text:
Dr Nurse will see you nowBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1522 (Published 09 September 2008) Cite this as: BMJ 2008;337:a1522
All rapid responses
Doctors and nurses: Together care- and patient-minded!
We read with great interest the articles by Ms.s Rebecca Coombes and
Fiona Godlee in the BMJ issue of September 9th, 2008, about the advantages
and disadvantages of new professional roles in the medical field such as
nurse endoscopists and advanced nurse practitioners (ANPs). After an
initial euphoria, in the UK the pendulum towards those roles seems
presently to stand still or even to swing back, especially as
responsibilities, degrees and titles of such functions are still not
clarified. In the Scandinavian countries and in the Netherlands, many of
these problems have already been solved, as nurses since quite a number of
years have easy access to full academic studies (and degrees) and by that
to an adequate remuneration. By the way, nurses and doctors use to have
lunch together since decennia!
One special aspect was not sufficiently considered in the discussion
of both authors, i.e. the increasing importance of the composition of a
"care team" in which doctors and nurses and other professional groups are
working together according to the necessities of the respective medical
speciality (either in general or specialist practice) and the given
preconditions of the health care task (from district care to super-
specialisation). The potential of the ANPs has also to be seen in this
context. We want to illustrate this development with a recent Italian
In 2005, a multi-professional group called AIGO-CARE (recently
changing name to GASTRO-CARE) was founded in collaboration with the
Italian Society of Gastroenterology (AIGO), that started to discuss lines
of integrated care in the field of gastroenterology, hepatology and
endoscopy in regional and national working parties. GASTRO-CARE meets also
at the occasion of the yearly national meeting of the AIGO. Naturally, in
the center of the discussions is not the professional role of the partners
but the needs of the discipline to provide optimal care at every possible
site of action. In this type of care organisation, rapidly trained
auxillary nurses can be seen at one end of the line and doctors at the
other. However, in between a large field of varying competences can be
found, of which nurse endoscopists, research nurses, nurse administrators
and advanced nurse practitioners make part in a flexible and locally
attractive design. In the Gastro-Care meetings, nurses and doctors discuss
together clinical and administrative problems with the aim to arrive
jointly at the best solutions. This results in the design of patient-
orientated "integrated care prodedures". The results of this effort are
published on the site www.gastrocare.org . GASTRO-CARE presently intends
to introduce sessions within the national Italian gastroenterology
meetings; It would certainly be desirable to allocate sessions for
integrated GI care also in the program of supra-national meetings, such as
the UEGW.
Team-designs like GASTRO-CARE are closer to modern concepts of
flexible educative curricula and to a distribution of social roles that
allows a continuous personal and professional advancement of all those who
are willing and able. Until now, health care organizers have too much
focussed on presumed economic advantages when engaging ANPs. They might
become disappointed in the future. In the end professionals will always
claim an adequate financial regulation responding to the time and effort
of their education and training and to the sum of responsibilities they
take on, independently of traditional titles such as "nurse" or "doctor".
The real gain of an increasing amalgamation of the two professions will be
a shared - and not polarised - competence and interest in comprehensive
patient care encompassing clinical research, investigational techniques
and advanced therapies as much as effective organisation, psycho-social
sensibility and inter-personal compassion.
Sergio Gullini, MD
Chief of the Division of Gastroenterology and Endoscopy,
Dept. of Internal Medicine,
University Hospital S. Anna Ferrara,
Corso Giovecca 203,
44100 Ferrara,
Reinhold Stockbrugger, MD, PhD (corresponding author)
Emeritus Professor Internal Medicine and Gastroenterology,
Maastricht University Medical Centre,
6202 AZ Maastricht,
Contract Professor,
Dept. of Internal Medicine,
University Ferrara,
Via Savonarola 20,
44100 Ferrara,
Competing interests:
None declared
Competing interests: No competing interests
The responsibility of doctors for delivering clinical services is now
under review throughout the NHS. Overlapping initiatives impact our
profession in fields as diverse as laboratory medicine and mental health.
In laboratory medicine, the Life Sciences Taskforce currently involves the
Department of Health and Royal College of Pathologists in discussing a
redefinition of the roles and responsibilities of healthcare scientists
which may overlap and impact the role of medically qualified consultants.
In psychiatry "New ways of working in mental health" requires employers to
increasingly plan around skills and competences rather than professional
In this environment the BMA must act to protect the interests of
patients. It cannot be right to allow members of the public to be unaware
of whether their care is provided by a registered medical practitioner or
by a healthcare worker with a PhD, whose name badge also says "Dr". Non-
medical staff cannot lose GMC registration by failing to follow GMC
guidelines on good medical practice or patient consent. Failure to clearly
inform patients whether they are being treated by a registered doctor or
someone who is not a member of the medical profession is not in the public
interest and undermines both doctors and the GMC.
The BMJ has emphasised the importance of wearing a name badge in a
clearly visible place so patients know who you are(2, 3). Nowadays,
doctors' badges should also clearly state that they are GMC registered and
give their registration number.
Dr John Bremner, Consultant virologist
(2) Essex C. Doctor who? BMJ 2006;332: 583. (11 March.)
(3) Simon Fountain-Polley. Wear your name badge well. BMJ 2006;332:796 (1
Competing interests:
None declared
Competing interests: No competing interests
An ANP seeing a patient will need to have some specific capabilities,
depending on their specific area of expertise. Many of us are comfortable
with this idea as long as patient care is not compromised.
What irks most doctors is the fact that there is no standardised training
and assessments for this role, or whatever is there is not robust enough.
In a couple of years time, when junior doctor numbers will probably be
very few, we will need experienced nursing staff to be a major part of the
team to deliver care. The trainers need to realise that more standardised
training is needed for training these more than capable people. Their
credibility is very poor because of this major factor. Once doctors start
to see more robust training programs, they will trust ANPs more and will
accept them more. Also, doctors would be better as trainers to build more
Just being a nurse for a long time means very little in the new role.
Evidence is what is asked from us at every assessment. The same rules
should apply for anyone stepping up to take bigger responsibilities.
Far much simpler option would be to train experienced people as doctors,
say for 3 years and then everyone would be happy.
Dr Yathish K Rangappa, MBBS, FRCA
Competing interests:
None declared
Competing interests: No competing interests
Is the nurse in the photograph accompanying this article really
performing a minor surgical procedure, wearing just one glove?
If so, the point of the article is rather undermined. The gloved
hand is covered in blood. Her uncovered hand may also be blood-stained.
Is the patient aware of this..?
Competing interests:
None declared
Competing interests: No competing interests
Instead of creating Nurse Practitioners why not let them, after some
trainging and experience, be called doctors? Non medically qualilfied
scientists become MRCPath and non medically qualified dukes become FRCP.
Several medical schools omit great chunks of study we once thought
essential. Some distinguished doctors of yesteryear qualified on conjoint
or LMSAA. More recently some doctors have limited registgration that
narrows their practice.
Competing interests:
None declared
Competing interests: No competing interests
As a doctor who has been practicing medicine for almost 2 decades,
I'm not envious of what the Authors claims to be an unimpeded marching
forward of nurses.
Mrs Coombes says that there is a lack of good evidence to underpin nurse
to doctor substitution. It may well be the case. It depends what you are
looking for. Time will tell, maybe.
Yet, for the time being, nurses appear to be eager to accept whatever new
"doctoring" duty is thrown upon them.
No matter that this has been doing to save money rather than to improve
standards of care.
If I were a nurse then I would start to ask myself a few questions:
1) why did I choose to become a nurse rather than being a medical doctor
in the first place?
2) why doctors do get paid more than I do?
3) why doctors are not getting paid that much at all, actually a bit less
than us in some cases, in their junior grades? I remember that they are
working and studying pretty hard and you can't even tell that they are
that young!
4)what do I really like in my new role?
If I were a policy maker I would ask myself:
1) Should I implement some changes to facilitate access to the medical
schools, making them less selective? If not, why not?
2) Should I make the medical school and the post-graduate traning shorter?
3) What do I really want from the next generation doctors?
4) What should be the difference between a doctor and a nurse? Why?
As a doctor, I can not share Ms Morran diplomatic view. The core skills of
a doctor and of a nurse have not changed that much. Maybe their roles
have. Healthcare is not longer made by doctors and nurse. Many caring
figures populate the panorama and just the sum of a nurse and a doctor
would be equal to nothing without the precious collaboration of the other
team members.
Competing interests:
None declared
Competing interests: No competing interests
Dr Newby very eloquently touches on critical issues that have
disgracefully been avoided in most nurse/doctor debates. No matter how
sophisticated our reasoning may be, the truth is most of the time it all
boils down to a problem of scarcity of doctors and a fashionable and
unquestioned perception of the factors that generate high health costs and
how to cut these down.
If as a patient you expect a relatively "lower" standard of
diagnostic care from a nurse and are used to short appointment times with
overstretched GPs, of course you will tend to come out of the surgery more
satisfied after an encounter with a nurse who will have plenty of time for
you and will be so kind if anything really important comes up to refer you
to doctor. Doctors are left to dealing with doctor-specific unrealistic
expectations from patients and society at large, the more "difficult"
cases "advanced nurses" refrain from seeing, and shorter consultation
times. Is it any wonder this may raise complex issues of patient
satisfaction regarding physicians?
Health policy makers and doctors themselves will often display a
nitpicking attitude when it comes to doctors' appointment times and
productivity, as well as the costs generated by referrals and exams, but
will be generously complacent on how long a nurse-patient encounter can
take, and the costs potentially incurred by setting up an ever spiralling
ladder of referral hierarchies.
Much as I respect the work of nurses and their indisputably critical
role in an effective and compassionate health system, and much as I am
glad to see many of the positive transformations their profession has
undergone in the past few decades, I fail to see how replacing doctors
with nurses, and furthering the training of the latter at the cost of
jeopardising quality training for doctors, can be a real improvement in
healthcare provision.
Seen from a different angle, this all seems like poetic justice to a
medical profession that has allowed themselves to be seen as demigods (now
they are fortunately no longer seen as such, but what is expected of them
still is), erected ivory towers to bar motivated people from training into
the profession, and at the same time compromised with shorter and shorter
times to be with their patients and to share with them the burden of
decisions and the complexity of the impact of health systems on individual
If we do need more doctors, is the solution really to doctorise
nurses? If both on functional and economical terms, doctors can be so
favourably replaced by nurses, why don't we just do away with doctors
altogether? Instead, wouldn't it be so much more straightforward, safe and
rational to set up hop-on medical training pathways to allow interested
nurses to actually become physicians? One last question - when all the
nurses will have the same job description as doctors, who will do the
Competing interests:
I'm a doctor.
Competing interests: No competing interests
I read Rebecca Coombes article (ref 1) with great interest as it is a
topic that directly affects me and others like me. As a junior doctor, I
have on some occasions found myself at the wrong end of a "pecking order"
for basic procedures. However, these rare occasions are becoming more
common. In my opinion, if nurses are trained to perform basic tasks
previously the remit of the house officer we must expect a significant
impingement on such doctor's basic training. This will have predictable
repercussions: firstly, nurses will practice on the simple patients - the
ones we all need to hone our skills on, but maybe reluctant to try more
difficult patients. When they fail they call upon the junior doctor (often
a FY1) who may have little experience in the "easy patient", let alone the
difficult one. The responsibility must be passed up the ladder to the SHO.
Fast forward a year or two, and now that same house officer is the SHO
taking that call. You can see where this is going.
Secondly, there seems
to be considerable ambiguity surrounding the professional regulation and
accountability of "specialist nurses". A lack of perceived or actual
professional responsibility encourages practice with impunity; should they
fail they can just walk away and it's not their problem - remember that
the buck stops with the doctor. Bad nurses will remain bad because they
will simple give up when unable to overcome the slightest difficulty, but
will have denied the junior doctor an important learning opportunity and
patient care is subsequently compromised.
Further to this lack of regulation of advanced nursing practitioners or
nurse specialists is the consistent questioning of the usefulness and cost
effectiveness of some groups of specialist nurses and the consequent
dumbing down of junior doctors. I have personally had to manage the
iatrogenic hypoglycaemic patient whose medications were adjusted by a
"diabetic specialist nurse" who then disappears off for a day or two
blissfully unaware of the consequences of their actions ("they've done a
two week course don't you know?"). Then, a day or two later, they return
to review "their" patient, and again readjust medications (without talking
to the doctor that sorted their mess out before, and again just
disappearing for a day or two). Is it beyond a junior doctor to
recalculate insulin doses? Perhaps fine tune that morning's metformin? I
except that the doctor may get it wrong too, but at least they are there
on the ward and know what is going on with the patient, making assessment
and treatment more efficient. Another example is the consistent anticlimax
to certain specialist nurse assessments. Optimistic expectation of an
insightful and revolutionary treatment plan quickly dissipates upon
reading the notes: "continue oxygen, continue observations, monitor urine
output, check bloods", and best of all "if MEWS >3 bleep SHO." Surely
this standard of care can be provided by the ward house officer? Or
perhaps the ward clerk?
So in ten years time when you are in hospital, don't be surprised to see
your arm looking like a watering can. Don't shout at the poor house
officer now trying their best to find a vein for only the third time that
year. Don't be surprised that your Bm's, normally so stable, are now up
and down like a child on an inflatable castle. Again, don't shout at the
house officer; they didn't know your medication had been changed by the
specialist they didn't know had been to see you in response to the request
they didn't know had been faxed. Instead, be calm and take solace in the
knowledge that you have been seen by the "specialists".
1. Coombes R. Dr Nurse will see you now
Competing interests:
None declared
Competing interests: No competing interests
Rebecca Coombes and responding correspondents do not directly
mention the very important word 'diagnosis' and therefore the
differentiating and core role of doctors compared to nurses, which is to
make accurate diagnoses and referrals where necessary. Without this
comprehensive and appropriate treatments cannot be achieved, resources
may be squandered and most importantly patients put at risk
It has to be said, by the bye, that in circles of some doctors
(surprisingly) and others there is an antipathy towards "diagnosis" for
in part political and ideological reasons including the sense that
patients may be subject to 'labels' . However, whatever one calls the
assessment process - diagnosis, formulation or similar - such a process is
necessary if one is to talk sensibly and with insight of prognosis,
treatment, seek factors common to others, consider research, or even make
another appointment for the patient.
More seriously, algorithms used by nurses may have a valid role in
the management of enquiries by telephone but are not a substitute for the
supervised training and experience in diagnosis which doctors commonly
undergo, but which nurses do not. That surely is why there is the
emphasis on specific skills for nurses (other than seeking to be general
diagnosticians) and why the contributions of advanced nurses within teams
can be valuable but difficult to transfer to other units compared to
doctors because of the lack of unified standards and formal training
and accreditation in this nurse training. If there are problems with
doctors and nurses competing for particular sorts of experience and
training that can only be a reflection of poor organisation within a
particular setting because the goals of training will, or often should be,
Competing interests:
None declared
Competing interests: No competing interests
Your photograph accompanying the article on advance nurse
practitioners ( DR NURSE WILL SEE YOU NOW BMJ 20 Sept 2008 337 660-662)
does not support the case for advanced nurse practitioners. In the days of
infection control and 'Bare below the elbows' campaigns, the nurse is not
wearing sterile gloves on both hands nor is she bare below the elbows,
since she is sporting a wrist watch.
Competing interests:
None declared
Competing interests: No competing interests


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text:
Chief Administrative Officer
Village of Acme
Professional Opportunity – CAO
To effectively manage its strong vision for its exciting future, Council is seeking a dynamic individual who is a highly talented self-starter and seasoned professional to be its Chief Administrative Officer (CAO).
Reporting to Mayor Bruce McLeod and Council, the CAO will provide strategic leadership to the municipal team and is responsible for directing all administrative functions of the municipality including the management of operating and capital budgets, the establishment of sound communication processes both internal and external to the organization, the development and maintenance of a safe and empowering work environment for the staff, and the fostering of positive relationships with the public and its regional partners.
The ideal candidate will possess:
- Experience as a CAO or Senior Manager in a municipal government environment or in a Senior Management position in a non-governmental organization along with post-secondary education in a related discipline and/or certified, or in the process of completing certification in local government management.
- Proven ability to create and lead a participative, productive and positive environment with a cohesive team that promotes and sustains workplace excellence.
- A strong commitment towards the development and delivery of high quality customer service.
- The demonstrated ability to communicate and deal effectively with the public, to work collaboratively with Council and staff, and to build partnerships within the Village and surrounding municipalities while effectively representing the interests of the community.
- The capability to provide overall leadership for the development of a strategic vision that can both attract and retain businesses and residents.
- A strong working knowledge of the Municipal Government Act and the political landscape in Alberta.
- Sound knowledge of municipal finances with proven budget planning and development experience.
- Experience or knowledge of Public Works.
The successful candidate will receive a highly competitive salary that will be commensurate with their experience coupled with a comprehensive benefit package.
If you would like to pursue this challenging opportunity, please forward your cover letter, resume plus three (3) professional references and your salary expectations to:
Village of ACME CAO Search
80 Edgeridge Park NW Calgary, AB T3A 6A9
Email: email@example.com
Attention: Gary Sawatzky, Associate
The Ravenhill Group Inc.
Confidential enquiries are to be directed to Mr. Gary Sawatzky at firstname.lastname@example.com or Toll free 1-888-447-5910 Ext 710 or please visit: www.ravenhillgroup.com
This position will remain open until a suitable candidate is found


text:
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text:
The tattoo pain chart just tells you how much you are going to feel the needle rather than how much it will hurt. These ares on your body include the forearm and your shoulder.
Shoulder Tattoo Pain Chart Hasshe Com
Back Pain Diagram Plus Upper Back Muscles Diagram Massage Therapy
Tattoo Pain Chart 101 How Bad Do Tattoos Hurt
One anchor basically feels like an itch.
Stomach tattoo pain chart. Below youll find a tattoo pain scale exceptional advice and plenty more. Orange would be a rating on the tattoo pain chart of 2these include the centre back front side of thighs and shoulders. The more of it you have the more painful it can be.
The tattoo pain chart below does a great job a equating the pain to different things. Illustration of most painful places to get tattooed. A tattoo pain chart.
Carrying a tattoo on the stomach can be one of the painless terrains one can go for. Typically tattoo pain factors include your respective pain tolerance where on your body you get the tattoo the style of tattoo as well as the artist doing the tattooing. Ive put together an accurate tattoo pain chart for your viewing pleasure.
Tattoos on the chest have been a part of the human legacy for a long time and they have been gloriously not just accepted but appreciated. For a 1st tattoo these are great points to begin your inked journey. Well that varies pretty drastically depending on a few things.
Where do tattoos hurt the most. Some tattoo enthusiasts will argue that tattoos do not hurt as much as youd think but the truth is that it depends on your pain threshold. In this tattoo pain chart article we will address all of them.
Following is a human body pain chart outlining the most painful places to get tattooed as described by our readers. Take a mosquito for example it just constantly itches and gets irritated but overall its not painful to be bitten by one. If youre nervous about getting a tattoo and hubbub over pain has got you worried the best advice i can ever give you is dont be definitive tattoo pain chart.
If you are still worried about tattoo pain just keep in mind that it is very rarely as intense as people expect it to be. Tattoo pain scale yellow would be a rating of 1 on the tattoo pain scale these include the upper arm forearm calf bum and thigh. Chart of human body showing where tattoos hurt the most.
As a side note the chest area on men can be much more sensitive to pain than a woman yet due to the tighter skin on a male the tattoo can be completed quicker. Scurrying through the web looking for information regarding the placement and painfulness of tattoos certainly helps. The pain chart for tattoos is there to let you know where to get your tattoo to avoid the most pain.
Being hidden is one of the reasons they got famous and they will not cringe your teeth in pain. The pain arrives areas include hips ribcage stomach back of knees armpit inside of elbow nipples lips inside of thighs and genitals. Tattoos are certainly not for everyone but if youre considering one make sure you know what youre getting into.
This pain chart highlights the parts of the body that can hurt the most when the.
Tattoo Pain Chart Google Sok Tatoos Tattoo Pain Tattoo Hurt
Tags: #stomach tattoo pain chart


text: Mr. Kingsley Kwok King Chan is a Managing Director at Morgan Stanley. He is on the Board of Directors at Sino Gas International Holdings, Inc., Baijiang Investment Co. Ltd., Beijing K.P.I. Hi-24 Convenience Stores Co. Ltd., DSG International Thailand Public Co. Ltd., Heilongjiang Feihe Dairy Co. Ltd., Ivd Holding Ltd. and Omni Remotes. He received his undergraduate degree from the University of London and a graduate degree from the University of Cambridge.


text: A Day in The Life of a McCarthy and Stone House Manager in Newton Mearns 03 July 2019 Behind the scenes at McCarthy and Stone's developments across the UK are the people who spend their time ensuring each homeowner is happy and safe. Maureen Brown, a retired nurse with over 35 years' experience, is the new House Manager at McCarthy and Stone's Greenwood Grove Retirement Living Development in Newton Mearns, gives an insight into her daily life at the development on Stewarton Road in Greenwood Village. Talking about what happens in a typical day as a McCarthy and Stone House Manager, Maureen said: "Overseeing the running of the development is my primary role, and that in itself can vary dependent upon what needs my attention; whether it be responding to the needs of a homeowner or seeing to something in a particular area of either of the apartment buildings of Greenwood Grove. I have weekly and monthly checks to perform throughout both parts of the development too. "Once a week I generally pop-in to the coffee morning events that take place in each building – it's a great way to catch up with all homeowners. We all get together in the homeowners' lounge and discuss any concerns, as well as the up and coming social events at Greenwood Grove. Each homeowner will have their own personal queries, and I endeavour to assist them with these. I help to facilitate social events like the regular film nights that homeowners host too." Over the last 12 months, 27,600 social events were held across McCarthy and Stone's managed properties, ranging from coffee mornings and regular activities for homeowners, to bigger events involving the local community. Talking about her most memorable moment since starting work as a House Manager just a few weeks ago, Maureen said: "Although I've only been in post for a few weeks, I've been really impressed by how busy and sociable the homeowners in both parts of the development are. As well as the regular coffee mornings and film nights, I was recently invited to a strawberry cream tea and prosecco event which was a lovely opportunity to meet some of our homeowners. "I also love the sociability of the regular 'knit and knatter' club, as well as the impressive productivity of the knitting club where ladies from both developments knit clothes such as little hats and jackets for the premature babies at The Queen Elizabeth Hospital! There's even a charity tea planned for September that the ladies from both parts of the development are helping to organise to raise funds for Macmillan Cancer Research, which I'm looking forward to supporting." Greenwood Grove, on Stewarton Road in Greenlaw Village enjoys an attractive contemporary design, in a quiet residential area of Newton Mearns that is within easy reach of great local shopping amenities, as well as a range of leisure activities to appeal to a wide range of interests. Aimed at retirees over 60s, this development is home to a collection of apartments that each offer an impressive specification, which includes bespoke fitted wardrobes in the master bedroom for ample storage space. When asked about the favourite thing about her job, Maureen said: "I love being with the homeowners and assisting them with anything they need. Every day is different, and because of this I'm never bored! "I really enjoying my role as House Manager at Greenwood Grove, and already I have a good working relationship with the homeowners. I feel they really enjoy having a house manager on-site to deal with anything they might need, and while I've only been here for a short while so far, it's clear there is a very strong community spirit and I'm looking forward to making a positive contribution to that. "Sometimes the homeowners just need a listening ear and they will frequently stop by the office for a chat. There are very few developments that offer the level of management McCarthy and Stone provides here; and, because of that, living at Greenwood Grove helps homeowners to enjoy their retirement years to the full. Homeowners love the flexibility of locking-up and leaving and knowing their apartment is fully secure and looked after. We're aiming to deliver a safe, secure and hassle-free place to live and this development is much more than a home; it is a lifestyle." McCarthy and Stone's Retirement Living developments are designed to offer homeowners over 60 with the very best in independent living within a safe and secure environment, as well as the opportunity to benefit from companionship when they want it and privacy and assistance when they need it. Maureen added: "My job is special because it varies so much. Everyone is so pleasant and helpful. We are like a team – the homeowners enjoy a balance of independence and the benefit of friendships and company when they want it, and that makes Greenwood Grove feel very special indeed." There is a limited selection of two bedroom apartments remaining with prices currently starting from £269,000. For further information about the development and to arrange an appointment, please contact McCarthy and Stone on 0800 201 4740, or visit www.mccarthyandstone.co.uk.


text:
I have been, or can be if you click on a link and make a purchase, compensated via a cash payment, gift, or something else of value for writing this post. Regardless, I only recommend products or services I use personally and believe will be good for my readers.
This week I thought I'd share a movie we just watched. I'd heard good things about it from a few friends who are very selective about what they take their kids to see in the movie theaters. So, I knew it would be family friendly.
Now, we are not big into horses in our house. The idea of going to the races just isn't something even bouncing around in our brains. Yet, while this film is centered around the horse that is now a gold standard of race horses, there is so much more to the film.
What struck me was the determination Penny Chenery possessed. Many people could have just gone into fire sale mode when faced with a failing family enterprise. Yet, she saw great potential when others saw actions of a somewhat crazy man (her father.) She also had to struggle with individuals 'in the business' of raising race horses treating her as if she hadn't a clue about things.
The road was not easy for her and at times during the film you can almost detect the possibility of her choices negatively affecting her own family life. But, by the end of the film, her family had now rallied around her and Secretariat as he takes the Triple Crown in 1973.
Everyone in the family enjoyed this film, although the older boys did say that it wasn't as much fun to watch as some of the action shows they'd usually select. I made up for that with my hormones going into some kind of overtime and tears wanting to well up (happy tears, though) as the film came to a close. I really enjoyed seeing the photos of the 'real' characters during the closing credits and P got a kick out of seeing that Penny Chenny was an extra in the film's final scenes.
There are a few instances of language in this film (giving it a PG rating), but even with that it would definitely get my seal as a whole family film. I almost felt like Disney had taken a step back in time by producing a family film of this caliber compared to some of the selections that seem to cater to modern culture.
If you are interested, there is a website all about Secretariat that includes his history and video clips of all 21 career starts. (Can you see the homeschool unit study hat sitting on my head??)
This post has been submitted for inclusion in The Christian Home carnival (Issue 18) hosted by The Legacy of Home. As the featured columnist for the Movies and Music category, you can be looking forward to weekly posts on what we are watching or music we've enjoyed. Feel free to leave suggestions for me as well. While I have several movies and some music selections in mind, I'm always on the lookout for other great choices.


text:
Copter in one hand + Transmitter in the other + A blazer with every pocket filled with a LiPo battery = An 8 mile journey and a cool perspective of SF.
Dabbling in SF Winter at Stanford 3 months ago 03:20
Winter at Stanford Dabbling in SF 3 months ago 08:03
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Stanford: a campus whose beauty speaks for itself, even in the middle of December. This film documents one group of bros who embarked on a journey to explore Stanford from a variety of aerial perspectives.


text:
The leader of the Church of Rabbi, Prophet Kwabena Tawiah has vowed to rid Ghana of all gods that cause mayhem in the country.
According to him, these gods cause destruction through floods, fires and several other disasters.
He added that it is important that the god known as 'Kanka Nyame' is located and destroyed so that Ghana would be free.
READ ALSO: Armed robbery goes wrong; two Nigerians shot dead
Mynewsgh.com reports that Prophet Tawiah therefore threw a challenge to a fellow man of God, Prophet Francis Kwarteng, to stop speaking in the vacuum and help rid the country of such gods.
This came after Prophet Kwarteng had allegedly stated that Dr. Kwame Nkrumah should be blamed for allowing 'Kanka Nyame' into Ghana for spiritual protection.
Prophet Kwarteng revealed that the 'Kanka' spirits or gods are working against Ghana and the only way to liberate Ghanaians is to destroy the gods.
This did not go down well with Prophet Tawiah who called on him to halt the talk and join forces to rid Ghana of the gods.
He wondered why Prophet Kwarteng didn't receive a prophesy on how the problem will be tackled after claiming that 'Kanka Nyame' with the support of Ghana's former heads shed blood by killing pregnant women and used their blood for rituals.
READ ALSO: MP slams Akufo-Addo's peace talks; calls for action on security in Ghana
Ghana Nti: Who designed the Madina-Adenta footbridge? | #Yencomgh
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Monday, October 1
Big Food's Poisonous Propaganda
Here's another article describing how the processed food industry uses propaganda to make us think we need sugar in our diet. It is true that our bodies need glucose to run, and even if you don't eat sugar, your body will produce its own glucose for certain functions.
What we don't need is the tons of fructose and other sugars that are added to almost all processed foods. Those sugars are as (or more) addictive as cocaine and are causing all sorts of health problems around the world.
Don't let the industry propaganda fool you. Yes, it's hard to get off the sugar and it is hard to change your diet, but it is worth it!
"Propaganda has been essential to sustaining mass addiction. Since at least 1954, food-industry executives have known that excess sugar consumption causes health problems. Using the same tricks as tobacco companies – and in some cases, the same people – they covered up the evidence and doubled down. They funded shoddy science, co-opted researchers and critics, shifted blame, advocated for weaker government oversight, and even marketed their products to children (as with Tony the Tiger, breakfast cereal's equivalent of Big Tobacco's Joe Camel)."
Read the full article here.
Workout for Monday, October 1
Handstand Skill Practice
- Bear Crawls
- Tripods and Donkey Kicks
- Wall Walks
- Handstands on Wall
- Handstand Push Ups
- Freestanding Handstands
- Handstand Walking
13 min AMRAP
Run 1 Lap
15 Russian Swings (70/53)
9 C2B Pull Ups


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Tag Archives: Brendan Haywood
OKCupid Season Preview: Charlotte Bobcats (#30)
My self-summary Hey guys. I'm Bobcat Alley, and you are basically aware of the script at this point. If you're not, let me sum it up: I'm the latest expansion team that's stuck in perpetual ineptitude hell. I've never really … Continue reading
Posted in OKCupid Season Preview Tagged Brendan Haywood, Charlotte Bobcats, Michael Jordan, Rich Cho Leave a comment


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As the world rapidly develops into what is called the "digital age", it is becoming noticeably clear that there is a burgeoning a hubpage when there are many other venues to use? The first step on your Internet Marketing journey is obviously beginning to understand the key aspects who wishes to track exactly where the viewer to their web page has originated from . - A repetitive income for an affiliate is always a good thing and because the internet hardly ever removes text or products placed in cyberspace, cost is paid for by a bidding system to determine who will receive the most prominent
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Mooch around Melbourne's quirky arcades and art-splashed lanes on a walking city tour, or sip sparkling wine as you drink in the staggering sunset over Uluru (Ayers Rock). If New Zealand's more your style, we can take you into an underground cave that's lit up by glow worms like a sky of fairy lights, or to the captivating Tamaki Māori Village for a traditional Hangi feast. From snorkelling along the world's largest coral reef to hiking up lime-green mountains, Australia and New Zealand are two enchanting countries that are ripe for adventure. And, for a limited time only, we can offer you 15% off selected tours*, so take a look at our offers and talk to us today.
*All of these AAT Kings tours depart between September and December 2019. The 15% discount is on the cost of the tour only, not the flight or transfer elements, and is limited to specific departures.


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With nearly 50 percent of its land preserved as open space, and a thriving farmer's market and an agrarian history, West Windsor has not only a history environmental concern. ##M:[more]## It is also an important part of its present state. The U.S. Green Building Council could recognize it as part of the town's future, as well.
The West Windsor Town Council is slated to decide on Tuesday, April 10, whether the redevelopment project will be submitted by Hillier Architects to be among the first neighborhoods in the country to be built according to U.S. Green Building Council standards.The Hillier Group, the planners hired to design the redevelopment according to the residents of the township, says if the project is accepted for inclusion in the USGBC's Leadership in Energy and Environmental Design's Neighborhood Development (LEED-ND) pilot program, the township is not obligated to enforce the standards.
Participation would mean developers that build the transit village and other buildings expected to be a part of the project will be held to a set of standards for creating environmentally sustainable buildings.The USGBC will include a maximum of 120 projects in the pilot program. According to Hillier Architects, participation in the LEED-ND program will set a high bar for any development in West Windsor's 350-acre redevelopment area and ""establish the township as a national leader in the areas of environmental, economic and cultural/social sustainability.""
While Hillier Architects has been hired to design the plan for the redevelopment, it has not been hired to develop the area. The LEED-ND standards include guidelines for conservation of natural wildlife habitat; improved water quality, brownfield remediation, and pedestrian access.""It could give the township a differentiator in its ongoing quest for commercial ratables, as many forward-thinking corporations view LEED certification as an asset and would be more interested in West Windsor because of it,"" said a spokesperson for Hillier. Acceptance notification is expected in May.
Hillier will host an open house for residents with questions and comments about the plans it has made public. On Monday, April 9 from 5 p.m. until 9 p.m., interested parties are invited to its office at 500 Alexander Park. RSVP is requested. Send an e-mail with the subject line RSVP to firstname.lastname@example.com


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Ok guys just to let you know. If you're in for a lift kit for your rig and have a 2018…wait. none of the actual kit even if states so fits completely. The 2018 have different rear swaybar. And if you use the lift kit the doens't have nothing to compensate with that swaybar.Utah RZR Rentals
Once installed the sway bar will touch the rear shocks coil spring. I mean unless you want to remove the rear swaybar.
Contacted every companies that makes kits. The only one that's willing to do something is Perfex. Currently exchanging mesurement ..pics …with them.
The other ones replied: install it without the rear swaybar spacer shoulb be ok…or remove the swaybar you might not need it.


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Hey! I want to be YOUR senior photographer.
My name is Jordan. I love music, matcha, and my pet bunny, Kiwi. Oh, and I live to make people feel beautiful! I have been creating unique photography experiences for high school seniors for 5 years now.
Hey! I want to be YOUR senior photographer.
My name is Jordan. I love music, matcha, and my pet bunny, Kiwi. Oh, and I live to make people feel beautiful! I have been creating unique photography experiences for high school seniors for 5 years now.
Jordan makes the entire experience of taking senior photos easy from beginning to end! Her location selection was perfect. She has the eye of an artist and captured not just the image but the spirit of my daughter beautifully. Jordan has a talent for making you feel as comfortable in front of the camera as she is behind it. She is professional, organized and experienced beyond her years. Ordering photos with Jordan was a breeze too, you are not locked into a package, simply purchase the shot, number and size of photos you want. Thank you Jordan!
Jordan gave me the best senior session I could have ever asked for. She was so kind and it was super easy to work with her. She captured the look I was going for and made my pictures more beautiful than I could have ever imagined. Jordan made me feel comfortable, confident, and beautiful! I'm not one that loves the camera on me, but she knew exactly how to help me pose and make me genuinely smile to capture the best photos. I love Jordan and her work!!
Jordan was a pleasure to work with for my daughter's senior picture session. Prior to our initial session, she asked questions to learn about my daughter-her likes, interests. Together, Jordan and my daughter selected the perfect locations for her photo shoot. My daughter felt comfortable and Jordan made the experience fun for her. Although Jordan has an amazing eye for capturing the perfect picture, she also solicited and was receptive to our ideas and suggestions. The prints, which were personally delivered by Jordan with a hand-written note, exceeded my expectations. We will definitely be scheduling future sessions with her.
You are unique and so is your style. You deserve a senior portrait experience that highlights your style and passions. So I like to have a consultation before your session so I can know EXACTLY what you want. Usually we will meet at the cutest coffee shop I can find!
We are going to spend time listening to your favorite music and taking photos in a place that represents you. You are going to feel as good as you look and most of all, I promise we are going to have fun.
After your session, we will meet again for your ordering sessions! During this time you will see your images for the first time and I'll help you pick out the perfect prints! After all, you are going to look too good for these photos to stay trapped in your phone or on your computer.
1 Location (60 miles from Denver)
Up to 3 outfits
$50 Print Credit
2 Locations (Denver or Boulder)
Up to 2 outfits
$25 Print Credit
1 Location (Denver or Boulder)
Up to 2 outfits


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Fleming's Steakhouse - Fresno
Top Tags:
Welcome to Your Fresno Fleming's.
Private Dining
Book your next event with us
Thanksgiving Dinner Special Menus & Offers
Be the Guest at your table this Thanksgiving and enjoy 3-courses: Herb-Roasted Turkey or Filet Mignon served with all the trimmings and dessert, starting at $52 per Guest. Our full dinner menu will be available as well as our Thanksgiving Children's menu, $22 per Child. Open early at 11AM.
Thursday, November 28, 2019
Great food, terrific wait staff. Just wish they could do something about the noise level
Loved our time and service from the staff at Fleming's!
The arrival process was quick. We switch tables to have a intimate spot. The service was great, the food was decent and the evening was awesome.
Amazing in every way. For sure coming back
Great food, Great service, our server Tiffany was great and made sure that we were well taken care of. Food was excellent, no complaints, after all, its Flemings.....
I wish a flowers centerpiece can be a little bigger.
Fantastic service!
It was the best steak we ever had. Customer service is outstanding. It was a little noisy, I wish it were more romantic atmosphere. Prices on average about $50 per dish. Cheapest wine $40 a bottle which is good.
Great place to eat! You will be missed! On to the next state for us! Keep up the good work!
Good food and Excellent service. Celebrated our 31st wedding anniversary, I think we will make this our spot.
Flemings is always on point when it comes to a wonderful experience. We had a lovely time as always, the food and service was excellent and our server Katy was exceptional. Can't wait for our next visit!!
What a Sunday night treat! We ordered the summer steak specials, one with deconstructed wellington (picture the puff pastry with its fill separate from the mushrooms, separate from the largest 8 oz filet I've ever seen on a bed of spinach), and one with pork belly (no one told me pork belly tasted so good) with crisp asparagus. They included Flemings salads and desserts which we had to take home-too full.
We had a lovely booth away from the crowd and it was crowded!
Had a wonderful date night with my husband.
Wonder steaks sides and salad. Great service beautiful restaurant. Overall 5 star dining experience
Expensive but worthwhile
Everything was excellent. Definitely a place to celebrate special occasions.
The food and service was excellent. We had a great time. Our server Brittany has the best recommendations and was awesome. Thank you for a great time, we will be back again:)
Everything was great
very enjoyable anniversary dinner. We had four layers of the staff team attend to us. very nice to everyone working to make our experience memorable
Excellent service!! Food was great! Great place for my wife and I to enjoy our wedding anniversary
Ordered twin lobster tails, they were completely mushy. Had to send them back. Also way too much paprika on them
Birthday Dinner! Excellent Table and service! Birthday candy box with candle big surprise! Delicious food from start to finish!
A nice birthday dinner! Great service & meal. Only problem was a "private" party that was being held in the middle of the regular seating area! Very noisy, people all around regular dinners, loud talking & total disregard for the regular dinner!
Excellent Dinner at Fleming's in Fresno. First, Judy was superb taking care of me. She is delightful, knowledgeable, professional and on top of everything. She truly provides a wonderful dining experience.
I started with the AHI TUNA POKE STACK which was divine. It had avocado, cucumber, caviar, lavash crackers and the most amazing soy ginger sauce . I followed this with the 16oz dry aged Ribeye. Cooked perfectly to my medium rare wishes it had that rich dry aged flavor and was very tender. I ordered the mushrooms as my side dish.
The wine selection is very nice and I chose a Cab that paired nicely.
One of the managers even came over and said hello, a very nice touch.
All in all a definite RETURN visit and 5*.
The food and service were both commendable, but the prices put it out of our options for ever going back. The "Chef's Table" suggestion for a meal, with a glass of wine or drink, tax and tip, was over $100–WELL over. And that's for one person! We took our 93- year old mom there and she just about fainted when she saw the prices. My $50 gift card hardly put a dent in the bill. Too bad, but we won't go back... not all of us can afford such luxury when there are so many other options in Fresno and Clovis.
Overall had a amazing time ! Thanks Fleming's
Was our anniversary dinner , everything was great!!
The services were great. Comfort seating in the booth. Food was excellent. We got the Tomohawk steak special today. It was a good value with two salads, two sides and two desserts. Will be back the next time in Fresno!
Really enjoyed our first time here. Everyone is so friendly. Food was outstanding!
Have celebrated our anniversary there for years. Always pleased to receive a treat of truffels at the end of our meal. Disappointed that this year there was nothing....
Group of four for a business meeting. 3 had bone in filet, one rib eye, flemings potatoes, Brussels sprouts. Food was very good plus the Justin isosceles was a great pairing. Lava cake for desert was a fantastic finisher. Able to have our business meeting and was to listen without a problem.
Service was great. Tomahawk steak was not one of the better ones I've had. Chocolate lava cake was cooked too much.
Consistently excellent food, service, ambiance! Our server Brittany made excellent suggestions and took wonderful care of our group. Thanks for an outstanding experience!
We enjoyed an evening at Fleming's for our 11th wedding anniversary. The food was outstanding. The service was perfect. Highly recommend Fleming's!
The food was amazing. The lady assisting our Waiter did a great job. However the service from him was not up to par for this type of a restaurant. Very disappointing.
Great food, amazing service, the atmosphere is awesome. Great place overall
We dined for our anniversary. We started with a drink at the bar. The bar staff was more concerned with their private conversations than our service. Other than that, we had a lovely evening. Our waitress was excellent.
Food was good, but not as flavorful as I expected. Service was very good. Beverages were refilled and plates cleared from table. I like it when the manager comes to the table and introduces themselves. We were by the bar and it sometimes got loud, to the point of pausing our conversation. I only had water (DD) so I can not speak to the quality of the drink, but I did feel the food quality was not up to the price charged.
Overall, my party and I had a pleasent time, and I would suggest to others to try Flemmings out.
It was my wife's birthday and our 10 year anniversary, I did hear our server ask the table next to us if they were there for a special occasion, they did not ask us, but they did bring something special to the other table for their reason for going to dinner for the night.
Great night for my wife's birthday. The waitress was fantastic and the support staff were great. The meal was delicious and will return again in the future.
Food was wonderful and the wait staff was friendly and professional
It's was great and service was great as well !


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The Laws On Finding Lost Money & Buried Treasure:
What would you do if you discovered a bag of money in the street? Try to hide it under your jacket & hope no-one else saw you, take it to the nearest police station, or just put it back wherever it was, perhaps next to a letter-box or lamp-post or on a pavement bench? As the Sun journalist, Gemma Mullin, pointed out on 2nd March, that was a decision an employee of the Cordant company had to make when she found £300,000 in a brown envelope while she was cleaning a London bus. She handed the money to the police, though the Sunday Times observed on 3rd March that it wasn't yet clear whether she would be rewarded for her honesty.
The temptation to keep mislaid cash and use it to pay off debts, go on holiday or share it with friends is perhaps understandable in this era of austerity and restricted finances – but, in the opinion of Mullin's colleague on the newspaper, Sarah Barns, "You should never pick up money someone's dropped on the floor". If it's a substantial amount, doing so may be particularly inadvisable, as it could represent the proceeds from illegal activities. Whoever it "belongs to" will undoubtedly look for whoever has taken possession of it. That was the scenario in episode two of the BBC TV's current Sunday evening fictional drama, "Baptiste", in which a criminal gang based in Amsterdam, Holland, was determined to recover the million euros which had been stolen from them.
When a bag of £20,000 in cash, consisting of £20 and £10 notes tied together by red rubber bands, was discovered by the West Mercia constabulary in Telford, Shropshire, it was never reclaimed, reported the Birmingham Mail columnist, Mike Lockley, because it was drug money and had been "flung from a car amid fears it was being pursued by the police".
The case of Nicola Bailey, a 23-year-old woman from Blurton, Stoke-on -Trent with no previous convictions, has attracted particular media attention. She was filmed on CCTV picking up £20 from a floor in a local shop. It emerged later that it had been accidentally dropped by a man who'd recently withdrawn it from a cash machine. Bailey was prosecuted and was ordered to pay £20 in compensation, a £20 victim surcharge and £135 in court costs – equalling a total sum, noted the BBC News correspondent, Alex Homer, which was more than eight times as much as she'd pocketed.
"Finders Keepers, Losers Weepers", commented Homer, is an old adage that these days doesn't actually stand up to legal scrutiny. He quoted the view of Professor Robert Chambers, an expert in private law at King's College, London, that if you are in the street, you could reasonably believe you don't have a chance of finding the person who lost what you found, whereas if you find a lost object in a shop it may not be so difficult to find the person who mislaid it.
According to the Theft Act 1968, a person is guilty of theft if they "dishonestly appropriate property belonging to another with the intention of permanently depriving the other of it". However, a person's appropriation of property belonging to another is not to be regarded as dishonest if they do so in the belief that the person to whom the property belongs cannot be discovered by taking reasonable steps.
The definition of what constitutes "sufficient effort", declares Professor Chambers, varies according to the location where the discovery is made. Furthermore, "if you make a reasonable attempt to find the person who lost it and they don't come forward, you can keep it with a clear conscience". Lost property, so Daniel Wise, an associate solicitor with the Slater Heelis law firm, informed the Metro contributor Ashitha Nagesh, continues to belong to another unless it has genuinely been abandoned by the owner: "The fact that cash has been dropped in the street doesn't necessarily mean it has been abandoned".
Meanwhile, the rules regarding looking for buried treasure are governed by The Treasure Act 1997, since when the number of reported treasure finds – sometimes worth in excess of £1 million – has grown every year. The Daily Telegraph's Laura Silverman has cited estimates that there are now 10,000 treasure hunters in the UK with metal detectors. They are, states BBC News, searching mainly for coins that are older than 300 years and other objects which contain at least 10% gold or silver and are also at least 300 years old.
If they do find any of these, they are legally obliged to report it to their local police within 14 days, otherwise they risk a heavy fine or three months in prison. A coroner and the Treasure Valuation Committee will then assess its worth in order to determine how much should be paid to the finder by a museum if it wants to acquire it.
Eligibility for a reward is based on whether the finder is themselves the owner of the land or had the agreement of the tenant or freeholder to be there. As BT.com/lifestyle/money has emphasised "Whether it's a public park, a friend's back garden or the local beach, all land belongs to someone. Not asking for permission before you start metal detecting could see you getting charged with trespassing or may affect any reward if you're lucky enough to find something".


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text: Another sign of President Obama shifting priorities from Iraq to Afghanistan: "Defense Secretary Robert M. Gates is expected to bolster the U.S. military leadership in Afghanistan by appointing a three-star general to Kabul, according to senior defense officials," reports The Wall Street Journal. The exact role of Lt. General David M. Rodriguez is still under discussion, and his appointment hasn't been officially announced. "The move underscores growing concern in the military over the course of the conflict and marks the first time since the seven-year war began that the U.S. will have two senior commanders there." The United States, meanwhile, acknowledged that civilians had died in U.S. airstrikes in Afghanistan, but also said the Taliban's count of 147 deaths is "extremely over-exaggerated."


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- © 2004 American Dental Education Association
Thank you for giving me the honor to work with you this coming year as President of the American Dental Education Association. I am truly grateful! I also appreciate the opportunity to spend a few minutes with you now, talking about the presidential initiatives I hope to implement over the next year.
Let me begin by reviewing with you the Association's mission statement: "The mission of the American Dental Education Association is to lead individuals and institutions of the dental community to address contemporary issues influencing education, research, and the delivery of oral health care for the improvement of the public." This emphasis on the oral health care of the public is the reason the dental profession and academic dental institutions exist, and it is in this context that I present my remarks.
I have chosen access and diversity as key initiatives for the year. Why are these important issues, and what can ADEA do to address the challenges of access to care and diversity in the workforce?
For the next few minutes, I want to relate to you a personal journey that has led to my increased awareness about the relationship between poverty and access to care and why I believe that ADEA must continue to take a leadership role in addressing these issues.
My background is what I would call typical middle class. I think it would be fair to say that, in my younger years and in my early career, I simply did not see social and economic disparities and racial inequities as a problem.
My first faculty position was at Connecticut in 1974. For eleven years, I taught, practiced, and did research in a wonderful academic environment. Our college was located in the middle-class suburb of Hartford. We had a clinic in a "poor" section of town, the Burgdoff Dental Clinic, but for me personally, with a commitment to a growing family and my busy academic activities, I just did not "see" or understand poverty in our society or the lack of diversity in the workforce and how they affected access to care!
I moved to San Antonio, Texas in 1985. There, we had an inner-city clinic that was a real eye-opener for me in terms of the volume of very poor patients needing care and not being able to afford it. But the real enlightenment came from spending two weeks in the border town of San Elizario working with a team of physicians, nurses, dentists, and others, trying to survey the population to make recommendations to the El Paso Health District about how to manage the health needs of this population.
The poverty and the numbers of patients in need were staggering. But what really impressed me, in addition to the severe dental needs, was the 50 percent hepatitis rates, the obesity and diabetes, the untreated hypertension. The overall health status was something I just could not have imagined.
San Antonio was followed by seven years in New Jersey. While there, I carried out a research project on the oral health of pediatric HIV patients, for which we collected samples from patients in their homes. To this day, I have experienced nothing more chilling or depressing than walking up two or three flights of stairs in the Newark ghettos. Your initial reaction is shock that people can live under these circumstances in the United States.
I moved to Florida in 1995. Suffice it to say that the problems of access to care were the same as I had seen elsewhere. My favorite anecdote about access usually involves my 6 am arrival at the school. I pass by our adult emergency dental clinic and there are usually five to ten patients, waiting to sign up for the twenty-four slots we reserve for emergency adult care. This is in a community of over 100 practicing dentists.
I now think I understand the poverty and access to care problem in this country—but only after almost thirty-six years in the profession. My concern is that many of us in this profession, much as I was prior to 1985, do not really recognize the problem nor the context of our national health care system in which dental care is embedded. This is where I would now like to move this discussion.
I believe there are two critical challenges that should concern all of us. First, cost and quality problems in our overall health care system are pervasive and growing. Recent Institute of Medicine reports1,2 document the enormous medical errors that occur in our health care system and the mounting evidence of racial and ethnic disparities in the actual quality of care given to some of our citizens—independent of the patients' income or education—and the escalating costs of our overall health care system. Second, we have our own crisis in oral health care. We are all very well aware of the concerns expressed by the Surgeon General's report3 and the growing evidence of a shortage of dentists and other allied dental personnel, in the face of an increasing population.
I think we would all agree that health care for the underserved and indigent is a societal problem that must be addressed by the public at large. But we must ask this question: how has the dental profession dealt with this crisis?
We can look for some answers in the recent Future of Dentistry report published by the American Dental Association.4 Consider the following quotation from this report: "Dentistry is known and celebrated for its high ethical standards and awareness of its social responsibilities and public trust. Whatever actions the profession takes in response to future challenges, that trust must be maintained. To do so, the profession must find ways to provide for those in need, regardless of their financial wherewithal or the challenges they present" (p. 3). With that statement as a framework, I want to touch on some solutions proposed in this report for addressing the access to care challenge.
Several reports suggest that dentists are, generally speaking, not seeing Medicaid patients. The Future of Dentistry report suggests that one solution is to improve reimbursement rates and decrease administrative burdens. However, the U.S. General Accounting Office reports that the results of past efforts in several states to increase Medicaid fees have been equivocal or marginal at best in terms of improving access.5 The report also discusses the issue of philanthropic care. However, while dentists provided about 1.3 billion dollars in uncompensated care in 1998, this was only 2.4 percent of total dental expenditures compared to a rate of 5 percent of total physician expenditures. This might suggest that dentists can do a better job in donated dental care, but, to be fair, some authors have pointed out that dentists simply could not handle the entire burden of the underserved with current practice models.6,7
A third recommendation in the ADA Future of Dentistry report focuses on increased advocacy. However, a look at the past track record of advocacy suggests that our profession could do more here. A recent report8 suggests that a consistent theme of dentistry related to access to care issues is a "lack of effective advocacy." The good news to me is that recent ADA leadership clearly has a focus on access!
One question we might ask at this point is: what are some of the reasons we in the dental profession are not adequately responding to the access challenges? The following responses come to mind:
Is there a lack of awareness of the nature and magnitude of the issues? That was certainly my problem prior to 1985.
Is the ethical framework of our profession focused on the right issues?
Does the profession truly understand cultural competency and diversity issues as they affect access to care?
And finally, are there, in fact, real workforce issues that are preventing an effective response to the access issues?
The question I now put before you is: how can ADEA help dental and allied dental education deal with these issues of access to care? One could make the argument that we in dental education are responsible for the knowledge, skills, and attitudes of our graduates. So have we failed our students and graduates by not educating them about these issues? Are there ways academic dental institutions can better educate our students that would make them more aware of and sensitive to the access to care problems and more amenable to innovative solutions?
The desire to grapple with these issues is why we came up with a focus on access and diversity initiatives for next year, along with the theme of "Access and Diversity: Educating for Change" for our 2005 meeting in Baltimore.
ADEA and our members are about education. That is what we do. So, we must ask ourselves, what do we want to happen if academic dental institutions make changes in our educational programs focused on access and diversity? There are four long-term results I would like to see for our graduates and for the profession:
First, more advocacy by the profession, which should lead to better awareness by patients about oral health and legislative support for public assistance programs.
Second, more dentists willing to provide care to Medicaid and other public assistance patients.
Third, more pro bono care.
And fourth, more receptivity on the part of the profession to innovative solutions and new models of care.
And what type of changes in our educational programs should academic dental institutions make to achieve these goals? In responding to the question, I turn first to the report of the ADEA President's Commission on Access.9 While there are numerous recommendations about what academic dental institutions can do to help address the challenges of access to care, I will focus for now on one particular part: summarizing what we called "Guiding Principles for Academic Dental Institutions." Incorporation of these principles into dental and allied dental education can help the profession—in particular, future practitioners—deal in a better way with access to care.
Although some in our society, and even in this organization, will debate this point, one of the key guiding principles is that "Access to basic oral health care is a human right." Second, the oral health care system must serve the common good. Third, and here I think we would all be in agreement, the oral health needs of vulnerable populations have a unique priority.
To me, the first three of these guiding principles are ethical issues. I believe one of the reasons why the dental professions may not deal well with the access to care challenges is, in fact, a fundamental weakness in the ethical framework of our professions. To quote the ADEA report9 on access: "Currently in the United States, the provision of . . . oral health care services is treated like a manufactured commodity. . . . In such a marketplace economy, the variety of factors influencing demand gives way to one major factor: the ability to pay for services rendered" (p. 565).
Fortunately, there is an alternative perspective founded in the concepts of Social Justice, the moral responsibilities of health care professionals, and the concept of "the good society," all discussed in the ADEA report on access.
The ADA Code of Ethics addresses issues such as Beneficence and Justice, but makes little mention of the concepts just mentioned. From this discussion, I would conclude that dental and allied dental education needs to help the professions reframe their ethical foundations by providing learning experiences for our students that focus on issues such as the good society, social justice, and the moral responsibilities of health care professionals.
The fourth guiding principle identified in the ADEA report on access addresses two key issues: cultural competency and diversity in the workforce. A recent article in the Journal of Dental Education by Wendy Mouradian10 provides a wonderful discussion of cultural competency. The questions we need to ask ourselves are: do we incorporate enough cultural competency into our educational programs, and do we help our students to recognize how critical culture is in our patients' response to disease?
Before I turn to the diversity issue, I would like to conclude this section with a recommendation that ADEA, which adopted a policy on cultural competency in 2000, needs to find ways to help academic dental institutions to provide more substantive educational experiences related to the ethics of health care and cultural competency. Hopefully, this will help our graduates become better practitioners who are more aware of and sensitive to the access to care issues facing our professions. This will be one of our goals this upcoming year.
That leaves the diversity issue. I would direct our attention to the newest IOM report dealing with this issue; it was released on February 5 of this year. Entitled "In the Nation's Compelling Interest: Ensuring Diversity in the Health Care Workforce,"11 this report makes a number of recommendations as to how the higher education community can assist in this goal of a more diverse workforce. I want to first spend a minute on the opening chapter, which to me is critical as it lays down the foundation for why we actually need a diverse workforce.
The report does a thorough review of the scientific literature to back up its claims that greater diversity among health professionals is associated with:
improved access to care for racial and ethnic minority patients,
greater patient choice and satisfaction, and
better patient-clinician communication.
The current problem, as we all know, is that we do not have enough minorities in the healthcare workforce. This latest IOM study clearly lays out some suggestions for us in dental education about how to increase minority enrollment.
ADEA and our academic dental institutions need to consider some of these recommendations as ways to help us all meet this challenge of increased diversity in the health care workforce. We are not short of methods that should work, but we must have the will to focus on implementation! Again, this year we will explore how ADEA can help academic dental institutions pursue such initiatives.
In closing, I want to thank you for your attention. I welcome your input and participation and suggestions for implementing these initiatives of improving access to oral health care for the public at large and diversity in our workforce. I ask for your personal support and commitment in helping ADEA help our academic dental institutions to achieve these goals.
This address by the President-Elect of the American Dental Education Association was presented to the membership on March 6, 2004, in Seattle, Washington. Dr. Catalanotto is Professor of Pediatric Dentistry and former Dean at the University of Florida College of Dentistry.
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On this Republican DHS Shutdown Threat
From Senator Barbara Boxer on the Senate floor, yesterday:
We all know Republicans won in huge numbers in the 2014 election, and they took over the United States Senate and they run it. They run it. Or at least they're trying to run it. And let's be clear, less than eight weeks after they took over the Senate, we are facing a shutdown; a shutdown of the very agency that protects the health, the safety, the lives, of the American people - the Department of Homeland Security. They're shutting down the program that funds our police officers back home, our firefighters, our first responders. Any way you look at it, this is a national disgrace. And think about what our friends abroad, and those who are not our friends, are thinking about this. Republicans say, 'Oh, we're in danger, we have to go to go to war, put combat troops on the ground!' But they're wiling to shut down the department that protects Americans here in the homeland, from a terrorist attack. How does it make sense, at a time when we're facing serious threats to our national security, to furlough 30,000, thirty thousand, department of homeland security workers, and to force more than 100,000 frontline homeland security personnel to work without pay?' Great questions.


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Keith Lemley, 90
Keith L. Lemley, 90, of Lone Tree, died Monday, Oct. 20, 2014, at his home in Lone Tree. Services will be at 10 a.m. Thursday at the Sorden-Lewis Home for Funeral and Cremation Services in Lone Tree. Visitation is from 4 to 7 p.m. Wednesday at the funeral home.
Read or Share this story: http://icp-c.com/1wgIarT


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