text:
Madam Speaker, last month, I chaired a Helsinki Commission briefing with a delegation of leading political opposition figures and democratic activists from Belarus. The briefing was entitled, "The Future Belarus: Democracy or Dictatorship" and focused on the prospects for change in a country located in the heart of Europe that has Europe's worst track record with respect to human rights and democracy. Unfortunately, developments since the delegation's visit to Washington have been deeply discouraging and do not bode well for Belarus' democratic future.
One of the young people who testified at the briefing, 19-year-old Zmitser Fedaruk, spoke eloquently of the dangers that young human rights activists face in Belarus. His words were prophetic, as a few days later, back in Belarus, he was beaten and knocked unconscious by riot policemen, then rushed by ambulance to the hospital. Just last week, the Minsk district prosecutor's office in Minsk refused to open an investigation into Zmitser's beating.
A day earlier, my friend Anatoly Lebedka, one of Belarus' staunchest defenders of democratic rights, who also testified before the Commission, was roughed up by Belarusian police as well. It was far from the first time that this leader of the democratic opposition had been beaten up or repressed by the Lukashenka regime. On January 4, the Lukashenka regime banned Anatoly from travelling abroad in what was obviously a politically-motivated decision. Today, Anatoly is in jail serving a 15-day sentence, along with several dozen other pro-democracy and small business advocates who participated in a January 10 protest against restrictions on activities of small businesses. Some of the activists–mostly young people–received injuries during their arrest. Tatyana Tsishkevch, who was severely beaten during her arrest and presented her bloodstained jacket in court, received a 20-day sentence. Arsien Pakhomau, a freelance photo correspondent for "Nasha Niva" weekly–one of the very few remaining independent publications in Belarus–was also sentenced to 15 days' administrative arrest. On the day of the protest, a number of websites that cover social and economic affairs in Belarus, such as Charter '97 and Radio Liberty, were partially or fully blocked by the authorities.
These most recent repressive actions follow the sentencing of opposition activist Artur Finkevich to 18 months in prison; the arbitrary use of judicial power to put out of business independent newspapers such as "Novi Chas"; steps to liquidate the opposition Belarusian Communist Party; and the fining of Baptist pastor Yuri Kravchuk for unregistered religious activity. Belarus is the only country in Europe with compulsory registration before religious activity can take place.
Unfortunately, the indications in just the first few weeks of this New Year are not encouraging. Lukashenka's presidential administration has recently rejected the opposition's proposal to hold talks on the upcoming 2008 parliamentary elections, refusing an offer by the Belarusian opposition to consider joint proposals on conducting parliamentary elections in accordance with democratic standards.
Madam Speaker, as Chairman of the U.S. Helsinki Commission and as someone who has long been involved in the OSCE process to promote security, cooperation, democracy and human rights among the 56 OSCE countries, including Belarus, I am deeply disappointed in the Belarusian Government's continual flaunting of freely undertaken OSCE commitments. It is my strong hope that Mr. Lukashenka will cease the self-imposed isolation of his country–threatening, most recently, to expel U.S. Ambassador Karen Stewart–and will give serious thought to the offers of cooperation that have come from the United States and the European Union if Belarus releases political prisoners and displays respect for basic democratic norms. In the meantime, the Lukashenka regime can be assured that my colleagues and I on the Helsinki Commission are determined to stand by Anatoly Lebedka, Dzmitri Fedaruk and all those in Belarus–young and old–bravely struggling for freedom, democracy and respect for human rights.


text:
That's oh-be-GUY-n, not oh-be-GIN, as some (primarily people from Texas) would like to refer to my chosen profession. Although, working in this field can sometimes cause one to develop a penchant for gin...hmmm.
Tuesday, April 13, 2010
"Why is my OB always running so *late*?"
Allow me to describe my day, in order to better explain why we may routinely run late. Today I am on call, and so, while I am responsible for all that happens on labor and delivery, in the office, I do have patients scheduled. The majority of patients are OB visits, most of which rarely take more than 5-10 minutes tops for routine appointments. We also will see check problem patients (early pregnancy bleeding, labor checks, blood pressure issues, hangnail, etc.) So, our scheduling staff (none of whom are medically inclined or have any clue what we do on a day-to-day basis) has most "on call" schedules looking something like this:
8:30 OB patient 1:15 OB patient
8:45 OB patient 1:30 OB patient
8:45 OB patient 1:45 OB patient
9:00 OB patient 1:45 OB patient
9:15 OB patient 2:00 OB patient
9:15 Problem 2:15 OB patient
9:30 OB patient 2:30 Problem
9:45 OB patient 2:45 OB patient
9:45 OB patient 2:45 OB patient
10:00 OB patient 3:00 Problem
10:15 OB patient 3:15 OB patient
10:30 Problem 3:15 OB patient
10:45 OB patient 3:30 OB patient
10:45 OB patient 3:45 OB patient
11:00 Problem 4:00 Problem
So, we have anywhere from 5 to 7 patients scheduled in an hour, and if everything is hunky-dory, there are no issues, long litanies of questions, no problems, or complications, I can generally run on time for these appointments (and by, "on time" I mean that once the patient checks in (usually running at least 5 minutes late, themselves) the nurse talks to them, does any necessary screening labs, checks their weight, urine and BP, listens to fetal heart tones, brings me the chart, which I then review, I am seeing them at *best* 15 to 20 minutes past their original appointment time).
Then, add in the inability to predict labors (I had a couple of laboring patients today) and scheduled procedures (I had 2 cervical ripenings and a C-section scheduled-not by me-at 7:30 am and then another scheduled C-section at noon. Unfortunately, one of my laboring patients delivered at 12:15, smack in the middle of when I was supposed to do my noon C-section, so the section was put on hold until after the delivery. So, by the time I finished the (complicated) scheduled C-section, did all the necessary charting and orders for both deliveries (mind you, not having any time for lunch) I was able to get back into the office by 3 pm. If I am lucky (today I was), my colleagues will have mercy on both the patients and me and pick up a few charts to see patient or two in between their already over-packed schedules. If I am not, then all of the patients scheduled from 1:15 are still waiting to be seen at 3 pm.
So, (whew) does this make it a little more clear why we are not running on the spot of time? It is completely different than making one appointment (that you probably schedule yourself, when it is convenient for you, allowing for travel time, and keeping in mind how long you expect most meetings to go) with one client for the span of 30 minutes or an hour, so the two are really just not comparable...at all. Hope that this helps the next time you are waiting for your physician. P.S. If you grow to expect the long waits, start bringing entertainment (iPo.d, magazines, books, cell phone bejeweled or solitaire) or little projects you can do (bills, checkbook, cleaning out your purse), and know, it really could be worse. Back in Whoo-ville, OtherDoc's patients would wait for him for upwards of 3 hours...now *that* is ridiculous. ;)
48 comments:
- Mama to Monkeys said...
I'm just wondering here (not criticizing), but how do you manage to built trust in patients and learn about their needs, cultural beliefs, their personal history beyond what is written on the blue intake form in such short bursts of time?
In contrast, my midwife appointments were an hour long at minimum, we discussed my nutrition, my sex life, my wants, needs, and expectations for my birth, and many other topics that I could not even begin to list here.
Does it really just boil down the fact that OB's tend to show up just for the "catch"?
How are a woman's emotional needs met in a set up like this?
Again, not criticizing, just searching for answers and understanding. - 4/13/2010 11:51 PM
- Katie said...
so....why schedule it that way? Shouldn't the doctor on call NOT have patients scheduled, since they obviously will have women delivering? Or at worst, shouldn't those appointments be rescheduled as soon as it is obvious that the doctor won't be available? And who on earth thinks that you can do a decent visit in 10 minutes???
- medstudentitis said...
wow. They don't schedule you a lot of time for your noon section... I mean I'm not sure where your clinic is in relation to your office but an hour to be back in the office (allowing that they always start late) isn't a lot of time if everything isn't straight forward.
- Diana said...
Just started reading your blog - looking forward to learning lots from it! Thanks for writing.
- Taking Heart said...
I am an OB nurse (I work L&D and PRN for an OBGYN friend in her office)... and mostly am overworked, understaffed, and stretched way thin... surprise surprise.
One noc, a co-worker and I decided we should quit nursing and come up with something more productive...
A snack cart! One that makes several daily stops at all of the OB offices... for the pregnant, grouchy, waiting women! We will offer juice for those sleepy babies who fail an NST from their long wait... and to hydrate their irritible dry uteruses... hee hee... and cookies, muffins, smutt magazines (none of those prengnancy mags that only show perfect pregnant bodies)... fruit snacks for the bored toddlers who tagged along...
We call them the Comfort Cart... Comfort for the cranky mamas... and comfort for the running behind... ever busy docs! Promotes fetal, maternal, and MD well being!
Are you in? - 4/14/2010 12:30 AM
- vldecker said...
Great explanation. My OB office is one place I never complain about waiting (though I have never been late to an appointment), because both of my children were born during office hours by my doctor who left patients waiting. I appreciate that and women need to consider that when they are giving birth.
Sure, it makes sense why you're not on time. You set it up so that it's completely predictable that you will waste your patients' time. I'm not sure why this would make anyone feel better!
How about scheduling appointment times you have a reasonable chance of keeping and if you happen to run a bit ahead _you_ can play Bejeweled? Wait, are you too busy and important for that? I think most women are too. - 4/14/2010 1:12 AM
- IASoupMama said...
Wow! That's quite a schedule!
When I'm in for prenatal visits, I try to be he patient who can get my doc back on schedule -- happy, calm, no complaints, no arm's-length list of questions.
Now if I could just get pregnant again... - 4/14/2010 1:54 AM
My OB/Gyn is in a practice of 3 physicians. One of them is on call on L&D while the other two see patients - with no L&D responsibility on that day. Therefore, they are usually on time. The most I had to wait was 20-30 min, and it was unusual! Usually it is 5-10min...
- The Semi-Domesticated Mama said...
My first OB back in Old Town was never on time. I would routinely wait up to 2 hours past my scheduled appointment time. It wasn't that big of a deal on the days when I had child care for the older 2 kids. On the other days, it was horrible and resulted in lots of dirty looks from the nursing staff.
My current OB in New Town is amazing. I chose a practice with 8 OB's on staff. 2 of them are on call each day -one in the am and one in the pm and then the am one does the overnight. The on call doc has no office patients scheduled during their call hours. If they are not called to the hospital, they will pick up a few patients at the office (which is next door to the hospital). I have never waited more than 10 minutes in the waiting room and I have never waited more than 5 minutes for the OB once I was in the room. I will never ever switch from this office.
One other patient in the waiting room commented that you get what you pay for. This practice does not accept Medicaid patients at all. Very few of the private practices in New Town accept Medicaid. It seems from my experience that the offices that do accept Medicaid are the ones with huge wait times because they are trying to cram too many patients into one day. Not knocking patients that need Medicaid at all, I had it during my first pregnancy. Just an observation. - 4/14/2010 9:54 AM
- Sarah Blue said...
I've never minded waiting for my OB. I know delivering & surgeries are the priority. This actually makes me happy because I know that when *I* deliver, *I* will be the priority...for however long it takes.
- Jedi Meg said...
I think my doctors (it's a practice of 4 female OB/Gyn's and I love them!) and all of their nursing and office staff are amazed at how calm and relaxed I am. At one recent check up the doctor I was seeing was the only one at that office that day and was covering L&D and had 2 deliveries while I waited for my appointment. And I was fine with it. I was kept up to date on what was going on, and I had a crochet project with me, so I was great until I ran out of yarn!
- dr. whoo? said...
Mama to Monkeys~ Thank you for your questions, and though I can see (and I do appreciate) that you are not trying to criticize, you may be finding it hard *not* to criticize. Being on the outside looking in, I can see how insane a typical day at my job must seem. That being said, you raise very good questions, and I am happy to address them. Trust is certainly not built in a day or even a couple of days, and, the unfortunate consequence of practicing in a larger urban practice, with several different physicians, is that the majority of our patients may not be able to develop a good rapport, trust, or good knowledge of each individual physician prior to their delivery. On the first OB visit, histories are discussed, reviewed, and updated. Thereafter the pt. may have anywhere from 10 to 16 appointments during which to discuss the issues that you outline: needs, wants, questions, fears, expectations, worries, et.cetera.
While a 10-15 minute appointment doesn't sound very long, I feel I am actually able to cover quite about of ground with discussion, if needed, as the majority of OB visits involve much more talking than actual examining/testing. Of course if my patients have worries or concerns I don't just cut them off, tell the m their time is up and move on to the next one. I take as much time as I can to sufficiently discuss with them the areas of their concern before moving on to the next patient. (Yet another reason why we may be running late...the patient before you may have a complex issue needing to be addressed).
As for the differences you see between a physician and a midwife, time spent is a big one, and I am glad you have found one that meets your particular needs. Midwives, in general, see a far lower volume of patients than physicans, and they are either self/home employed, or employed by a larger heath care specialty group, so they are free to focus on the patients without worrying about pesky things like overhead or paying a larger staff's salaries. In contrast, our group has more than 50 employees. There are several physicians in our practice, and our group does approximately 60-90 deliveries a month. Mulitply that over 10-16 visits and there is no way on this green earth that we could ever spend an hour at each and every visit, it just is not feasible. - 4/14/2010 6:12 PM
- dr. whoo? said...
Mama to Monkeys (cont.)~ I really find it insulting that you would insinuate that "for OBs" it all just boils down to the "catch." Of course that isn't true. My colleagues and I keep meticulous notes and communicate with one another about on going patient care. On the off chance that a woman comes in laboring that I have not had the chance to meet in the office, I do take the time on admission to get an idea about her desires and preferences for delivery, as well as personally discussing her prenatal history with her. Even if I am not constantly at the bed side (as you can see above, I am usually attending more than one laboring woman/patient at one time), I am always checking in and communicating with her about her ongoing care, before, during, and after the delivery.
As for meeting women's "emotional needs" during pregnancy and delivery, I'm not really sure how to answer except that not all women expect their prenatal care provider to fulfill an "emotional need" for them. Most will seek this in their husband, close friends, and family members. Most women that I encounter want to have a good relationship with their OB, but they see us as a means to an end...a healthy pregnancy and delivery. I believe that being a firm knowledge base, source of information, provider of technical skill and assistance, and yes, reassurance that everything with the pregnancy is progressing "normally" are the main tenets of my job when it comes to caring for OB patients. There are always patients with whom I will form a fast and easy rapport, while others never really click with me. This is just basic human nature. I think that my role in the pregnancy and delivery process boils down to being the safety net and the guide through the pregnancy, and while I do my fair share of holding hands and sharing, most of the time, we leave the hand-holding to those closer to the woman, herself.
Hope this helped you to gain a bit better understanding of my perspective on the other side of the exam table. - 4/14/2010 6:13 PM
- dr. whoo? said...
KT ~ Great question...only, read in my post above, *I* am not the one that "schedules it that way." Our scheduling staff does the schedules, and they have very little clinical knowledge or comprehension about how much time certain medical exams take, all they see is an open slot on the computer, and all they hear is MarySue on the other line complaining about how she just *has* to be seen today at only 2:15 because she has "bumps" and she needs to know *right now* what they are. They are our customer relations, and they are trained to accomodate patients wishes to the best of their ability. They do not know (nor do they have any way of knowing) what we may or may not have going on on L & D that day. They see an open slot, and they fill it.
I think it would be awesome not to have patients scheduled during the days that we are on call, and as the practice is growing, we may move to that model. However, there are many days where we have absolutely nothing going on at L&D, and seeing a OB patients or problem patients allows us to accomodate our patients' needs for immediate appointments, as well as eases the burden on the other physicans seeing both OB and GYN patients in the office that day.
The patients are informed at the time that they make their appointment that the physican is the physician on call, and that they may have to wait if there is a delivery. Of course they are given the option of rescheduling if the physician is otherwise occupied. Most of our patients do not mind waiting, as they know that one day it may well be them that one of us is attending on labor and delivery.
As for "who on earth" thinks you can do a "decent" routine follow up OB visit in 10 minutes? For one, me. See my answer above to Mama to Monkeys. I feel I can cover a lot of information in the span of 10 minutes face-to-face with a patient, and often, if everything is going well, the visits do not even need to take that long. It is when things are not going well, or patients need a little more coddling or reassurance that the house of cards comes falling down, and we, as physicians, fall farther and farther behind schedule rather than hurrying a patient along or just simply cutting them off in order to "run on time." - 4/14/2010 6:14 PM
- dr. whoo? said...
Hi Medstudentitis! Oh, how I loathe the noon section. I really, truly loathe it. Because I like to eat lunch. A lot. And on the days we have noon sections, I so rarely get to eat lunch. I also like to use the time to catch up on charting and patient messages so I am not there at the end of the day doing it. Our schedule is set up this way so that we can maximize prodution in our 8:30 - 5:00 office work day, so the better to not have to stay late to do 5 pm scheduled surgeries. We are in the building right next door to the hospital, a brisk 3 minute walk or 2 minute jog door to door, so travel time is not an issue. If the surgery would actually ever begin right at noon (exceedingly rare, as you so astutely point out), it is usually quite manageable to get it all done in an hour or so, even with more complicated repeat sections. We usually have 2 physicans and a scrub tech doing the noon sections, so that does help immensely. In theory, on the days we have a noon section on the schedule, we are not supposed to resume seeing patients until 1:30 pm, in order to afford us some more time flexibility. HAHA! Um, er, I mean, this rarely happens (see comments on our scheduling staff, above).
Diana J~ Hi and welcome! I hope you are enjoying reading the blog thus far! Thank you for reading and taking the time to comment. :)
Taking Heart ~ LOL! Your idea is totally awesome. Maybe you can add sour gummy worms and red bulls for the physicians so we can keep our energy up! :) I think you'll be a millionaire in no time, I'd love to get in on the ground floor of that business! - 4/14/2010 6:37 PM
- dr. whoo? said...
vldecker~ Aw, thanks for being someone who understands. I always feel so guilty staying on labor and delivery (even though I know it is the most important place to be) when I know that the patients in the office are stacking up, the guilt is alleviated by patients who understand.
Geez, Anon 1:12~ Why all the anonymous vitriol? Afraid to leave your name? See my comments above with respect to the fact that *I* do not "set it up" the way that it is. It has been this way in my current practice for upwards of 30 years. It is a well-established, well-respected, and growing practice in our area. We don't want to turn women away for care so that we can twiddle our thumbs in between appointments. Physicans happen to be fairly efficient with the time that they do have. As for whether or not my patients think their time is wasted, you will have to ask them. Most are very gracious and understanding when, as the on call physician, I get a bit behind...you know, because one day it may very well be them that I am caring for while others wait. I don' t know about you, but when I am at my job, I prefer to be productive. While I may be busy, and, I don't know, but I think helping other women deliver their babies is pretty darn "important, but YMMV, that has nothing to do with my work schedule. If I have time to play video games when I should be working, then that is one more woman I could have seen for a possible yeast infection or another OB patient that I could have taken care of instead of goofing off. I like to work when I am at work, and play when I am not working. Funny how work ethic varies from person to person, huh?
IASoupMama~ You have no idea how much patients like you are appreciated on the days we are running around with our hair afire. Thank you, and good luck with conceiving your next pregnancy! :)
Anon 8:48~ I agree that having no office duties while on call would be ideal, but it really isn't economically feasible or practical for our current practice. Hopefully in the future, this will change. I will say that when I am not on call, I run fairly well on time (notwithstanding checking in processes and the like). I don't like anyone to wait in the room naked any longer than absolutely necessary.
Snarky Mom~ That sounds like a very interesting call set-up that your OBs have in New Town. I may have to propose that to my colleagues as our practice continues to grow and expand. Personally, I would prefer not to have patients scheduled in the office during my call days, because I always feel so torn and guilty about leaving people waiting vs. leaving a mother in active labor. I tend to be a labor-sitter, while many of my colleagues are not. Right now, I am "just an employee," so my thoughts and visions for the practice may not have much clout, however, if I am offered partnership, I may be able to help effect change that would benefit both our patients and our physicians. I will say that on my non-call days, I do my very best to run right on time. My patients rarely wait more than 5-10 minutes in the room once they are checked in on my "normal" days, as well. This makes us all happier. We do not accept Med.caid either, and I agree that it makes a huge difference in the practice (my old practice was majority Medicaid). You have to see so many more Medicaid patients in order just to break even. Thank you for your comments.
Sarah Blue~ You are absolutely right! No one likes to wait, but one day, the proverbial "shoe" may well be on the "other foot." Thank you. :)
Jedi Meg ~ I am sure that your serenity is so welcome to a physician who probably feels hurried and harried whilst trying to do it all. Your patience (and industrious-ness) are so appreciated. :) - 4/14/2010 6:37 PM
I have no issue with the fact that ob/gyns are often pushed off their schedules due to deliveries. However, I think my dr's office should call and tell me when there is a significant delay so I can stay at my office a little longer and get more of my work done.
By "significant" I mean running more than 30 minutes behind. - 4/14/2010 8:22 PM
My OB was by herself and sometimes I had to wait. I never minded because I figured if my delivery happened during office hours she'd be with me and not in the office, although it turned out one kid was born on Saturday and the other around lunchtime. This was before the days of NPs and PAs but there was a kind of scary ex-military nurse guy (think lots of tattooos) who did some of the prenatal checks when she was real tied up--nicest guy in the world once you got to know him. I was able to catch up on a lot of my medical journal reading while in the waiting room (even though I hid them behind Redbook magazine), and since boards were during my first pregnancy, that was a good thing. One more thing for patients: if you make an appointment for one issue, don't come to the visit with a laundry list of issues/concerns/problems. Happens all the time in my field and makes everybody behind. If you have multiple issues for pity's sake be honest when you make the appointment so enough time can be allotted. And don't expect a warm reception if you whip out that list when you're being worked in that day for an acute problem.
another thing that happened to me today so the infertility patient that showed up for a 30 minute appt 1 minute before the appt was scheduled with no paperwork filled out. Now we have both online and offline paperwork that is easily accessible but nahh just wait until that appt. so I ended up being 30 minutes long all afternoon long because of her.
She was told to do paperwork ahead of time but never got around to it, so should i have rescheduled her right as she arrived on time for her appt but not ready for her appt, so should i have just seen her as I did.
Interestingly she was a women with 2 previous children from her last marriage but oddly her new husband who has no children but was previously married, well they can't figure out why she isn't getting pregnant.
so for hippa's sake, i'll go anonymous on this one so then you can't even tell what state i'm in so i can't be breaking hippa that way. - 4/14/2010 10:58 PM
- Katie said...
I have to say that I find this statement upsetting - " It is when things are not going well, or patients need a little more coddling or reassurance that the house of cards comes falling down, " Women who have legitimate questions, fears, or needs during this incredibly emotional time of their lives deserve to be respected and met at the place they are. Calling this "coddling" is disrespectful. And you said that you expect women to get the "hand holding" they need from people closer to them, like their husbands. This is great to an extent, but the problem is that their husbands don't have the medical knowledge to truly be able to support the women in the way that her care provider should. And you as a care provider can't give a woman that kind of support if you only have 10 minutes with her once a month. And honestly, by the time she has spent over an hour trying to entertain a cranky toddler in your waiting room she doesn't have the time to go over all her questions even if you do. You say that it's not economically feasible to see fewer patients per hour...I suppose that depends on what you mean by economically feasible.
- dr. whoo? said...
KT~ Um, who said that the woman who needed more time or attention did not get it?? (or as you say, "deserve it?") Patients are *given* as much time as they need, regardless if it blows the schedule all to hell or not. If issues need to be addressed, they are. As far as being economically feasible, it is a long, involved topic, but suffice it to say that OB/GYN practices simply cannot survive on 8-10 patients seen per day. It is impossible to cover overhead this way, and if you do not work in the medical profession, there is no way to easily explain so that you may comprehend.
- Katie said...
Also, given the incredible importance of nutrition in pregnancy, how can you cover that in 5 minutes, along with what symptoms the woman is having, what fears she has, what she should expect in the coming weeks, etc? I am not trying to be snarky, I just don't see how to fit that in 5 minutes.
- dr. whoo? said...
I can sum up pregnancy nutrition in a few sentences. "Concentrate on increasing fresh fruit and vegetables, and target an increased protein intake. Go for as natural a diet as you can possibly tolerate. Stay away from white bread, white pasta, white rice, potatoes, cake, cand, chips, and any processed foods. Aim more towards natural foods that grow, swim, fly, or run. Eat small frequent meals, every two to three hours (200-300 calories at a time(, taking protein and carbohydrates together at each meal. Calcium is important, if you are not taking 2-3 8 oz glasses of milk/day, look at calcium supplementation. Your goal is 1200 mg of Calcium daily." This discussion takes 60 to 90 seconds, max.
- Katie said...
"This discussion takes 60 to 90 seconds, max." Ok, first of all, a patient is going to have trouble remembering all that if it is only given 60 seconds of your time. If it isn't worth more of your time, how are they supposed to understand how important it is for them to follow it? Not to mention that when a woman is nervous and excited about finding out how her baby is doing she is unlikely to remember something barely touched on. Also, you called this a conversation takes longer than that. A conversation involves two people talking, not one. A conversation about nutrition starts by asking what the woman knows about nutrition, what she is eating now, if she has any dietary issues such as allergies or intolerances or relgious beliefs precluding certain foods. Then you talk about how to modify that. For instance, my care provider knew that I get excema when I eat dairy, and that my son was allergic. So she discussed alternate calcium sources, including greens. She also asked about diet at every appointment, so although I wouldn't have thought to mention that i was craving fast food (and giving in to those cravings), when she specifically asked I admitted it, and she told me that the baby's brain was growing a lot that week, and it was normal to want more fats, and helped me figure out some healthy options. (guacamole!!!). I guess what I'm thinking is that unlike a dermatoligist, who is dealing with something JUST physical, an OB has to be a doctor, a nutritionist, and a bit of a psychologist. Pregnancy is NOT just a physical event, birth is also emotional, cultural, and spiritual. And there is no way to deal with all that, AND talk to the woman about how her baby is growing (my favorite part of my visits was having my provider pull out a chart and show me what my baby looked like that week, and explain the changes), how her body is changing, and make plans for the birth, all in 5 minutes. I know that at your current position you don't have control over how many patients you see...but you have to admit it is no where near the ideal situation.
- Katie said...
I understand that you are giving the woman who asks for it more time. However, you obviously resent it on some level if you consider a woman who needs more than 10 minutes someone that needs to be "coddled". That is condescending at best.
Also, you say "but suffice it to say that OB/GYN practices simply cannot survive on 8-10 patients seen per day. It is impossible to cover overhead this way, and if you do not work in the medical profession, there is no way to easily explain so that you may comprehend." Um, I do work in the medical profession, as do most of my friends, so I do get it. I really do. Doesn't mean it can't be done differently, many people here have mentioned that the offices they go to do it differently, so it is possible. Not an hour per person maybe, but at least 20 minutes is feasible, and not having patients in labor and in the office at the same time IS feasible. - 4/15/2010 11:26 AM
"As for meeting women's "emotional needs" during pregnancy and delivery, I'm not really sure how to answer except that not all women expect their prenatal care provider to fulfill an "emotional need" for them. Most will seek this in their husband, close friends, and family members..."
This response did wonders for me to understand the difference between me and so many of my friends who tend to bash OB/GYNs and praise midwives. In a provider, I was looking for a medical guide in my pregnancy and birth, not a doula or a new best friend. My 2 OB/GYNs I have had for 2 births have been top notch! And if I knew you, I would try to get into your practice for a potential third! And your responses in the comments were extremely helpful. - 4/15/2010 3:25 PM
I always waited 2-3 hrs for my prenatal care & would gladly do it again. I had incredibly complicated pregnancies that were managed 100% by a Perinatologist (most of his patients also saw a regular OB, I was an unusual case) and I knew his schedule was overbooked because he was in high demand. He is the best. And he didn't even deliver me, it was the hospital-only Peri (no office patients) who was did my emergency deliveries and was a fantastic provider as well. The delivering Dr only met me a couple of times during emergency L&D visits but I loved the care I got from him too. He was in constant contact with my primary Peri plus he was incredibly skilled & had a fantastic, calming manner even when I was terrified & very sick.
I was content with my busy docs because they had awesome nurses, techs & NPs who did most of the patient education, gave reassuring talks & tons of hugs. My Peri made himself avail to me by cell phone & email because he knew his patients wanted that safety net of constant access & personal attention. That worked for him: all the panicky moms-to-be shared happy stories of how they felt well cared for when we were chatting during those long waits in the clinic.
Busy docs with extremely complicated patients CAN still give wonderfully personal attention. Mother & baby care is a TEAM EFFORT. I think skilled docs, well-educated support staff & teamwork made it a positive experience for me. Good people skills makes the difference when juggling too many patients; tons of experience helps too. I met nice Residents & Fellows but they couldn't do as good a job, they let their frustrations & stress show. The most experienced practitioners can make it look easy.
I only wish they had massaging recliners in the waiting room- when I was on bedrest I usually got a NST recliner or exam table to lay down on while waiting to be seen & I felt bad for the other moms sitting on hard waiting room chairs- and that food cart would have been awesome!! - 4/16/2010 3:52 AM
Speaking as a home birth midwife, I don't know how OB/GYNs do everything they do. And I say that with admiration and respect, not sarcasm. I can do home visits, spend 60-90 minutes at every prenatal, really get to know a woman, analyse her diet habits and individual nutritional needs, and be there for her entire labor and several hours immediately postpartum *because I only attend 3-4 births a month.* I can't do a c-section if she needs one (or a forceps rotation for a persistent posterior baby with a nuchal arm, or an emergency D&C for a placenta accreta -- I've had clients who needed both of these in the last two months, and the fantastic OB who sees them for back-up care was there we needed him. I don't know when he sleeps with juggling office hours, scheduled surgeries, and deliveries -- he's in private solo practice and is almost never really off call. I could not do what he does, and it would not be reasonable to expect him to do what I do.
- Alex said...
No offense to midwives and their clients, but for some women, it is just not important to them to make pregnancy and birth such an emotional, cultural, and all-encompassing life-stopping event. (I know, I know, shocking!) When I chose my OB, I didn't want her to pry into my life to where I needed to spend 60 minutes each appointment hashing out my diet, my sex life, my emotional void that I was wishing and praying she would be the one to finally fill... etc. Some women just want a doctor to monitor their progress and deliver their baby. End of story.
I do understand and appreciate how packed the OB schedules are, but so is mine. So when my OB would be running 45 minutes late, that was another hour off the clock at my job, another appointment I had scheduled later that I was late for. I realized that I couldn't control the doctor's day, so I'd anticipate an hour appointment wait. Sure it was frustrating and annoying, but at least I got a lot of reading done. :-) - 4/16/2010 1:28 PM
To the homebirth midwife who posted above me ~ THANK YOU. You are correct in saying that you cannot do what your OB does and he does not have time to do what you do. You are 2 seperate professionals with a common goal ~ helping bring life into the world. :-)
Come on people, Dr Whoo did not make the rules, she only plays by them. If it works for her and the pts that see her and the other docs in her practice, that is GREAT! If it doesn't work for you, you can go to a clinic / midwife that can give you what you need. It is really that simple. She was posting info on her blog that she thought would be helpful and this has turned into a p*ssing contest on who delivers better care, midwife vs OB. Everyone is different and we have a ability to choose who we want to see.
JMHO ~ as a L&D nurse and mother of 3 who has waited FOREVER to see her doctor. - 4/16/2010 1:31 PM
- MamaDoodle said...
I was a clinic RN in an OB/Gyn clinic similar in size and patient load to the one you describe. Our on-call physician was scheduled every 30 minutes with a few specific appointment times left open for me to use at my discretion for patients who needed to be seen urgently. Patients scheduling on a call day were told ahead of time that they may have to wait or be rescheduled. Our other providers all managed to reasonably stick to their schedules.
We scheduled routine OB patients for 10 minute appointments, annuals for 20 minutes and consultations for 30 minutes. Our physicians' schedules were booked months in advance. And NEVER double-booked, as you describe. Patients who wanted to be seen sooner could be seen by one of the 3 ARNPs who often had appointments available within a day or two. Or they could try to make their case with me and I would decide (or ask the physician) if they should be seen in one of the urgent spots that day or the next on the on-call schedule. For patients who needed to be seen sooner than the 1-2 month wait for an appointment but not urgently, I would keep a list and the receptionists would notify me of cancellations.
Having worked in a well-run, but very busy OB/Gyn clinic, I see no excuse for patients waiting more than a few minutes to see their physician other than exceptional circumstances. I know you're going to point me to the fact that you don't do the scheduling and you have no power about the way your clinic is run. But I think that's a cop-out.
Making excuses for the clinic shows a lack of respect for your patients' time. If I were a patient at a clinic that regularly double-booked patients and physicians regularly ran late (on a call day or not), I would change clinics and write a letter to the clinic manager and/or physician group letting them know that their disrespect for my time was the reason I was leaving. I understand occasionally waiting, if the patient ahead of me needs extra time or there's an emergency of some sort, but setting up a schedule guaranteed to cause providers to run late is inexcusable. - 4/17/2010 11:53 PM
Im sorry, but I never expected my OBGYN to handhold me, coddle me, and blow sunshine up my ass. What I needed from him was telling me that everything is progressing within normal ranges, that the test results were nothing astounding, and that while vomiting all the damned time sucked ass, and required my little red emergency bucket the whole time, that i was NOT going insane for it.
Oh, and I needed him to deliver my son. I put my faith in him, and went as far as telling him that if there is even a NIGGLE of some doubt of something "not quite right" that I as not going to get upset if we needed a section.
Did I wait in his waiting room? Yep. Did I get a midwife who was already skating on thin ice fired? Yup. Dont bloody tell me in an office where your supervising OBGYN is a male, that it is IMPOSSIBLE for a male to know what is going on in a womans body.
I spent roughly ten to fifteen minutes per appointment with him, and often times much longer in the waiting room. Loved him. Will use his practice again. I would much rather have ten minutes with an OBGYN that I trust, than have a twenty or thirty minute appointment with someone i cant stand.
Personal Choice. - 4/18/2010 10:42 PM
- LauraT said...
These comments are so interesting for this post. Having 4 different OBs between 6 kids I came to a few conclusions. I WOULD NOT wait more than an hour or so for my doctor. If need be, I would check in, get my blood pressure, weight, and urine checked and then leave after a half hour or so. Any questions could wait till next month, or I could call the doctor. I would anticipate, at tops, a 2-5 minute phone conversation. Does this bother you, Dr. Whoo, when your patients don't see you in the office because they have lots of little kids at the babysitter's or in your office and they can't stay to see you? From their chart you can see their weight, urine, blood pressure, etc. I never had high risk pregnancies, or the need to be overly chummy with my doctors. Although, even friendly banter would only take 2-3 minutes and accomplished a lot in establishing a trusting, good rapport with my doctors. What I've since learned in reflecting on all my OB visits over 14 years with 6 pregnancies and 2 miscarriages, was that I should have focused more on what my concerns and preferences for my labor and delivery were. The delivery is the culmination of the pregnancy and is very important to have good communication regarding all those details. With our internet, info overload society, I would read a lot, inform myself, and then boil down my questions to just a couple. This allowed my doctor the opportunity to clear up my misconceptions or understand my concerns and add his experience in so that I was truly informed. Anyway, those are some thoughts from a very experienced and very understanding former OB patient who expected my appts. to be canceled several times throughout my pregnancies due to the erratic, unpredictable nature of OB/GYNs schedules. Keep up your good work Dr. Whoo.
Can I ask, is it appropriate for a patient who has other responsibilities to ask to have an appointment rescheduled for another day? (Is that even possible?) Is there a waiting time when that might become appropriate? (Assuming, say, this isn't an emergency or anything.)
- Unknown said...
Sounds like an entire system that needs changing. What about midwives or NPs for low-risk patients and OBs for high risk? Or what's an alternative? Are there really none? I agree that 60 minutes is unnecessary, but 20 would be nice, and no more than half an hour wait. I don't need hand holding but I did like knowing the OB who delivered my babies. It sounds like many fields are headed towards the big practice model with many doctors sharing call. I'd rather have one or two GPs, peds, obs, whatever, than 10 in one practice.
- Brit said...
(...continued) My OB wasn't there just to catch, she checked in once or twice while I was delivering (I was only in labor for 6 hours), I know that she also had a computer in her office where she could see all the readings of the machine and check the progress of my contractions, giving her and her other patients forewarning of how close I was to delivery. Also, the nurses regularly corresponded with her (probably more than normal 'cause I walked a lot and was never hooked up to the machine). Of course, my OB was also blessed with a practice within 5 minutes of the hospital.
Another thing, I was always told that if I felt I had a lot of question or wanted more time I could always ask to schedule a double appointment. I think by coddling Dr. Whoo means those patients who tell the nurses that everything is fine, they have no concerns, and then suddenly lays a list of problems on the doc. Tell the nurses they prepare the doc so she is prepared and can use that time most efficiently. Or the patients that haven't done their own homework, haven't read the handouts given at the last appointment or who unfortunately are listening to horrible advice and horror stories from little old ladies and mother-in-laws.
I know that physicians are very busy, that my OB tried her hardest, that she often skipped lunch, and stayed hours after the office closed to catch up on paperwork, and I also know that insurance companies generally regulate the patient load a physician sees, and they are the ones who tell physicians to have an average appointment of 8 minutes. Midwifes only deal with select insurance companies, and not the worst of the crew, Medicare.
Dr. Whoo and the rest of the busy, overworked, tired, hungry OB's and other physicians out there. I want to say thanks, and I understand and appreciate all you do. - 4/20/2010 5:53 PM
- Brit said...
Come on guys, be nice! In case you haven't noticed Dr. Whoo spent years training, and puts a lot of focus into trying help her patients. She even skips lunch, how many of you frequently skip lunch at your work place to help another customer, or do you just put up a sign that says "The office is out to lunch and will be back at 1:00"?
I went to an OB for my pregnancy, and I loved it. I thought about a midwife, and part of the consideration was the price. But for my first pregnancy I'm very glad I choice an OB, I was comforted in the fact that if something suddenly went wrong she could handle it and could perform an emergency C-section.
10-15 minutes with my OB was plenty of time! To help cover all the things you guys are mentioning there are things like plenty of hand-outs, nurses who can go over some more basic information, and a number to call for questions.
Dr. Whoo is right, all of those 15 minute are spent talking, even the basic exam of measuring the belly and listening to the heart beat, and you can still talk during. My OB was able to explain everything she was doing, what was normal, if I deviated from the norm what it meant, what to expect over the upcoming weeks, what I could do and answer questions, it can be done. It also helps if a patient has done her own research (come on What to Expect When Your Expecting, and WebMD exist) so that it's not all new information, and I can ask if my doc agrees with the information I've found.
Amazingly, by some miracle my doc was rarely behind more than 1/2 hour. And this is amazing because she is on call every day. And for that I'm grateful. She was in a practice of 4 physicians, who were all on call every day for their own patients, they rotated weekends and holidays, and there was one day a week that they would be in the OR (Mondays for my doc). I was told all of this at the first visit. I am also very grateful that the doc I went to all my visits with was the one there for my delivery, and not some doc I was unfamiliar with just because it was her office day and she didn't want to schedule on call days during office visits.
However, occasionally she did run a little behind, and for that I was perfectly fine, like many others I was glad to know that the priority was for those delivering and that she cared about her patients, all of them, not just me. On those times, if it was severely behind, I was called before my appointment. Otherwise I was told at the office and was given the options of waiting, rescheduling, or seeing another of the practitioners. I felt the staff always did what they could to be courteous while still acknowledging that things happen, babies come at the most unfortunate time. - 4/20/2010 5:53 PM
- Brit said...
Also, if any of you absolutely cannot stand waiting, and need to get in and out quick, schedule one of the earliest appointments. Doctors are rarely falling behind on their first appointment. And I swear most babies like to come at night or in the afternoon, after Mom has been up walking around all day.
- Suzanne Lucas said...
I'm another one that doesn't want my OB to meet my emotional needs. I have friends that have their babies with midwives and they gush about how the midwife stays with them throughout the labor. I would rather stick pins in my eyes then have someone hovering over me while I'm in labor.
But, the OBs that delivered both my children have a much more patient friendly focus. The doctor who is on call doesn't see patients in the office. Longest wait in two pregnancies was 45 minutes and that was when I had the last appt of the day. Most times, I was called back 5 minutes before my scheduled time. - 4/22/2010 1:55 PM
- Kyla said...
I enjoyed the post, but then I got to the comments and WOW! I wasn't expecting some of this.
I'm a premed mother of 2 and my younger child has special medical needs and we've spent AGES waiting in various doctor's offices. I never, ever expect a medical office to be running on time, especially in a specialty like OB where urgent situations (deliveries, c-sections) are a frequent occurrence. Regardless of scheduling, doctors can never adequately predict how any particular visit will go. A quick visit for a stomachache can end in a doorknob question which resets the entire visit, eating up double the allotted time...or a visit that seems to be of high acuity can go unexpectedly quick. Doctors do the best they can to meet the needs of each patient and that sometimes results in running behind schedule. If you are the patient with a game-changing door knob question or the patient who needs an emergency c-section, you certainly don't begrudge the doctor devoting that extra time. We should all keep that in mind the next time we are kept waiting a little longer than is ideal. - 4/23/2010 11:26 AM
- RoseAG said...
Being seen 20 minutes past the official appointment time is standard in my book. My feeling is that if you aren't happy with the timeliness of your doctor then you should find a different one because small things matter.
To illustrate: I had an appointment with a new Pediatrician. We'd changed insurances and were expecting #2 so I took #1 to meet the fellow and get ourselves established.
This was pre-GPS/email/cells phones and I got lost getting there and was 20 minutes late. I'd left work, ridden the train home, picked my son up and gotten lost during this journey so I had already exerted a considerable amount of effort and taken half a day off. He tells me I'm "too late" and will have to reschedule.
I did reschedule, and you know what? Although he was a recommended and on the "Best Docs" list in my area I never liked him. He was timely but our outlooks were different, he sent us to several specialists I thought were un-called for, urged me to have one son have a surgery that was a waste, plus his advise/care recommendations always seemed to "forget" that I was a working Mom who did not have unlimited time.
A couple of years later we changed insurances again and I got us into a large group practice with an easy to find location that habitually ran 20 minutes late. Both kids are still alive and well.
My take-away is that if you are unhappy with the way a Physician runs their office you need to find another Physician. There is no telling what else you will not agree on and you'll both be happier. - 4/23/2010 8:15 PM
- RH+ said...
Another reason I run late is when people book an appointment for one reason and actually have a different , more serious problem that they are hesistant to tell the receptionist.
example: twice I've had people who came in for yeast infections but were really suicidal!
or someone who found out their spouse was unfaithful and needs STD screening.
Also, when I have someone comes in for a routine visit and actually has a miscarriage, this visit will take much longer than scheduled.
Our office employs an NP who is amazing and helps pick up the slack when we run behind. - 4/26/2010 9:43 AM
- IASoupMama said...
Wow! You got a bunch of comments on this one!
I am very willing to admit that I am not in a medical profession, however, my mother-in-law has been an OB nurse for 35 years (now a nurse manager). It's been great having someone in the family to bounce stuff off of and, though I am never prone to panic, talking with someone as experienced as she is was helpful during both of my pregnancies.
That being said, even with that ace in my pocket, I did my homework. I attended pre-conception classes, pregnancy classes, and childbirth classes. They were all free at the hospital at which I was planning to deliver, so why not educate myself? I read voraciously -- not to the point of hypochondria, though. It is true that you shouldn't believe everything on the internet, but if 98% of the sources you check say that heartburn in pregnancy is normal, then it probably is.
I adore my OB -- she clicks with me and my hubby, we usually spend the visit laughing. I hope that she enjoys our visits as much as we do. With my second child, we had a bet -- I said she wasn't going to be that much bigger than my son and she was guessing that baby would be at least a pound bigger. I was right, BTW!
I view my relationship with my OB as a partnership with the mutual goal of healthy baby/healthy mom. I pay attention, I take notes, if I need to, I ask relevant questions. She is currently guiding us through infertility treatments (Clomid/IUI) with her trademark blend of information and humor. Keeping my fingers crossed for next month! - 4/27/2010 2:36 PM
Good god you are simply amazing.
That is all. - 4/27/2010 7:44 PM
- Nicholas Fogelson, MD said...
I have to support Dr Whoo here. Practicing OB/GYN is not something that can be done in 1 hour blocks, at least not if your patients are expecting you to bill their insurance. The overhead of practice requires that you see at least 15-20 patients a day just to pay your rent, utilities, staff, and malpractice insurance. It isn't until patients 20+ that you are actually making money to bring home to your family.
In a practice like Dr Whoo's, seeing OB patients while you are on call is a necessity. In a practice with 7-8 docs it probably isn't, as labor and delivery will be busy enough to occupy the on-call doc.
I've found that if I start each OB appointment by sitting down and asking "Do you have any questions or concerns?" I can answer the things that the patient is concerned about and still finish most visits in about 10 minutes. If a patient really needs an hour to talk about how they're feeling in pregnancy, they really should be working with a midwife, or hire a doula that will help them through the pregnancy.
OBs look at pregnacy as primarily a physiologic process that usually goes right and sometimes goes wrong. While we're there for emotional support for some patients, mostly we're there to catch and/or avert problems.
Larger practices that use midwives and OBs together are often work well to address patient's needs. - 4/27/2010 8:33 PM
- sweetorunsweet? said...
Well as an RN at a very busy 9 doc ob/gyn office (5 ob/gyn's and the others gyn only)I would like to weigh in on this topic. I gather that Dr Whoo is a girl. I work for one of two lady docs in our practice and our schedule is "always full". We have stopped taking new gyns, referrals etc because there is no room in the inn. Everyone wants a female and there is just not enough of my doc to go around. She has at least 3 ER calls/month and once weekly office call. She has two hospitals to round at and not all ob/gyn pts are on the same floor so rounding takes forever. She tries to do her scheduled inductions on her weekly call day which is also her surgery day. The OR is never on time so you stay behind all day on surgery day.
The very first rule of OB is that babies come when they want to and if I could streamline the process to predict the exact time she should whiz over for a delivery so as not to disrupt the office, her family time etc,etc,etc.- I would be a gazillionare! It is a crap shoot and if you want to continue to see Dr Wonderful then put up or shut up!!!! We have a great group of older gyn only docs who will never leave you to deliver a baby and don't have to spend hours rounding.
With that said, we see a lot of people for a lot of things that are not our specialty so a typical office visit can take awhile if we are addressing your psych needs as well as your Dermatology, Gastroenterology, Ortho,Neuro, primary care needs. If you expect her to listen to and address all this did you consider that she might do the same for the other 15-17 patients she is seeing today?
As for the staff calling you-we tried but you did not answer your phone or we did not have your cell number. The nurse(me) can only see certain patients and in doing so then I am behind on returning your phone calls( a whole other can of worms)We offer to reschedule patients when our doc is behind but most patients don't want to do that because they know it will be month before we might have another appointment time to offer.
I don't know what the solution is but I am sure it costs money and takes more that a few days to make a big difference.
My suggestions: If it is your annual exam - come with a good book or electronic toy to occupy your time if we are behind. Don't schedule four other things around this appointment time. Address some of your health issues with your PCP. Pick someone who does not deliver if these hints are not helpful.
If you are a school teacher- please don't ask us to rearrange our schedule so you don't have to miss work- guess what- my doctor and I has to miss work to see other doctors or attend parent/teacher conf. etc.
If you are an OB patient then keep in mind that if you were the patient at the hospital you would want her there when you delivered .
One of the things that makes your OB doc so wonderful is that she is a person with a family and a life that she needs to be apart of to keep her going. So cut her some slack if she is behind. She wont get to go home anytime soon and neither will I. - 8/04/2010 12:58 AM
I am sorry, that I interfere, but it is necessary for me little bit more information.

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Happy almost St. Patrick's Day!
You know I have a major thing for Jello and my co-workers love it too. So, I pulled out a card from my mom's cookbook and made this Jello cream cake. My auntie used to make this every holiday season as well (it is great with a topping of Cherry Jello!)
The crust is butter, brown sugar, flour and nuts. Easy peasy to make! Bake it off and let it cool before adding the next layers.
The ingredients are simple. Jello, cream cheese, heavy whipping cream and a little more sugar. The middle layer is cream cheese and sugar with whipped cream folded in. The lemon Jello is dissolved and gives the layer stability because of the gelatin.
A big tray of this gelatin treat is always a big hit at potlucks or...the library! :)
If you don't want to make this one for St. Patty's day, try the Ice Cream Jello I made two years ago!
1 1/2 sticks - butter, softened
1/2 c brown sugar
1 1/2 c flour
1 c chopped walnuts or pecans
Cream Layer:
1 - 3 oz package of lemon Jello (small box)
1 c boiling water
1/2 c sugar
8 oz package of cream cheese (one block), softened
1 cup heavy whipping cream
Jello Layer:
1 - 6 oz package lime Jello (large box)
2 c boiling water
1 c cold water
1. Make the crust. Cream together butter and brown sugar until smooth. Add flour and nuts to the mix. Press dough into buttered 9 x 13 inch pan. I use the Pyrex pan. Bake crust for 10-15 minutes in pre-heated 375 degrees oven or until crust is brown. Let cool.
2. Make cream layer. Dissolve lemon Jello with 1 cup boiling water. Let this mixture cool. In a large bowl, cream together sugar and cream cheese. In a separate bowl, whip the heavy cream to stiff peaks (but don't make butter). Fold the whipped cream into the cream cheese mixture. Don't worry about it blending perfectly. Add the cooled lemon Jello and hand whisk together. Pour cream mixture over cooled crust and chill until firm in the refrigerator.
3. Make the Jello layer. In a large bowl, dissolve lime Jello with 2 cups boiling water. Add 1 cup cold water. Let this mixture cool. Pour on top of cheese mixture and return to refrigerator to cool completely.
4. Cut and enjoy!
5. Notes: You can, of course, change the color to suit your mood or holiday. This makes a bunch and can get pretty tall! When you add the cream layer, make sure you leave space for the top Jello layer. I usually place the 9 x 13 pan on a half-sheet pan in case I have spillage when placing the top layer on the cake!


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WASHINGTON (AP) - Congress made the obvious official on Friday. President Barack Obama has been re-elected.
In a joint session, Congress formally certified that Obama and Vice President Joe Biden were the winners in the November election with 332 electoral votes, well more than the 270 required. Republican Mitt Romney and his running mate, Rep. Paul Ryan of Wisconsin, won 206 votes.
It's a mostly ceremonial - yet constitutionally necessary - vote that's mostly intriguing to political junkies and policy wonks. The count Friday lacked the suspense of the drawn-out campaign and election but was steeped in tradition.
Biden and about a dozen senators trekked across the Capitol from the Senate to the House chamber, and the vice president joined House Speaker John Boehner, R-Ohio, on the rostrum. Senate pages carried two dark wooden boxes that contained the results of the electoral votes that had been counted in the state capitals last month. Clerks used silver letter openers to unseal the envelopes.
Taking turns, the leaders of the Senate Rules Committee - Chuck Schumer, D-N.Y., and Lamar Alexander, R-Tenn. - and the top members of the House Administration Committee - Reps. Candice Miller, R-Mich., and Robert Brady, D-Pa. - read the results from each state. Biden, who presided over the session, announced the final results to applause from the scattering of House and Senate members in the chamber.
The 12th Amendment directs the electors chosen by the states to meet and vote for president and vice president. Each state gets its equivalent in the 435-member House and the 100-member Senate. The District of Columbia gets the other three electors. Their certified tally sheets must be counted in Washington.
The low-key session was in sharp contrast to the drama in January 2000, when Vice President Al Gore, the loser in the disputed election, presided over the certification of an electoral count that gave the presidency to his rival, Republican George W. Bush. Gore had beaten Bush in the popular vote but lost the electoral count.
Months after the November election, the final official vote from all 50 states and the District of Columbia showed Obama with 65,899,660 votes, or 51.1 percent, and Romney with 60,932,152 votes, or 47.2 percent. Obama is the first president since Republican Dwight Eisenhower to win back-to-back presidential elections with more than 51 percent of the popular vote.
Chief Justice John Roberts will swear in Obama at noon on Jan. 20 at the White House in a private ceremony, and then administer the oath again on the West Front of the Capitol the next day. The Constitution requires that the inauguration take place on Jan. 20 but because it is a Sunday, the public session and the accompanying parade and festivities will occur on Monday.
Biden has asked Supreme Court Justice Sonia Sotomayor to swear him in for a second term. She will be the first Hispanic to administer either a presidential or vice presidential oath.


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- 1 New Features in EPrints 3.1
- 1.1 Redesigned "Manage Deposits" and "Review" pages
- 1.2 Issues tracking system
- 1.3 Views
- 1.4 Submission Process
- 1.5 Export
- 1.6 Import
- 1.7 Search
- 1.8 Database
- 1.9 Configuration
- 1.10 Administration
- 1.11 Semantic Web/Complex Objects
- 1.12 Indexing
- 1.13 Autocompletion
- 1.14 Searching
- 1.15 Improved privilege handling
- 1.16 Templates
- 1.17 Toolbox
- 1.18 New field-rendering tools
- 1.19 XML based Scripting
- 1.20 Handy Hooks
- 1.21 SWORD (beta-3)
- 1.22 AJAX Phrase Editor (beta-3)
- 1.23 Summary Page Plugin Boxes (beta-3)
- 1.24 Uncategorised features
- 2 Upgrade Notes
- 3 Changes to repository configuration
- 3.1 Suggested Changes
- 3.1.1 New Document Formats
- 3.1.2 cfg.d/views.pl
- 3.1.3 lang/en/phrases/views.xml
- 3.1.4 cfg.d/indexing.pl
- 3.1.5 cfg.d/search.pl
- 3.1.6 cfg.d/user_roles.pl
- 3.1.7 workflows/eprint/default.xml
- 3.1.8 namedsets/eprint_relation
- 3.1.9 workflows/user/default.xml
- 3.1.10 issues.xml
- 3.1.11 citations/document/default.xml
- 3.1.12 cfg.d/eprint_fields.pl
- 3.2 Other Changes to the default configuration
- 3.1 Suggested Changes
New Features in EPrints 3.1
Important note. Some new features will be enabled in NEW repositories, but if you upgrade you will need to modify your configuration to use them. We strongly recommend you review the "changes to default configuration" section at the end of this page, and apply them to your configuration, where appropriate.
Redesigned "Manage Deposits" and "Review" pages
- Columns may now be moved left and right.
- Columns may be deleted.
- A column may be added for any eprint field.
- Changes to columns are saved on the user record.
- Added icons for common actions (edit, deposit, etc.)
Issues tracking system
The new issues system allows the discovery of eprints with issues. For example, duplicate titles, or an item from five years ago still listed as "in press". You can configure the issues system via a simple XML file, similar to the citation file format. More richly specified issues discovery can be achieved using the new issues-plugins system.
- A issues_audit script is run nightly to discover and note issues. Issues which were there last time, but not there today are marked as "resolved" so you can review the resolution time. This audits items in the live archive and review buffer.
- An Issues Tab on the eprint control page shows the current logged issues, and also a live list of issues (although not all issues, such as a search for similar titles, can currently be done "on the fly")
- An Issues Search tool to search the
- New "Issues" system and plugins, with a tab on eprints and an issues search. You can order the list of items with issues by the number of issues, or by the most recently discovered issues.
Planned extensions to the issues system
These are not yet implemented, but we may provide as a set of plugins to 3.1.
- Tool to allow QA staff to mark auto-discovered issues as "ignored". For example, two items which really DO have the same title.
- Tool to allow staff to add issues by hand, and mark these issues as resolved.
The views part of EPrints has had a significant rewrite.
- Significant speed improvements
- On the command line, epadmin refresh_views, and a button on the Admin web page, which both cause all view pages to be regenerated next time they are requested.
- Groupings: You may configure alternate groupings for the views pages. Eg. group results by type, or by creators first initial.
- Views can be set to regenerate if they are requested and the file on disk is older than a specified age.
- Generate_views can be limited to just one view or language. Also just the menu pages, or just the lists-of-citations pages.
- Groupings can be displayed with a "tag cloud" at the top of things like co-authors or keywords. The more items in the group, the bigger the link. (beta-3)
- A "first_initial" option on groupings so that "Smith, J" and "Smith, John" get grouped together.
- Added a "divisions" view to the default configuration.
Submission Process
- Document Upload now allows upload+unpacking of .tgz or .zip files.
- Document Upload offers "capture from URL".
- Documents now have an option to convert them to any format available in the convert plugins.
- There's a convert plugin to turn .doc into .pdf, which is available from the upload screen convert option.
- Also plugins to convert PDFs and images to various image formats (png, jpg etc.)
- Option to allow import plugins to caputre full text from URLs in the imported data.
- Existing export plugins have been improved in terms of speed and memory usage.
- The BibTeX export no longer requires an external module.
- EAP (SWAP) Plugin - The EPrints Application Profile.
- XSLT based export plugins support.
- IDs Plugin - just export the IDs of each item.
- ListUserEmails Plugin - lists the emails of a set of users. Only available to repository staff. This replaces the list_user_emails command.
- DatabaseSchema Plugin - exports the database schema.
- Plugin to Export history dataobjects in ical format. Potentially useful for preserving/sharing history in a standard format.
- XSLT import plugin system
- Import scripts can now download documents from a URL (mainly aimed at the EP3 XML format).
- Added import dataset for keeping track of imports.
- In the web interface, you can import from a file instead of just cut-and-pasting metadata.
- Also, the Import screen has an import full text option, if web imports are enabled in the config.
- added importid to eprints to link them to the related import object.
- added source_id to eprints to describe the id in the source repository.
- Search by a sub-object field (eg. search eprints by the format of their documents)
- Search by a related-object field (eg. search eprints by the name of the depositing user)
- Abstracted database layer to allow support of other databases.
- Oracle Support!
- Writing objects which have not changed is now optimised to not actually write, speeding up some parts of the system.
- EPrints fields may be marked as volatile. These fields can be modified without causing a change to the last_modified time of the eprint, the revision_id does not increase and no history event is created. These fields are useful for storing values which change frequently, such as citation counts or hit counts imported from an external tool.
- Messages and login_tickets are now datasets.
- epadmin has a command to create anything missing in the database. Handy if you want to add a field, you no longer have to fiddle with the SQL.
- New form based interface for admins to add metadata fields via the web.
- Admins may view configuration via the web.
- Admins may modify configuration via the web.
- Phrases, Citations, Workflows, Templates and static files are automatically re-read if they are altered. This means no more running generate_static every five minutes (although you still need it to ADD files)
- Buttons to refresh the configuration, the views and the abstracts, via the Admin page.
- When creating a new repository, a db connection error doesn't abort the process, and you are offered a random password to use for the db account.
- errors and warnings in executing code from .pl files now show correct line number and filename making debugging less annoying.
- epadmin erase_data now recreates all tables, rather than drop and recreate the entire database.
- Added plugin-masking so a local plugin can take the id of an existing plugin even though it has a different Perl class.
- epadmin has a command to create anything missing in the database. Handy if you want to add a field.
- Plugins can now be installed in a repository-specific plugins dir, although the perl package names must be unique.
- Batch editing: An administrator can perform a search and then set or modify values on all items which match the search.
- New buttons on the admin screen:
- send a test email (to check outgoing email is working).
- refresh the abstracts (on request, not right now)
- refresh the views (on request, not right now)
- reload the all configuration files.
- Staff can now queue an eprint for re-indexing via a button in the list of EPrint actions.
- New status screen to show database schema (replacing explain_sql)
Semantic Web/Complex Objects
- We've assigned URI's to each object in each dataset, and you can get at them using $eprint->uri, $user->uri etc.
- EP3 XML Export now adds the URI to each record.
- URIs take the format <ARCHIVE_URL>/id/<datasetid>/<objectid> eg. http://foo.eprints.org/id/eprint/23
- URIs for eprints redirect the abstract page for that eprint.
- URIs for documents redirect the base URL of that document.
- Added a "Content" field to documents to describe their relationship to the main record.
- Added a "Relation" field to documents and eprints. This is a list of URI's and relationship type, and using several eprints records, complex objects can be described.
- Significant improvemnts to the speed items are indexed.
- Can now auto-complete on "select" fields.
- New options for autocompletion to target cells in the row being autocompleted, and to hide & show HTML elements when the auto-completion is triggered.
- Added some divs to the input forms to act as targets for the autocompletion and other javascript.
- Float fields are now searchable (and searches can be mixed with ints)
- search cgi now understands the "EX" flag for exact matching. Not available via the form interface, but handy for some scripts.
- Made it possible for search results to show zero matches (so you can create an export).
Improved privilege handling
First, a quick refresher on the way privileges, roles and usertypes relate to each other:
- A privilege is a very fine-grained right. It allows, for example, a user to view the "history" tab on eprints they submitted, while the eprint is in the inbox. In this case "eprint/inbox/history:owner".
- A "role" is a bunch of related privs that may be assigned to a user or usertype.
- A "user" has a "usertype". The user_roles.pl config file defines what roles are assigned to each usertype.
Now for the changes in 3.1:
- You can add (and remove) individual privs in the user_roles.pl
- Also a new field in User can be used to assign
- New roles can be configured (roles are a set of related privileges)
- And you can define a new role. These are hats for assigning to individual users. For example a "edit item in buffer, but don't approve" hat.
Additional templates can be added and used instead of the default template. You can configure a search and view to use such a template. You can also apply a different template to a static page, abstract page or screen plugin. A good application of this new feature would be to create a view and search filtered to only show items from the university maths department, and give that view and search a template in the style of the maths dept.
The toolbox is a command line tool allows eprints and documents to be searched, queried and modified. Even adding files to documents. This is potentially very powerful as it allows a way to script reading and writing data without learning Perl. There's also a CGI interface, but it should be carefully secured before use.
New field-rendering tools
We've added some new field renderers to EPrints::Extras. If you're upgrading, you'll need to add these to eprint_fields.pl by hand.
- renderer for URLs which truncates very long URLs at the end
- renderer for URLs which truncates very long URLs in the middle
- renderer for the related-urls field to lay out the values more sensibly.
- render_possible_doi links to the DOI resolver if the field appears to be a DOI, otherwise doesn't.
XML based Scripting
Expansion inside epc:phrase
This means you can place a bit of EPScript inside {} in the ref element of a phrase tag and have it expanded before the phrase is selected. Eg.
<epc:phrase ref="page:html_description_{somefield.as_string()}" />
So if the value of somefield was "foo" this would display the phrase "page:html_description_foo".
This is a new tag for XML files: <epc:foreach> takes a list (eg. the value of a "multiple" field) and returns the contents of the tag once for each value in the list.eg.

 <epc:foreach expr="creators_name" iterator="name">
(<epc:print expr="$name" />)
 </epc:foreach>

which would resolve to something like:

(Smith, John)

(Jones, Davy)

This just returns the length of a string. Useful in the issues.xml for identifying very long or short strings.
<spc:print expr="title.strlen()" />
would return the number of characters in the title field.
The today() function takes no parameters and returns the current date.
DATE.datemath( CHANGE, TYPE )
CHANGE is a positive or negative value and type is year, month or day. Returns the resulting date. For example:
today().datemath( -6, "month" )
would return a date six months before today.
This strips any EPrints MetaField type from the value and returns a plain STRING. This is used to suppress the normal render function. So that, for example, a value from a set field will be printeda as the database value, rather than the phrase associated with it.
Handy Hooks
Hooks are easy ways to add some code to be run on certain events. New hooks are:
- When a user logs out.
- When the thumbnails for a document are (re)generated.
SWORD (beta-3)
SWORD is a standard interface for depositing records.
AJAX Phrase Editor (beta-3)
This new admin tool allows the admin staff to edit any "phrase" from the system via a simple web interface. This means that you can now get little changes done without bugging the UNIX admin person.
Summary Page Plugin Boxes (beta-3)
This is a little feature with some big possibilities. It allows you to create screen plugins which appear as boxes on the summary/abstract pages. In the next few months we hope people will create and share some via [1] - we of course will develop some too.
The boxes can appear as a left hand column, right hand column, below or even above the default summary page contents. They can appear as javascript "roll downs" if they are too big to show normally.
We are very excited to see how people use this new feature.
A default "Box" plugin is supplied - just subclass it and add a render function!
Uncategorised features
- Abstract pages can now be refreshed using epadmin or the web-interface.
- oai_accesslog script to allow users with a given privilage to get access to access-logs via OAI.- New random data generating script to create any amount of random eprints.
- New types of "thumbnail" format can be added. You're not restricted to the ones we think our useful - eg. "fullsize" is handy to add to get a large image of the front page of documents.
- Added EPrints::Extras::english_title_orderkey - which can be used to cause a field to be sorted, ignoring a leading a/an/the.
- Lists of checkboxes which are more than 5 items long are now rendered as two columns. This makes search pages much more tidy.
- Added config option to set the citation style used in in saved search emails.
- New document icons for zip, tgz, rtf, xml, ppt, video, audio.
- Improved default document citation style.
Upgrade Notes
- If you have the "SWORD" extension installed, remove the two sword eprint fields from your repository configuration, these are now part of the core EPrints data fields.
- Apply the suggested configuration file changes below (most are optional except for those relating to "view")
- Upgrading from 3.0.x
- run "bin/epadmin upgrade repoid" once for each repository
- Upgrading from 3.1.0-beta-X
- run "bin/epadmin update_database_structure repoid" once for each repository
- run generate_apacheconf
Changes to repository configuration
We've made some changes to the configuration of a new repository. These will not be automatically applied to your current repositories when upgrading.
Suggested Changes
If upgrading from 3.0 to 3.1, the following changes to your own configuration are suggested to gain the features described above.
New Document Formats
Added new default document formats: zip, tgz, rtf, xml, ppt, bz2, audio and video.
- lang/en/phrases/document_formats.xml
- namedsets/document
The "subheadings" option has been replaced by the variations heading. This only allows one level of subheading but is much faster.
The way the titles of views pages are configured has changed.
The title of the first page of the view with id "subjects" is now:
<epp:phrase id="viewtitle_eprint_subjects_menu_1">Browse by Subject and Year</epp:phrase>
if there's a second level menu, configure it with:
<epp:phrase id="viewtitle_eprint_subjects_menu_2">Browse by Year where Subject is "<epc:pin name="value1" />"</epp:phrase>
The actual list page title is configured like this:
<epp:phrase id="viewtitle_eprint_subjects_list">Items where Subject is "<epc:pin name="value1" />" and Year is <epc:pin name="value2" /> (Grouped by <epc:pin name="grouping" />)</epp:phrase>
A new version of this was added in the 3.0 series, but if you're using an early 3.0 version of this file, then replace it with the one that comes with 3.1 - it's much faster.
- added documents.format to advanced search
- changed all searches on "userid" to search "userid.username" instead. Another good option might be userid.name or even userid.usertype
- Most earches are now configured by default to show zero results (rather than returning to the search form). The option to add to searches in search.pl is show_zero_results => 1. This is handy for people who want to make a saved search, even if there were no results yet,.
- Added the "edit-config" role to admin users.
- added "content" to the "Upload" component, as the first field (just before "format").
This is a new file which describes the options in the new "document.content" field. Add this file if you enabled the field in the workflow.
- Removed item_fields and review_fields from the user workflow as these can now be modified more easily from the screens themselves.
- Added user.roles to the "usertype" stage, so it's only editable by people who can also set the usertype.
This is a new (optional) configuration file which defines some simple issues to warn about in live eprints.
We've designed a nicer document citation format (which appears as the link to the document in the item summary page). It includes information on licenses etc. and is a bit neater. You may wish to replace the one in your repository config with the one from lib/defaultcfg.
We applied some of the new Extras render and order methods:
- title field: 'make_single_value_orderkey' => 'EPrints::Extras::english_title_orderkey' - so when ordering by title, leading "a", "an" and "the" are ignored. If you add this as an upgrade you'll need to run epadmin reorder repositoryid eprint
- id_number field: 'render_value' => 'EPrints::Extras::render_possible_doi' - which links to the DOI resolver if the field looks like a DOI.
- offical_url: 'render_value' => 'EPrints::Extras::render_url_truncate_end' - this now chops the end of very long URLs for nicer page rendering.
- related_url: 'render_value' => 'EPrints::Extras::render_related_url' - this is a renderer specifically for this field. It links the word "author", or "publisher", etc. to the URL. If no type is specified, it links the URL (truncated if over 40 chars).
Other Changes to the default configuration
These are changes from 3.0 which you probably don't need to bother applying when upgrading.
- Changed thesis to only be set to "unpub" if its' not yet defined. Thesis are not always unpublished.
Contributor Field
The contributor field is like the creators field, but each contributor has a "type" set (with a default list of about 200 possible types of contribution. This field is not added to the workflow, by default, as it's more than most sites need. We suggest trimming the contributor type list down, but we started with a big list to ensure commonality of the values over all repositories using it.
- eprint_files.pl: added contributor field
- namedsets/contributor_type: List of all possible types of contributor.
- lang/en/phrases/eprint_fields.xml: Added related phrases.
- workflows/eprint/default.xml: Added the field in a comment, so people can add it if needed.
- Improved the message at the top of the default homepage to be more friendly and link to a "what next?" page in the wiki.
- Some cfg.d/*.pl files gained additional example code. Eg. user_roles.pl


text:
The Alexandria Chamber of Commerce named John T. Long III its new president and chief executive officer Tuesday after a national search.
Long comes to the city from St. Petersburg, Florida, where he is CEO of JTCK Associates, a Florida-based consulting firm that specializes in "small businesses, not for profit organizations and association and chamber management," according to his LinkedIn profile.
Under Long's tutelage, the St. Petersburg Chamber was selected as one of the top three Metropolitan chambers on the continent, said Alexandria Chamber spokeswoman Catherine Roper.
"John is a proven business leader," said chamber chairman Andrew Palmieri. "In addition to his chamber resume, he also has several years of experience in the banking industry. What attracted us to John was not only his extensive executive level experience but also his impressive business development expertise. We feel he is a perfect fit for a city as dynamic as Alexandria."
Long has worked for the Bay Area Chamber Foundation, the chamber, visitors bureau and political action committee in Kalamazoo, Mich., and president and CEO of the Talbot County Chamber in Maryland.
"I am grateful for the confidence that the presidential search Committee and the Board of Directors have shown in me," Long said in a statement. "It is with much appreciation that I enthusiastically accept this position and look forward to an aggressive program of work, while getting to know all of our members and encouraging others in our community to be a part of the momentum that we will create."
Long replaces Tina Leone, who left Alexandria's chamber to head the Ballston business improvement district in Arlington.


text:
Nightclub Fire Kills Hundreds in Brazil
The death toll in a horrific nightclub fire in Brazil as risen to 232, according to news sources. This number is updated from the original count of 245 first reported by local news sources.
A fire started at the Boate Kiss nightclub around 2 AM in the southern city of Santa Maria. The club was at capacity when club-goers stampeded toward the doors.
Smoke inhalation claimed many of the lives lost in the fire, while others were trampled in the rush from the club.
Pyrotechnics were being used at the club for a performance by a rock band, but authorities have not said they caused the blaze.
The death count may continue to climb as responders pull bodies from the charred building. The club was about 1,000 people over capacity according to fire officials in Brazil.
"Sad Sunday!" tweeted Tarso Genero, the governor of Rio Grande do Sul, the state surrounding Santa Maria. "We are taking appropriate action. I'll be in Santa Maria in the late morning."
Brazilian President Dilma Rouseff addressed media inside the country this morning. "I want to tell the people of Santa Maria in this time of sadness that we are all together," she said.