bradenton, FL, who can provide a positive environment that might make it easy to learn and understand. Varsity Tutors' educational directors learn about your needs in your finance coursework, as well as your learning style and your personality, so that we can pair you with a great tutor. Working with a tutor gives you undivided attention that a teacher or professor may not be able to offer. You could work in a safe environment, which gives you the space you need to ask any questions until you understand the subject. Your tutor will work with you to find the best approaches to studying, so that you will not only learn concepts like using credit, setting up financial services, or supply and demand, but you can also enjoy the process. Let us find you a finance tutor in Bradenton, FL, who will understand your needs and offer positive reinforcement to make the learning process easier. Whether you plan to start a business when you graduate, want to understand stock market fluctuations, or simply desire a solid basis in money management so you can support yourself throughout your life, a class on finance can go a long way to helping you prepare for your future. Just because you know the value of the class, does not mean you inherently enjoy the class, though. Fortunately, finding the right tutor could help you find entertaining approaches to learning more about finance. For assistance in understanding your finance course in Bradenton contact Varsity Tutors' educational directors today.
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Allay Senior Care Of Meyers Lake
3328 13th street NW Canton OH 44708
for a local advisor
Allay Senior Care is a member of the Canton Regional Chamber of Commerce. In the past 10 years we have had 9 deficiency free surveys!
Pricing at Allay Senior Care Of Meyers Lake
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*Prices quoted are monthly rental charges and are provided by the communities themselves. Actual prices may differ due to one-time fees, timing and care services required. Speak with your Senior Living Advisor to learn more.
Reviews of Allay Senior Care Of Meyers Lake
The staff at Allay are amazing people. They were very caring and patient with our loved one.
- A sense of relief
I found that as my wife had issues, the help spent more time with her one on one. I had problems dealing with circumstances but knew, after leaving the Vacility, she was in the best place possible. I had a...
- Allay is the perfect fit.
I have a family member at Allay Senior Care. She has been there for nearly two years, and I have found that the facility and staff are a perfect match for an older person with memory care needs.It is a welcoming...
- See all 25 community reviews
Community Details at Allay Senior Care Of Meyers Lake
Senior Housing Types Provided at Allay Senior Care Of Meyers Lake
The features and amenities that are displayed on this page contain marketing information provided by the community. A Place for Mom has not confirmed the completeness of the provided information, and cannot guarantee its accuracy.
To conduct a complete investigation, seniors and their families should:
- Tour any listed location to confirm the accuracy of the community description;
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- Check additional licensing and state audit information.
If you become aware of any information that should be updated or noted, please contact A Place for Mom.


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Fowl River area in a delightful subdivision across the street from the river. Custom built home with...
Description of 8411 Bay Harbor Road Lot 17, Elberta, Alabama, 36582 - Bay Harbor
Enjoy watching the dolphins play at Wolf Bay from this Beautiful Bay front lot with bulkhead, pier, boathouse with metal roof and boat lift to accomodate a 16-20' boat. Also offers storage for floats and fishing equipment and has freezer. Pilings are in place for a 30' sailboat or boat with -4 draw with additional pilings already in place for another boat or just to extend for an additional deck area. Awesome redfish fishing and blue crabs. This awesome lot is at the end of the inlet so less water traffic and more privacy. Lot has been partially cleared so not much left to do to make this lot ready to build your dream home on or just enjoy as it is. 70' bulkhead with boat launch. Water has been run from the road to beginning of the walkway and power pole is already in place with electric to boathouse. You will see views of the most magnificent sunsets. Just a short drive to the Foley Beach Express and OWA and outlet malls. Elberta has a new high school and plenty of home town friendly restaurants and quaint shops. Close to the Pensacola Naval Air Station and Airport. You must come out to see all the detail of this waterfront beauty and its well established neighborhood. If you have been seeking the perfect waterfront location, THIS IS IT. No subdivision dues but has covenants to protect your investment. RELAX, your bay front living lifestyle is yours for the asking. Call now so you will not miss out on this opportunity. This area is so delightful and sure to please you. The property across the street on road side has been designated Forever Wild and is not to be built on and is owned by the State of Alabama. Coastal Alabama living as it was meant to be. ENJOY!!
Essential Information
- Price$299,901
- Acres0.00
- TypeLand & Lots
- StatusActive
Community Information
- Address8411 Bay Harbor Road
- UnitLOT 17
- AreaElberta 1
- SubdivisionBay Harbor
- CityElberta
- CountyBaldwin
- StateAlabama
- Zip Code36582
Boat Facilities
Boat Dock, Boat Lot, Boat Ramp, Covered, Power Available, Water Available, Water Depth (4 ft-), Boat Lift
Additional Information
- Terms of SaleCash, Conventional
Residential Lots, Other-See Remarks
- AmenitiesNone
- UtilitiesBaldwin Co Sewer Service
- ViewDirect Bay View
- WaterfrontBay Front, Wolf Bay
School Information
- ElementaryElberta Elementary
- MiddleElberta Middle
- HighElberta High School
Listing Details
- Listing OfficeExit At East Bay Realty, Llc
Property Location for 8411 Bay Harbor Road Lot 17, Elberta, Alabama, 36582 - Bay Harbor
You may be searching for a house, condo, or other property for sale, and we are here to help you with your search. As Elberta real estate agents, we know that not just any property will do, and you can use the powerful tools on our website to find precisely what you want.
The details about this land & lots property in Elberta, Alabama – from the Elberta MLS – include property information, local demographics, Google Streetview and Bing Birdseye view when available and a map to the property. The demographics give you information about schools and the community, but if you need more information, be advised that we are here to help.
We will give you all the information available in the Baldwin County MLS® so we can find the perfect home for you - maybe even this property.
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This 4 Bedroom 3 Bath GOLD Fortified Home is Situated on One of the Largest Lots in Hunter's Cove. ...
Unrestricted 2.5 acre level, corner property with 347 ft. road frontage Theodore Dawes Rd. and 385 f...
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Listing information last updated on September 18th, 2019 at 11:15pm CDT.


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Californian rock stars Buckcherry delve into their punk rock roots and have given us a taste of what's to come for their album to be released later this year with their latest six-track EP. A censored label is definitely in need for the language used within this record as they "give tribute to our favourite four letter word".
The title track Somebody F#cked With Me, gives a Rage Against The Machine vibe with the use of a gritty vocal effects, angst fuelled lyrics, short repeated riffs and a heavy but slow beat. It's a head-banger and gives a great insight as to what to expect for the most part of the record.
The second track shows a renamed/ slightly rewritten cover of Icona Pop's hit song, I love it (changed to Say F#ck It) which personally let this Ep down. The musicianship of the epic guitar lick in the chorus and the athematic vocals was the only thing that saved this cover.
An honourable mention to the fifth track It's A F#cking Disaster (our personal favourite), to begin with slows down to a deep drum beat and ambient guitar riff then goes back into their hard-hitting style with an epic guitar solo to turn this track into the hard-hitting punk vibe to return to true Buckcherry style.
This EP was filled with guitar driven songs with hard-hitting beats and catchy lyrics, even with an appearance from Minor Threats guitarist Brian Baker for the final track. If you're really in need to get out some aggression but also want to dance, this EP is definitely for you. I've never heard so much swearing in one collection of songs but it works. They should maybe reconsider calling themselves F#ckcherry.


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Northwest Pipe
The 10-second takeaway
Comparing the upcoming quarter to the prior-year quarter, average analyst estimates predict Northwest Pipe's revenues will decrease -8.7% and EPS will drop -31.6%.
The average estimate for revenue is $119.6 million. On the bottom line, the average EPS estimate is $0.26.
Revenue details
Last quarter, Northwest Pipe chalked up revenue of $140.6 million. GAAP reported sales were 1.1% lower than the prior-year quarter's $142.2 million.
Source: S&P Capital IQ. Quarterly periods. Dollar amounts in millions. Non-GAAP figures are normalized by S&P Capital IQ and may vary to maintain comparability with normalized estimates.
EPS details
Last quarter, EPS came in at $1.00. GAAP EPS of $1.00 for Q1 were 100% higher than the prior-year quarter's $0.50 per share.
Source: S&P Capital IQ. Quarterly periods. Non-GAAP figures are normalized by S&P Capital IQ and may vary to maintain comparability with normalized estimates.
Recent performance
For the preceding quarter, gross margin was 15.1%, 350 basis points better than the prior-year quarter. Operating margin was 10.5%, 400 basis points better than the prior-year quarter. Net margin was 6.8%, 350 basis points better than the prior-year quarter.
Looking ahead
The full year's average estimate for revenue is $472.0 million. The average EPS estimate is $1.63.
Investor sentiment
The stock has a five-star rating (out of five) at Motley Fool CAPS, with 216 members out of 226 rating the stock outperform, and 10 members rating it underperform. Among 36 CAPS All-Star picks (recommendations by the highest-ranked CAPS members), 34 give Northwest Pipe a green thumbs-up, and two give it a red thumbs-down.
Of Wall Street recommendations tracked by S&P Capital IQ, the average opinion on Northwest Pipe is outperform, with an average price target of $30.67.
If you're interested in companies like Northwest Pipe, you might want to check out the jaw-dropping technology that's about to put 100 million Chinese factory workers out on the street – and the 3 companies that control it. We'll tell you all about them in "The Future is Made in America." Click here for instant access to this free report.
- Add Northwest Pipe to My Watchlist.


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Mileage: 1,141
Economy: 40.1mpg
There can't be a more fashionable type of car currently than a premium SUV. And we've just taken delivery of one of the very best in the shape of the Volvo XC60, which held off the likes of the Jaguar F-Pace and Mercedes GLC to be crowned class champion at our New Car Awards last summer.
I headed over to Volvo West London in Chiswick, where sales executive Perry Lodge was delighted to hand over the keys. If first impressions count, the XC60 is off to a great start, because it looks absolutely fantastic in premium metallic Crystal White paint (£950).
• Best SUVs and 4x4s on sale in 2018
While Volvo has succeeded in giving the car a simplistic, classy look, the name of the model we've gone for is anything but understated. So say hello to the – sharp intake of breath – D5 PowerPulse AWD R-Design Automatic.
The D5 sits above the entry-level 188bhp D4 model, and with 232bhp transmitted to all four wheels via an eight-speed auto, it promises to deliver 0-60mph in a punchy 6.8 seconds.
We've yet to stretch the XC60's 2.0-litre four-cylinder engine, but it's clear that it has more than enough muscle for our needs, and is impressively refined, too. The PowerPulse label refers to under-bonnet tech that improves performance by reducing turbo lag.
Although our model is bedecked in the raciest trim, R-Design, don't be fooled into thinking that the drive is overtly sporty. The focus is more on comfort, with the £1,500 adaptive dampers and electric air suspension taking the edge off any bumps that might catch out the special R-Design diamond-cut matt-black 19-inch alloys.
Inside, there's the same sense of cutting-edge style. The dashboard is dominated by the nine-inch portrait-style touchscreen that has become a feature of all Volvos since the debut of the XC90 three years ago. All the car's key functions are controlled via the display, and although on first use the set-up can appear quite daunting, it's actually fairly straightforward to follow after a couple of outings. There are a lot of menus and sub-menus, but once you work out where everything is, operating them is absolutely logical.
And an example of the attention to detail that has gone into the XC60 is that there is even a branded cloth supplied to wipe away the inevitable grubby fingermarks that amass on the screen after regular heavy usage.
The touchscreen also displays the Sensus navigation with traffic info and lifetime map updates that come as standard on every XC60. But if I'm completely honest, it's not my favourite sat-nav set-up.
The mapping could be clearer, although I like the fact the standard 12.3-inch active TFT driver's information display also shows the routing. Yet the navigation got off to a less than auspicious start when it failed to recognise the very first postcode I tapped into it. I reached my destination of Woburn Abbey without any problems, but is it too demanding to expect better of a £50,000-plus car?
The £51,930 total as tested includes a number of options designed to make life with the SUV even more enjoyable.
First up is the £525 Winter Pack, which hopefully we won't have to make too much use of as summer approaches. This comprises a heated front windscreen and washer nozzles, plus headlight cleaners. Yet the headline act is a truly lovely heated steering wheel.
There's also Volvo's impressive Intellisafe Pro safety kit (£1,500), which includes adaptive cruise control, a blind spot information system, cross traffic alert and rear collision mitigation.
All in all, then, the XC60 is shaping up to be a wonderful addition to our fleet. Will it deliver? We're looking forward to finding out.
*Insurance quote from AA (0800 107 0680) for a 42-year-old in Banbury, Oxon, with three points.


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DIY Easter Theme Wreath
It's hard to believe that Easter is next weekend. It feels like only last week we were shoveling snow (oh wait, that did happen in New England on April fools!). This time of year is one of our favorites. Spring is in the air and the joy of new life brings a kind of warmth that lasts even through next winter. In honor of this blessed season, we put together an adorable and fun DIY Easter themed wreath.
Natural twig wreath (we got ours from Michaels)
Bird nest
Mini craft eggs
Delicate blush flowers
Hot glue gun
Craft paper with cute patterns
Intersperse moss into the twigs of your wreath. We let the moss phase out as we got closer to the spot we wanted to place the banner.
Hot glue the eggs into the bird nest. Once dry, use the hot glue to secure the bird nest on the lower left side of your wreath.
Adorn your wreath by delicately placing the blush flowers throughout the moss and twigs.
Fold craft paper in half and create a banner template at the crease. Cut out the paper banners and fold them over the twine. Secure them with hot glue. Tie the banner on the top right and middle right of the wreath in a juxtaposition manner.
Once you feel happy with the design of your wreath, hang it on your door with a nail or a wreath hanger. Enjoy!


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Quiet, Buissness
✔ Suits
✔ Family Rooms
✔ No Smoking Rooms
50-B, Chanakyapuri, New delhi, New Delhi-110021, India
Every person with wanderlust has Delhi on their list and for the right reason. This culturally diverse city is known for it's ancient heritage, colorful noise and rich background. Plan your visit soon, for this city has a lot to offer.


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Northwest Region Crop Report Prepared by: Manitoba Agriculture, Food and Rural Initiatives GO Teams & Crops Knowledge Centre August 12, 2013 |
Northwest Region
The Northwest Region saw very little precipitation with total accumulations of up to 5 mm for the week. Cloudy and windy weather conditions, and the below seasonal average temperatures, continue to persist.
The cool conditions and adequate moisture are favouring good development for canola and coarse grains. Pod fill of canola and grain fill of cereal crops is good as crop matures. Canola acres are 75% fully podded with the remaining acres at various stages of podding and flowering. Winter wheat is ripening slowly with no reports of fields ready for harvest operations. Hemp is flowering and the corn is beginning to tassel. Soybeans are developing slowly into initial stages of reproductive growth. Some perennial rye grass is combined and much of the remainder in swath.
Disease pressure on canola appears average based on the incidence levels of sclerotinia being reported. Insect pressure is low on all crops; however, some light grasshopper activity is reported on pastures especially on lighter soils and ridges.
First cut haying operations are reaching completion in many areas. Forage quality has remained variable. Under fair harvest weather conditions, barley silage is reported to have above average yield and quality. The native hay harvest is proceeding where more accessible drier fields allow. Wet and inaccessible native hay lands remain through the Westlake area, as well as other pockets throughout the northern sectors of the region. Pastures are rated as fair to good in most areas. Dugout water levels are at 100% capacity all areas.


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Gerald Earl Niemeyer Obituary
Here is Gerald Earl Niemeyer's obituary. Please accept Everhere's sincere condolences.
It is always difficult saying goodbye to someone we love and cherish. Family and friends must say goodbye to their beloved Gerald Earl Niemeyer (Indian Wells, California), who passed away at the age of 84, on October 26, 2018. You can send your sympathy in the guestbook provided and share it with the family.
You may also light a candle in honor of Gerald Earl Niemeyer or send a beautiful flower arrangement to the funeral service. He was loved and cherished by many people including : his parents, Alfred Niemeyer and Margurite Niemeyer; his children, Jeri Lynn Gibbons Tom, Jim Niemeyer (Linda), Jodi Adam and Joan Gilroy (Tom). He was also cherished by 11 grandchildren and 4 great grandchildren.


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Language Arts Letter Cubes: Fun Literacy Center Freebie
I love to use foam blocks for all sorts of language arts fun. Most recently, I created a game that my students adore. Here are the steps so you can create it too.
1) You can purchase colorful foam cubes on Amazon for a very reasonable price. I included a link at the bottom of the post.
2) Select 12 cubes and with a permanent marker add the vowels and consonants as suggested in the table below.
3) Assign the point value on the bottom right hand corner. This will also help the players to orient the letters. For example, the letter M will look like the letter W when it is upside-down but as long as the number indicating the point value is in the bottom right hand corner, players can recognize that they need to rotate the letter to the proper orientation. Also, using capital letters helps with letter confusion.
4) Other items needed to play:
- a timer
- a set of 12 colored cubes with the letters and point values for each player.
5) How to Play:
- Each player rolls a set of 12 colored cubes onto his or her playing area (players can not change the orientation of the cubes but must use the letters rolled).
- Set and begin the timer for 2-5 minutes. You can decide on the amount of time you prefer.
- Words must crisscross or join like a scrabble game, and players must try to use as many cubes as they can. Like Scrabble, proper names and abbreviations can not be used.
- When the timer goes off, the round ends and players add up their points as indicated on the cubes for each word created.
- Bonuses are granted as follows:
- 4 points for a 6 letter word
- 5 points for a 7 letter word
- 6 points for a 8 letter word
- 5 points for using all 12 cubes
- The winner is the player with the highest score after 5 rounds
Enjoy, Erica
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English »
The Messages »
Vassula, I wish to disclose My feelings to (...); hear Me: brother! soul! cast away forever the theory of "God approaching and elevating only souls dedicated to Me;" I do not approach only devout souls; I make no difference; why, am I a God of predilection? My Heart pains Me to see how many of you still believe that My graces are given only to devout sisters or brothers; you see, My child, how little I am understood by My own?
(Jesus sadly bent His Head on one side and lifted His Hand to His Heart. He stayed in this position for a while. He was very beautiful.)
I have approached many who are out of My Church, yes,...wretched souls... 1 converting them into devout followers of Mine; I made disciples out of them; I made saints out of them, yet, many ecclesiastical authorities overlook those works of Mine and ignore them; they have never recognised these souls, they know not about them, many were rejected because of their predilection! the theory of "God approaches only devout souls who wear the habit" is wrong; O how wrong you are!
(Jesus, from being calmly sad, became distressed.)
if you only knew the number of souls I have approached without necessarily wearing the habit, or being devoted to Me, and out of these I made saints!
beloved, have you really forgotten how you yourself scented My Presence? I had bathed you in My fragrance, blessing you! come, you will learn; I have converted many souls with My Message of Peace and Love; lost lambs came back to Me, falling in My arms; rejoice, soul! what greater miracle than a lost lamb who's found his Master! what greater joy for the Shepherd to find His lost sheep again! 2 announce My Miracles of Salvation to your brothers! to your neighbours! announce the good news, announce My works! let My Works be known, let My Miracle be known;
I have come to you and replenished your lamp; I have given you My Light, do not hide this lamp under your bed, for it is of no use then; come, rejoice brother for I have replenished your lamp that it may shine on a lampstand; let them all see the Light and know that It comes from Me;
announce My Holy Works, honour Me by exposing My Light on the roof of your house so that everyone may see It; let It be seen by all; when they will perceive this Light, they will assemble from far and wide; let them know how I came to you giving you this Light;
have My Peace ...
Chronological Listing
A Complete Listing of Messages in Chronological Order
Alphabetical Listing
A Complete Listing of Messages in Alphabetical Order
Notebook Listing
A Complete Listing of Messages Grouped by Notebook
Recent Messages
A small number of Messages that have been made available after the 'Odes of the Holy Trinity', the last published Messages in 2003.
My Angel Daniel
The Early Dawn of the Messages. Vassula converses with her Guardian Angel Daniel
Mobile Apps
Download the newly revamped iPhone/iPad app and have the Messages while on the go
Message Downloads
Messages in PDF format available for download
The Handwritten Messages
The original handwritten messages online
Online Book
The Messages now available to read as an online book
Message Search
Text search within the Messages
Random Message
Randomly Selected Message


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Think okra is slimy? Think again, with this spicy grilled okra – crunchy, creamy, and totally delicious. Plus, the top cooking tips to keep your fresh okra slime-free!
Let's take a little break from summer desserts this week, and talk about one of my absolute, all time, most favorite foods: grilled okra.
A little unexpected? Perhaps. I'm not from an area or culture that frequently cooks with okra; in fact, I'm not sure if I ever even tried okra before I was in my 20s.
And yet now, as an adult, I love okra… as long as it's grilled or roasted. (Or dehydrated in those crispy okra snacks from Trader Joe's which might be laced with something illegal because they are so dang delicious.)
I owe my recent love affair with okra to our CSA few years ago, who packed up a few pounds of okra into our weekly box. I had never made okra before and wasn't quite sure what to do with it. So I did what I do with all the vegetables that leave me stumped: throw them on the grill.
Suffice to say, I was hooked. Now I spend my summers grilling as much fresh okra as I can find, and roasting it in the winter (a close second to grilling).
Now, look. At the end of the day, this is still okra. Grilled okra isn't a french fry or a mozzarella stick or any other crunchy, salty, delicious food. But it's about as good as a vegetable comes (and I generally love vegetables).
Let's talk a little about okra, before I get into why I love spicy grilled okra so much.
To understand why okra is slimy, it's time for my favorite subject… kitchen chemistry!
Kitchen Chemistry
Okra gets it slime from mucilage, which is that sticky, slimy substance that seems to ooze from okra. Mucilage is composed of sugar residues called exopolysaccharides and proteins called glycoproteins, both of which thicken when heated. Mucilage is produced by nearly all plants, but okra produces it in much greater quantities (so do other sticky plants – like aloe and licorice root).
This increased viscosity is great when it comes to gumbo — the mucilage acts as a thickening agent. Buuuuut… it can also make okra feel pretty slimy. There's a reason you don't usually come across sauteed okra, where there is nothing to absorb this excess mucilage.
The biggest trick to reducing the 'sliminess' of okra is to cook it quickly, over high heat. Grilling is a great way to accomplish this – it's fast and easy.
Grilling over high heat means some bits get nice and charred and crispy (i.e., the best part of grilling anything). The seeds have a nice little pop, offset by the creamy inside (because high heat = creaminess, not slime!).
Grilled okra is also the perfect side to just about anything you'd toss on the grill: burgers (or my favorite veggie burgers), sausage, fish, chicken, etc. Toss on some ears of corn and these three ingredient grilled potatoes for a true summer feast.
Okra itself is a little bland in flavor (almost like an eggplant), so I like to make mine a little spicy. After washing and drying the okra (remember, dry it well!!), toss with a little olive oil and a heaping pile of spices for a little zing. The smoked paprika adds a smokey flavor, which pairs so perfectly with the charred bits from the grill. Add a little garlic powder, chili powder, cumin, and salt, and toss on the grill.
If you're careful and your okra is large, you can lay the okra directly on the grill grates. I usually put mine in a fish basket (Amazon links may be affiliate) or string them on skewer sticks. Grill for a few minutes per side and that's it.
Perfectly creamy, crunchy, spicy grilled okra… no slime allowed.
Think okra is slimy? Think again, with this spicy grilled okra – crunchy, creamy, and totally delicious. A Bunsen Burner Bakery Original Protocol As an Amazon Associate and member of other affiliate programs, I earn from qualifying purchases.
Spicy Grilled Okra
Recommended Products
Nutrition Information: Yield: 6
Amount Per Serving: Calories: 94 Carbohydrates: 11.9g Fiber: 5.2g Protein: 3.1g
Think okra is slimy? Think again, with this spicy grilled okra – crunchy, creamy, and totally delicious.
A Bunsen Burner Bakery Original Protocol
As an Amazon Associate and member of other affiliate programs, I earn from qualifying purchases.


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Adrien Broner's second defence of his WBO Super Featherweight title will be against Dewsbury's Gary Sykes
After browsing the various boxing forums on the internet, I can't find one boxing fan who thinks that a) This is a suitable match-up for a world title and b) Gary Sykes has a chance of winning this fight. I tend to agree with them, how can a guy who lost one of his most recent fights at British level, get a world title fight?
I'm not having a go at Sykes, if I was in his position I'd jump at the chance of fighting for a world title and I actually want him to win the fight. But if Sykes gets beat by Gary Buckland twice, what chance does he have against Adrien Broner?
Broner is the better boxer so Sykes can't out-box him, you would think that Sykes would have to try and knock Broner out, but with only a 22% knock-out ratio, Sykes doesn't even have a punchers chance.
It's good that Broner is fighting on a big fight under-card, but he should at least fight an opponent who has a chance of making it competitive. Is anyone excited for this fight? Or are you as disappointed in this fight as I am?


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Fragmentation protective body armor
ISO9001:2008 certificate
Our workshop:
OEM of Liu Gong,Foton Lovol and Power Plus
YN 915 Common model:
1. Features:
* Adopt Xinchai C490BG four cylinder engine;
* Full hydraulic transmission technology, simple structure and reliable performance;
* Split flow of single pump for working hydraulic system, significant effect of energy conservation;
* Double sealed hydraulic pipeline joints with 24°awl and O ring of international standard, avoiding oil leakage;
* Load sensing fully hydraulic steering system, easy and flexible operation;
* Safe and reliable single pipeline brake system; Caliper disc brakes.
* Working device with automatically leveling ability at high position.
* Bucket articulated points take sealed, lubricated, dust-proof layers, which owns good durability.
* Integral, luxury instrument board.
* New, luxury cabin.
2.Main Specifications:
Bucket capacity
0.5 m3
Min. turning radius (outside of rear wheel)
3600 mm
Rated load
1000 kg
Steering angle
35º each direction
Dumping height
2420 mm
Min. ground clearance
230 mm
Dumping reach
900 mm
Wheel base
1820 mm
Boom lifting time
Wheel tread
1400 mm
Total cycling time
Engine model
Xinchai C490BG
Max. speed
16 km/h
Rated power
32 kW/2400 rpm
Max. breakout force
36 kN
Max. drawing force
22 kN
Overall dimensions
4960*1620*2420 mm
Max. grade ability
Operating weight
3. Quality certificate:
(1)CE Approved.
(2)Obtained the certificate of ISO9001:2008.
(3)Manufacturing license number: TS2510025-2009.
4. Quotation:
YN915 Wheel Loader(with 0.5 cbm, 1.0 ton capacity, Chinese Xinchai C490BG engine)
Shandong Yineng Heavy Industry Co.,Ltd (Taian Luneng Machinery Co.,Ltd) was found in 1999, is a collection of development and production as one of the engineering machinery manufacture enterprise. It is Situated at the foot of the world famous Mount.Tai, the main products are YN series wheel loaders, with more than 20 different models loaders in total. With 10000 units of annual production capacity, YINENG has passed the ISO9001:2000 international quality management system certification and assessment of State Engineering Machinery Quality Supervision & Testing Center. It also obtained the Special Equipment Production License and a member of China Machinery Council as well. The company expanded the scale in 2010 again and established Shandong Yineng Heavy Industry Co.,Ltd, It also has "Taian Yineng Hydraulic Co., Ltd ", "Taian Luneng Import & Export Co., Ltd", "Taian Luneng Trading Co., Ltd" and "Taian Luneng Frame Co., Ltd" as branches. Always following the philosophy of "Prosper enterprise with super quality products; to create YINENG brand", YINENG considers products quality as the life of enterprise and control the quality strictly to strive to fine products. Customers' needs as the direction of products development and "to build the top brand of small loader" as striving target. YINENG has won wide market with excellent products, better service and reasonable price. YINENG products are not only popular in more than 20 domestic provinces and cities, but also exported to Kazakhstan, Indonesia, UAE, Saudi Arabia, Syria, Iran, Brazil, Venezuela, Nigeria, South Africa, Australia, etc.
Agent Supporting Services
Technical Guidance:
1. Provide the video for technical guidance2. Factory send technician to agent country for technical guidance three times per year3. Agent also could send technician to our factory to learn technologyTraining Support: 1. Provide the video for training
2. Factory send technician to agent country for training three times per year3. Agent also could send technician to our factory to learn technology
Marketing Support:Factory will provide any way to help the agent to promote, such as fair....
After-sale Service:
Factory provide one year or 2000 hours after sales service in worldwide, Agent shall provide local technicians and staffs to satisfy the management , operation and training of after sale service, and provide workshop, warehouse, office and other facilities to support a sustained after sale service.
Commission & Profits: Agent could get 3% to 10% commission according to the size of the profit.


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List of all Bollywood Drama Movies with starcast, confirmed release date, reviews, genre, duration and other details.
Genre: Horror
Release date: 25th June 2003
Six friends, stranded on a highway, tell each other scary stories....
186 minutes
Genre: Drama, Comedy
Release date: 27th November 2003
Naina is a very serious girl with a very serious life. But one day, her soul is awakened by the happy-go-lucky Aman, who teaches her that life is meant to be lived. Naturally, she falls in love with him. But Aman is harboring a secret that keeps him from reciprocating Nainas love. But he cannot stand having her live a ...
Director: Nikhil Advani
120 minutes
Genre: Drama
Release date: 16th January 2004
A woman falls for a charming and mysterious businessman. The whirlwind romance turns sour when she is framed for his underworld crimes. Now, finally out of prison she is ready for sweet revenge....
Director: Sriram Raghavan
Genre: Action
Release date: 23rd January 2004
Anant Shrivastav is assigned to escort a dangerous terrorist to Mumbai. But someone doesnt want him to make it....
Director: Rajkumar Santoshi
Genre: Drama
Release date: 2nd April 2004
Simran and Sudhir Saigal have been married for several years, and are settled in Bangkok, Thailand. They live a fairly harmonious but busy lives, and have a child, a son. When Sudhir returns unexpectedly, he finds his wife is having an affair with another man. He hires a private detective by the name of Ramanathan, who...
Director: Anurag Basu
Genre: Drama
Release date: 23rd April 2004
Bardhaasht is a Bollywood drama and thriller film released in 2004. The director is E. Niwas. It is based on the screenplay written by Vikram Bhatt. The main cast of the movie is Bobby Deol, Lara Dutta and Rahul Dev. Bardaasht is noted for its gritty and brutal portrayal of police force and triumph of human will and ju...
Director: E. Niwas
Genre: Drama
Release date: 30th April 2004
An army major goes undercover as a college student. His mission is both professional and personal: to protect his generals daughter from a radical militant, and to find his estranged half-brother....
Director: Farah Khan
161 minutes
Genre: Drama
Release date: 21st May 2004
Michael (Ajay Devgan) , Arjun (Vivek Oberoi) and Lallan (Abhishek Bachchan) are three young men in Kolkata , with different ideals and objectives . Michael is an idealistic youth leader who dreams of a better India being created by the youth power . Arjun is a self-centered , opportunistic , easygoing fellow whose obje...
Director: Mani Ratnam
Genre: Drama
Release date: 28th May 2004
Hum Tum (Hindi: हम तà¥à¤®, translation: You and Me, Urdu: ÛÙ… تم) is a Bollywood movie, released in India on May 28, 2004, directed by Kunal Kohli and produced by Aditya Chopra and Yash Chopra. The movie stars Saif Ali Khan and Rani Mukerji in the lead roles....
Director: Kunal Kohli
Product of VGB IT Solution, made with ❤ in India


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Maxwell Q. Bartels
All articles by Maxwell Q. Bartels
Taher and Effect on Permanency Awards for Claimants with Both Schedulable and Classifiable Conditions
The New York State Supreme Court Appellate Division recently decided the case of Taher v. Yiota Taxi, Inc., in which it addressed the specific situation where a claimant is classified with a permanent partial disability and designated with a loss of wage earnings capacity (LWEC), but has both classifiable and schedulable conditions. The court has determined that a claimant may ultimately receive a schedule loss of use award (SLU) even
Continue reading...
Difficulties and Questions Presented by the Board's New Digital Audio Recordings
Since the inception of the statewide virtual hearing platform in March of this year, there have been many concerns over the efficiency and effectiveness of the new hearing process. One of the major concerns has been whether there will be a clear, concise, and easily accessible record of workers' compensation hearings. The virtual hearing platform brought with it a digital audio recording system that records all workers' compensation hearings verbatim.
Continue reading...


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text: … by Christopher M. Breit January 12, 2019, 5:23 am See more Previous article How to Get Personal loans For Bad Credit Guaranteed Instant Approval or Good Credit 2019 Next article Indias Fast Loan Provider +919355350795 Personal Loan , Instant Loan , Loan Provider Company Leave a Reply Cancel reply Your email address will not be published. Required fields are marked *Comment Name * Email * Website Current ye@r * Leave this field empty Notify me of follow-up comments by email. Notify me of new posts by email.


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Chelsea's Eden Hazard has had a season to forget.
A year on from winning both the Premier League title and the PFA Player of the Year award, the Belgian international has put in a series of substandard performances that have let the Blues down.
But next term could be a fresh start for him under Antonio Conte and he could even be the ideal person to replace John Terry as captain.
The 25-year-old certainly hasn't earned the responsibility through his form and he's got the backs up of many fans who argued that he's looked disinterested throughout Chelsea's disastrous campaign.
Despite this, he could well be the West London club's best option.
Whether Terry signs an extension to stay at Stamford Bridge or not, you get the feeling that he's going to be in a significantly reduced role considering his age and the difficult year he's had.
Conte has a lot of work to do when he takes charge and the defence is one area he's going to have to overhaul, so even if the skipper stays on there'll be less room for him.
Whoever is vice-captain will essentially be the main man for all intents and purposes, much like Terry was when Marcel Desailly was coming to the end of his Chelsea career.
Branislav Ivanovic is currently Chelsea's vice-captain but is nowhere near good enough to rely upon and although Cesc Fabregas has captaincy experience he drifts in and out of seasons and too often goes missing on the big occasion.
Gary Cahill isn't first XI material, Cesar Azpilicueta isn't made of stern enough stuff and Nemanja Matic should be shown the exit door, which leaves Hazard – who ought to be the star player – as the only viable option.
Hazard has been awarded the vice-captaincy of his country for the upcoming European Championships and will lead his side in the absence of the injured Vincent Kompany.
The tournament now represents a good opportunity to see how he handles the additional responsibility and whether or not he's capable of thriving in a leadership role. It could be the making of him.
The playmaker clearly wasn't happy over the past term but is already talking about Chelsea coming back stronger rather than looking for an out.
He cannot be blamed for the toxic atmosphere during Jose Mourinho's last days, nor is he responsible for the poor preparation, ill-thought signings and the form of the dead wood within the squad.
He is, however, responsible for his own performance and reportedly didn't return from pre-season in good shape following the title win.
That's a failure he ought to learn from and handing him a leadership role should be the right incentive to really kick-on under a new manager and fresh start for the club.