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I. Problem/Challenge.
Unique Implications of the Hospitalist-Patient Relationship.
Barriers to a Good Beginning.
The hospitalist faces a unique challenge due to the nature by which patient relationships are introduced. Patients would generally meet their hospitalist for the first time. Unlike elective visits, patients do not have the opportunity to choose the practitioner. Unexpected acute illness, acute-on-chronic illness and morbidity, characterize the majority of inpatient encounters. Complex transitions of care are also typical. The hospital environment lends a feeling of vulnerability, a lack of control, and privacy. These circumstances challenge relationship establishment and development with patients and families. It necessitates that trust is established quickly and as early as possible in the relationship.
Medico-legal Implications.
The hospitalist-patient relationship is a decidedly transient. The end of such a relationship and transition of responsibility to the primary care physician must be clearly defined by the hospitalist.
II. Identify the Goal Behaviors.
Main Goal: Aim for a Relationship-Centered Hospitalist-Patient Relationship.
Execute Skills and Techniques That Foster Meaningful Therapeutic Relationships
Effective physician-patient relationships result in effective care. The ideal behaviors include the proper execution of a relationship-centered interview and an effectively negotiated plan of care. The crucial skills to possess to achieve these objectives include the ability to:
Continue Reading
Establish a common agenda for the hospitalization.
Explore the patient's perspective through reflective listening.
Express empathy throughout the relationship.
Involve the patient in decision-making.
Know the Medico-Legal Implications of a Hospitalist-Patient Relationship.
A physician-patient relationship is said to begin once a practitioner attempts to diagnose or treat an illness or provide counseling. The preceding statement is subject to broader interpretation. A relationship can be terminated on mutually agreed terms. The improper or premature termination of a physician-relationship may constitute abandonment. The hospitalist should be aware of the unique medico-legal implications of a transient relationship and in this context, must responsibly set the stage for safe transitions of care and turn-over of responsibility.
III. Describe a Step-by-Step approach/method to this problem.
The Approach Towards an Optimal Hospitalist-Patient Relationship, as adapted from The Cleveland Clinic REDE© Model of Healthcare Communication. Therapeutic relationships can be divided into three phases, with each providing a critical element in relationship-building.
Phase 1: Establish the Relationship.
Convey value & respect with the welcome.
Collaboratively set the agenda.
Demonstrate empathy at the beginning and throughout the relationship.
Phase 2: Develop the Relationship.
Engage in reflective listening.
Elicit patient narrative.
Explore the patient's perspective.
Phase 3: Engage the Relationship.
Share diagnosis & information.
Collaboratively develop treatment plan.
Provide closure.
Convey information through dialogue, not monologue.
Steps, words, and/or actions for each phase:
Phase 1: Establish the relationship.
Convey value & respect with the welcome.
Review chart in advance & comment on their history.
Knock & inquire before entering room, if possible.
Greet patient & companions formally (using title & last name) with smile & handshake.
Introduce self & team to patient & any companions; clarify role(s).
Position self at patient's eye level.
Recognize & respond to immediate signs of physical or emotional distress; attend to patient's privacy.
Make a brief patient-focused social comment, if appropriate.
Collaboratively set the agenda.
Orient patient to elicit a list of presenting concerns.
Use an open-ended question to initiate survey, e.g. "I'd like to get a list of all the things you'd like to address today.", or "What concerns brought you in today?"
Ask patient to list all concerns for the visit or hospital stay.
Summarize list of concerns to check accuracy.
Ask patient to prioritize concerns, e.g. "Of all the things you brought up, what's most important to you?"
Propose agenda that incorporates patient & provider priorities
Obtain patient agreement.
Demonstrate empathy at the beginning and throughout the relationship.
Recognize emotional cues and respond "in the moment".
Demonstrate verbal empathy using the SAVE mnemonic.
S – Supportive Statement: "I'm here for you. Let's work together.".
A – Acknowledge what they've gone through or what they've done: "This has been hard for you.", or "I'm sorry for the wait. I value your time.", or "I wish there were better alternatives."
V – Validate: "Most people would feel the way you do.", or "Anyone in your position would feel upset."
E – Emotion-naming: "You seem sad."
Demonstrate non-verbal empathy.
Embrace the pause.
Open, forward leaning posture.
Facial expressions of care, concern, and curiosity (e.g., raised eyebrows).
Head tilt or nodding.
Moving closer to patient.
Appropriate touch.
Gentle tone, slow pace to speech.
Phase 2: Develop the Relationship.
Engage in reflective listening: Listening in such a way as to understand & acknowledge what is being said nonverbally & verbally using continuers such as "mm-hmm", "I see", "go on" or brief statements summarizing the underlying meaning or emotion "What I hear you saying is…" or "Sounds like…"
Elicit patient narrative: The narrative is the history according the patient's own words and perspective. Use open-ended questions to initiate the patient narrative. e.g. "Tell me about your headaches… what else can you tell me?"
Explore the patient's perspective.
Know the person not just the patient.
Elicit the values, beliefs, and experiences that shape their perspective.
Goal is not to presume and assume but rather be curious to explore and open to learn.
Do not presume that your goals and expectations are the same or aligned at the onset.
Using the mnemonic V.I.E.W., ask about the patients.
V- Vital activities (occupational, interpersonal, intrapersonal): "How does it disrupt your daily activity?", or "How does it impact your functioning?", or "What made you decide to come in now?"
I – Ideas: "Often people have a sense of what is happening. What ideas do you have about it?", or "Do you know others who have had similar symptoms?"
E – Expectations: "What are you hoping we can do for you today?", or "What outcome do you hope to achieve with treatment?"
W – Worries (concerns, fears): "What worries you most about it?"
Phase 3: Engage the Relationship.
Share diagnosis and information.
Orient patient to the education and planning portion of the visit.
Present a clear, concise diagnosis.
Collaboratively develop treatment plan.
Describe treatment goals and options (including risks, benefits, and alternatives).
Elicit patient preferences and integrate into a mutually agreeable plan.
Check for mutual understanding.
Confirm patient's commitment to plan.
Elicit potential treatment barriers and need for additional resources.
Provide closure.
Alert patient that the visit is ending.
Affirm patient's contributions and collaboration during visit.
Arrange follow-up and consultation with other team members.
Provide handshake and a personal goodbye.
Convey information through dialogue, not a monologue. Information through a "lecture" or a monologue is retained at around rates of 10% or 25% at best. Providing information in chunks and allowing the patient to explain what he knows, may increase retention by 60%. Counsel patients through a dialogue using the A.R.I.A. mnemonic.
A – Assess using open-ended questions.
What the patient knows about diagnosis and treatment.
How much and what type of education patient desires/needs.
Patient treatment preferences; health literacy.
R – Reflect: Use reflective statements restating meaning and emotion.
I – Inform patient in context of patient's perspective and preferences.
Speak slow and provide small chunks of information at a time.
Use understandable language and visual aids.
A – Assess patient understanding and emotional reaction to information provided.
Empathy skills and conflict-resolution skills can be learned and practiced. Effective physician-patient relationship sets the stage for improved health outcomes, compliance, patient satisfaction, diagnostic accuracy, patient safety, patient trust, healthcare savings, and physician satisfaction. Literature also suggests reduces medical errors, malpractice litigation and physician burnout.
Establishing a trustful relationship can prevent accusations of abandonment or breakdowns in the relationship. The initial phases of establishment and development, like rapport building, discovering the patient's agenda and responding with empathy all add meaning to the relationship. These will be helpful when managing difficult relationships where conflict is involved, therapeutic boundaries are being tested, where emotions run strong and/or if the conversation is difficult.
From an organizational point of view, initiating a system of care that seeks to discover the patient's expectations might be far more productive than assuming what patients want to meet expectations. Healthcare organizations have sought to highlight relationship-centered behavior and train staff in these methods.
Unplanned Relationship Terminations.
While generally avoidable, unplanned deteriorations of the physician-patient relationship do occur, usually in the context of strained relationships. In this context, it is best to involve your own hospital's legal or risk management department. The patient should also be allowed to air grievances to an independent third party as established by the risk management protocol of your organization. If medical errors are involved, relationships become decidedly complicated.
Secret Information About Patients.
For a patient that decidedly meets criteria for medical decision-making capacity, all communications are to be held in strict confidence until permission to disclose to third persons is given. Hospitalists must be familiar with the regulations set forth by Health Insurance Portability and Accountability Act of (HIPAA) of 1996. Any Protected Health Information (PHI) should be kept in a reasonably secure database that is not discoverable.
Gifts from Patients.
Patients may occasionally need to express appreciation of a practitioner's care. There are no clear guidelines on the subject matter. Several references suggest that a thank you note, a bouquet of flowers or other simple inexpensive gestures are generally welcome. In contrast, questions are raised when a physician accepts gifts that are extravagant or of significant monetary value. Admittedly, value is a relative term, and often left up to individual judgement.
As with gifts from the pharmaceutical industry, the proposed screening questions are:
Will my acceptance of this gift raise a reasonable amount of scrutiny into my clinical and ethical judgement?
Will it call into question misguided motivations on my part for the treatment and management of the patient in question?
Answering yes to any of these questions, may point to a decision to not accept the proposed token of appreciation.
IV. Common Pitfalls.
Physician-Patient Relationship Killers
Entering the Room Unprepared:
In order to avoid "foot in mouth" syndrome, do enter the room armed with good background knowledge of the case as well as recent events.
Failing to Set Expectations/ Mismatched Agendas:
A patient may have totally different therapeutic goals than that of the medical team. At the beginning of a relationship, these should be explicitly uncovered, discussed and reconciled with realistic goals. Otherwise, the practitioner runs the risk of not meeting most, if not all, of the patient's expectations.
Not Knowing Patient's Personal Situation:
Treatment plans are at high risk of failure if the patient's personal and socio-economic situation are not factored into management and therapeutic planning.
Lack of Empathy Skills:
The lack of perceived empathy from the patient is a common reason for litigation. An empathetic statement adds meaning and understanding to a relationship.
The Unintentional Doctor-Patient Relationship:
Do understand that medical advice given outside of a hospital or office may unintentionally herald a doctor-patient relationship. These chance encounters may place the patient at-risk for an incomplete evaluation and lack of formal follow-up. "Curbside" patients should be counseled to seek medical care in the correct setting to ensure proper follow-up to the medical complaint.
Lack of Awareness of own Hospital's Risk Management System:
Nearly every hospital is mandated to have a process for recording patient grievances, as well as a systematic approach to risk management. These resources are best utilized when a hospitalist is plagued with a troubled or dysfunctional physician-patient relationship. Stakes are higher if the grievance is in the context of patient harm and/or medical errors.
V. National Standards, Core Indicators and Quality Measures.
Joint Commission Standards for Patient-Centered Communication.
These new and revised standards stipulate that:
The hospital should have a written policy on patient rights.
The hospital informs the patient of his/her rights.
The hospital treats the patient in a dignified and respectful manner that supports his or her dignity.
The hospital respects the patient's right to and need for effective communication.
The hospital respects the patient's cultural and personal values, beliefs and preferences.
The hospital reflects the patient's right to privacy.
Existing paper forms or computer data entry screens use the term; "patient's preferred language."
The medical record must identify the patient's race and ethnicity. The hospital should have policies prohibiting discrimination based on at least 11 factors: race, age, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.
Laws and Regulations.
The Emergency Medical Treatment and Active Labor Act (EMTALA).
The Patient Safety and Quality Improvement Act.
State and Federal Credentialing and Licensing.
Society of Hospital Medicine (SHM) Core Competencies.
SHM core competencies were published in 2006 and are a series of articles that outline a proposed approach to hospital medicine education. Core competencies relevant to this module are found in section 3 (Healthcare Systems):
Risk management.
Patient Education.
Patient Handoff.
Patient Safety.
Professionalism and Medical Ethics.
Risk Management.
Transitions of Care.
Readmission Rates.
Readmission rates may be a key metric affected by the quality of the physician-patient relationship.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally uniform survey of discharged patients. It is mandated by the Centers for Medicare and Medicaid services. HCAHPS and patient satisfaction standards are further discussed in a separate module ("Patient Satisfaction").
VI. What's the evidence?
Windover, A, Boissy, A, Rice, T, Gilligan, T, Velez, V, Merlino, J. "The REDE model of healthcare communication: Optimizing relationship as a therapeutic agent". Journal of Patient Experience. vol. 1. 2014. pp. 8-13.
Frankel, RM, Stein, T. "Getting the most out of the clinical encounter: the four habits model". J Med Pract Manage. vol. 16. 2001. pp. 184-191.
Randolph, DS, Burkett, TM. "When physicians fire patients: avoiding patient "abandonment" lawsuits". J Okla State Med Assoc.. vol. 102. 2009. pp. 356-358.
"The core competencies in hospital medicine: a framework for curriculum development by the society of hospital medicine". J Hosp Med. vol. 1. 2006. pp. 2-95.
Van Herck, P, De Smedt, D, Annemans, L, Remmen, R, Rosenthal, MB, Sermeus, W. "Systematic review – Effects, design choices, and context of pay-for-performance in health care". BMC Health Serv Res. vol. 10. 2010. pp. 247
Anderson, J. "Is it better to give, receive, or decline? The ethics of accepting gifts from patients". JAAPA. vol. 24. 2011. pp. 59-60.
"A new look at the hospital patient grievance process". Hosp Peer Rev. vol. 34. 2009. pp. 141-144.
Hickson, GB, Clayton, EW, Entman, SS, Miller, CS, Githens, PB, Whetten-Goldstein, K, Sloan, FA. "Obstetricians' prior malpractice experience and patients' satisfaction with care". JAMA. vol. 272. 1994. pp. 1583-1587.
Kandula, NR, Malli, T, Zei, CP, Larsen, E, Baker, DW. "Literacy and retention of information after a multimedia diabetes education program and teach-back". J Health Commun. vol. 16. 2011. pp. 89-102.
Spath, P. "When does a complaint become a grievance? Part 1". Hosp Peer Rev. vol. 25. 2000. pp. 12-14.
Tan, AS, Moldovan-Johnson, M, Parvanta, S, Gray, SW, Armstrong, K, Hornik, RC. "Patient-Clinician Information Engagement Improves Adherence to Colorectal Cancer Surveillance after Curative Treatment: Results from a Longitudinal Study". Oncologist. 2012.
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
- I. Problem/Challenge.
- II. Identify the Goal Behaviors.
- III. Describe a Step-by-Step approach/method to this problem.
- IV. Common Pitfalls.
- V. National Standards, Core Indicators and Quality Measures.


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In a historic decision, Allen Andrade has been convicted of first-degree murder and a hate crime for his killing of 18-year-old transgender woman Angela Zapata (at left, her family reacts to the trial).
Andrade's defense attorneys claimed that Andrade reacted without premeditation, in a rage at finding out that Zapata was born male (which Guanabee suggests may have happened after the two had sex). One lawyer said, "Justin Zapata lived like a female, looked like a female, sounded like a female. That's what Mr. Andrade believed. And when he found it wasn't Angie, it was actually Justin, he lost control." But prosecutors countered that Andrade knew that Zapata was born male for 36 hours before he killed her, and that he did so "out of his dislike for homosexuals." The jury agreed, deliberating for only two hours before finding him guilty of both murder and hate crime — one of the first times hate crime law has been applied to a transgender victim. Andrade will serve a life sentence without parole.
A really telling — and disturbing — aspect of this case is the language used on both sides. Andrade's defense lawyers insisted on referring to Zapata as Justin, perhaps implying that Andrade's actions somehow made more sense because Zapata wasn't "really" a woman. Andrade himself referred to Zapata as "it" when he was first arrested. There's also an interesting contrast between the AP's description of Zapata as "biologically male" and the Times's "born male." Does the Times's version do a better job of acknowledging the complexities of biological gender?
Blogger Drew Wilson reminds us that Zapata's death was, sadly, not a first for Colorado. A Navajo teen, Fred Martinez, was killed in 2001 because he identified as a two-spirit, a Native American who occupies both male and female gender roles. Notably, his murderer, Shaun Murphy, was not convicted of a hate crime. The conviction of Angela Zapata's killer on this charge is the saddest kind of progress.
Murder And Hate Verdict In Transgender Case [NYT]
Jury reaches verdict in Colo. Transgender Slaying [Breitbart]
As We Remember Angie, Let's Not Forget Fred [Drew Wilson, Denver Gay Examiner]
Breaking: Allen Andrade Convicted Of First Degree Murder [Feministe]
Defense Says 'No Hate Crime' In Angie Zapata Trial, Prosecution Proves Otherwise [Guanabee]

subset: commoncrawl


text:
I'm looking for a recommendation for a receiver that I can use on the road in rental cars. Really I'm looking for something that can be windshield mounted and plugged into the 12v outlet (like my GPS unit) and doesn't need any kind of additional hardware in the car to make it work (antenna, etc.. etc...).
Any pointers? Does such a device even exist?


text:
From: Andrew Johnson
Date: 2011-03-18 09:05:11
Let's get it all out in the open!! www.telegraph.co.uk/… US backing for world currency stuns markets US Treasury Secretary Tim Geithner shocked global markets by revealing that Washington is "quite open" to Chinese proposals for the gradual development of a global reserve currency run by the International Monetary Fund. Link to this video By Ambrose Evans-Pritchard 6:05PM GMT 25 Mar 2009 24 Comments The dollar plunged instantly against the euro, yen, and sterling as the comments flashed across trading screens. David Bloom, currency chief at HSBC, said the apparent policy shift amounts to an earthquake in geo-finance. "The mere fact that the US Treasury Secretary is even entertaining thoughts that the dollar may cease being the anchor of the global monetary system has caused consternation," he said. Mr Geithner later qualified his remarks, insisting that the dollar would remain the "world's dominant reserve currency … for a long period of time" but the seeds of doubt have been sown. The markets appear baffled by the confused statements emanating from Washington. President Barack Obama told a new conference hours earlier that there was no threat to the reserve status of the dollar. "I don't believe that there is a need for a global currency. The reason the dollar is strong right now is because investors consider the United States the strongest economy in the world with the most stable political system in the world," he said. RELATED ARTICLES Geithner seeks power over hedge funds and derivatives 26 Mar 2009 Tim Geithner and Barack Obama 'at odds' over economy 25 Mar 2009 Positive noises cheer Wall Street 25 Mar 2009 A world currency moves nearer after Geithner's slip 26 Mar 2009 Geithner about-turn on dollar shocks currency markets 25 Mar 2009 Gold price spikes as dollar falls 25 Mar 2009 The Chinese proposal, outlined this week by central bank governor Zhou Xiaochuan, calls for a "super-sovereign reserve currency" under IMF management, turning the Fund into a sort of world central bank. The idea is that the IMF should activate its dormant powers to issue Special Drawing Rights. These SDRs would expand their role over time, becoming a "widely-accepted means of payments". Mr Bloom said that any switch towards use of SDRs has direct implications for the currency markets. At the moment, 65pc of the world's $6.8 trillion stash of foreign reserves is held in dollars. But the dollar makes up just 42pc of the basket weighting of SDRs. So any SDR purchase under current rules must favour the euro, yen and sterling. Beijing has the backing of Russia and a clutch of emerging powers in Asia and Latin America. Economists have toyed with such schemes before but the issue has vaulted to the top of the political agenda as creditor states around the world takes fright at the extreme measures now being adopted by the Federal Reserve, especially the decision to buy US government debt directly with printed money. Mr Bloom said the US is discovering that the sensitivities of creditors cannot be ignored. "China holds almost 30pc of the world's entire reserves. What they say matters," he said. Mr Geithner's friendly comments about the SDR plan seem intended to soothe Chinese feelings after a spat in January over alleged currency manipulation by Beijing, but he will now have to explain his own categorical assurance to Congress on Tuesday that he would not countenance any moves towards a world currency. Are you interested in what's really going on in the world, behind the facade? Then…www.checktheevidence… happened on 9/11?www.drjudywood.com/


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Jason Aldean Doesn't Feel Pressured to Top 'My Kinda Party' Album With New Project
There is no question about it. Jason Aldean's 'My Kinda Party' album was a career record for the singer from Macon, Ga. Now, as he gears up for the release of his fifth studio album, Aldean says the pressure is on to outdo the 'Party' album, but he's not about to let it phase him one bit.
"I still feel like my career is relatively new and young," Aldean tells Taste of Country. "It gives me more incentive to go out and see if we can't beat it the next time. I say that, but I didn't record the album [saying] we've got to beat this record … we've got to beat this record. 'My Kinda Party' did what it did just by us going in and being ourselves and recording music the way we record it."
Aldean knows by now what works for him and numbers will work themselves out in the end. "To me, it's [about the] songs," he notes. "It's cliche to say it, but that's what it boils down to. I feel like as long as you have great songs, everything else is going to take care of itself. Do I hope that the next record does better? Absolutely. If it doesn't, will I consider it a failure? No.
"[My third album] 'Wide Open' didn't sell that many records, but I didn't consider it a failure," Aldean continues. "We still sold a million-and-a-half records. I mean … that's fine with me! I'll take that all day! I don't worry about that stuff too much. I think it's going to do what it does, and I think it will be fine."
Fans who have been able to catch Aldean's live show in the recent weeks have been treated to a couple of new songs from his highly-anticipated new album, including the first single, 'Take a Little Ride,' and another track titled 'Wheels Rollin'.'
"We just started putting some of the new songs in the show for the first time," reveals Aldean. "I think closer to the time of the record coming out, we'll start adding more and more songs into there. You have to be careful because you can loose them really quick if you try to overload them with new music before they even know what it is. Once the album comes out, I think that's the time to start adding a lot of the songs in."
We are certain that Aldean's fans have been eating up 'Wheels Rollin',' seeing how the tune was penned by two of the singer's favorite songwriters — Neil Thrasher and Wendell Mobley — both who are also writers on his recent chart-topper, 'Tattoos on This Town.' Aldean says the new tune is "a big kind of throwback, '80s rock, 'Wanted Dead or Alive' thing." That works for us!
Aldean's album is slated to hit stores sometime in October.


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Canadian police have arrested a 19-year-old man for allegedly using the Heartbleed bug to steal data about taxpayers.
Stephen Arthuro Solis-Reyes, of London, Ontario, took advantage of the vulnerability to steal information from the Canada Revenue Agency's website, according to the National Division of the Royal Canadian Mounted Police. They arrested him on Tuesday without incident. Solis-Reyes faces one count of unauthorized use of a computer and one count of "mischief in relation to data."
The CRA, one of the first victims to report a Heartbleed attack, said on Monday that the vulnerability had been used to steal the Social Insurance Numbers of about 900 people. After discovering the attack, the agency temporarily halted online filing of tax returns. Social Insurance Numbers are required to work or get government benefits in Canada.
Read: The critical, widespread Heartbleed bug and you: How to keep your private info safe
Heartbleed lets attackers capture data from server memory 64KB at a time, putting passwords, encryption keys and other data at risk. It lived in the popular Web encryption tool OpenSSL (Secure Sockets Layer) for about two years before it was exposed last week. Though the bug affected a broad swath of websites and was found in many models of server and network equipment, reports of Heartbleed attacks only started to emerge after the flaw had been disclosed.
The RCMP arrested Solis-Reyes after four days of investigation. It searched his residence and seized computer equipment, and the investigation continues, the agency said in a press release. Solis-Reyes is scheduled to appear in court in Ottawa on July 17.


text:
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text:
You are Not Too Old to Become a Data Scientist
October 20, 2020
Last Updated on October 23, 2020 by Editorial Team
Author(s): Moeedlodhi
Why making a career transition is not the end of the world.
Continue reading on Towards AI — Multidisciplinary Science Journal »
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text:
Marco Chacon had only spent about $20 on his conservative news website, RealTrueNews, when he heard his words in prime time on Fox News' The Kelly File.
"Yeah," Chacon said. "That was an accident."
Just as he'd done for the last few months, Chacon had read the latest explosive conservative news—this time it was Hillary Clinton's leaked speeches to Wall Street banks—and typed up an imagined transcript of his own.
"So in the transcript, she's explaining Bronies to the Goldman Sachs board of directors," said Chacon. "Do you know what Bronies are?"
Bronies are hard-core, usually adult fans of the cartoon My Little Pony.
"In this one, [Bronies] are part of a threat of subalterns who are going to take over the election. And people believe all this," he said. "And I'm just… I'm telling people, 'How can you believe this!?'"
Somewhere in the middle of that block of text about My Little Pony, Chacon's transcript contained the phrase "bucket of losers," attributed, falsely of course, to Clinton, which legitimate conservative news websites picked up as real.
Sure enough, by 9 p.m. that day, Trace Gallagher was on Fox News telling viewers that Clinton had "apparently called Bernie Sanders supporters a 'bucket of losers.'" (Megyn Kelly later apologized after the Clinton campaign vehemently denied Clinton said it.)
Taking official-looking documents at face value isn't just burgeoning among alt-right media. It's a tactic now endorsed by the Republican candidate for president.
Two weeks ago, GOP nominee Donald Trump implored supporters in a speech in Colorado Springs to "forget the press. Read the internet."
The internet is filled with verifiable information from journalists at places like The New York Times and The Washington Post, who face real consequences if a story turns out wrong. But, especially this election cycle, the web is equally saturated with factually inaccurate disinformation, verified by no one, turning up on Facebook and Twitter feeds across all demographics and party lines with no way to stop it.
An analysis conducted by BuzzFeed last week found that Facebook posts from 38 percent of right-wing and 20 percent of left-wing news sites "published false or misleading information."
Chacon, a 47-year-old veteran infantryman, father, bank executive, and moderate Republican, saw it all over his Facebook feed, and he was sick of it.
"I saw something posted sincerely with a headline like, 'Obama Issues Executive Order to Take Over U.S.,'" he said. "How do you counter that? You can try to debunk it, but nobody cares about that. They just say it's liberal media bias."
So, three months ago, after a conversation with a childhood friend, he bought a domain name, RealTrueNews.org. He was going to come up with the most ludicrous right-wing conspiracy theories he could think of, give them a narrative and timeline, and put them into quasi-official looking documents.
Then he and that childhood friend, Mike, would post the website on his alt-right friends' Facebook walls to prove how ridiculous they looked.
That was it. That was the whole plan.
It's two weeks before the election now and those documents have accrued millions of views across his website, the document drop site Scribd, and various social media accounts. They've appeared on cable news. They've trended on Facebook and Twitter. Two polling companies, barraged with hatemail from Trump supporters about "leaked" memos created for RealTrueNews articles, have had to put out official statements denying the existence of such memos. Chacon's stories are regularly accepted as fact in the pro-Trump message board canon. YouTube videos with tens of thousands of views exist solely to reinforce sentences and ideas Chacon dreamed up on his laptop in the middle of the night.
How did this happen?
"I don't know. I'm stunned," said Chacon. "If you can, maybe call Monmouth (University polling) and see if they'd accept an apology."
Mike Klasfeld has known Marco Chacon for 30-plus years. They went to middle school together and never really lost touch, especially on Facebook, where they have a "couple of mutual friends who are very right-wing."
"Every time I opened up my Facebook page there would be 20 new, complete bullshit right-wing articles," said Klasfeld. "Either the title would be an outright lie, or the article would have nothing do with the title."
Most of them, Klasfeld said, came from a website called TruthFeed. "Nothing in TruthFeed had any truth in it," he said. So he thought it'd be funny if he and Chacon had a right-wing blog of their own, called "Truthinessfeed," like the Stephen Colbert-coined term about how feelings are the new facts. Klasfeld even bought the domain name.
But by the next day, Chacon had already cooked something up. "What do you think of this?" he asked. It was a fake right-wing news article, replete with forged documents to back it up.
"I said, 'Holy shit, this is good!'" Klasfeld said.
RealTrueNews was born. And right away, the stories were obviously too good to be true.
"I am absolutely not trying to fool people the way some of these conservative sites are. Everything on there is satirical. It's all funny," said Chacon. "Well, it's supposed to be."
Chacon is right: Most of it is a pretty obvious gag, filled with traditional, bang-you-over-the-head obvious references to the occult. One of his documents is filled out on Illuminati letterhead.
"I know conspiracy stuff cold. But this is all 30 years of Dungeons & Dragons," he said. "There's stuff in there that's just obviously fiction. I don't mean absurd potential news. I mean, there's no shred of believability. One of the nations that's 'paying for Hillary's hitmen' is the one Doctor Doom runs."
But here's where it gets messy. After years in IT and white collar jobs, it turns out Chacon is very, very good at the Microsoft Office Suite. Nothing fancy—PowerPoint, Excel, that kind of thing. But when he would upload those documents to RealTrueNews' Scribd page—a sort of document-dumping cloud service that makes PDFs and PowerPoint presentations visible in your browser—that's where those good-looking documents lost all satirical context.
From RealTrueNews' Scribd page, anybody can screenshot a somewhat believable portion of the document and post it on Twitter, then link to the full document, which nobody takes the time to read.
Then all hell breaks loose.
The first time it happened was in August, when Chacon created a fake Public Policy Polling "internal memo" that talks about "purchasing Republican Disapproval from policymakers" and shows that Donald Trump has a secret 74 percent lead in Florida.
Notably missing from these screenshots? The conclusion section, which includes these sentences.
"The question is going to be how far we can maintain this charade. It might be time to find other jobs. I bet those fuckers at Monmouth are living it up with their interns," it reads. "I also have some contacts at Quinnipiac. I hear they're all smoking up Bernie-grade weed. Fucking College polls."
Still, many Trump-backed message boards and Twitter supporters believed the "memo," and began bombarding PPP's Twitter account, demanding answers.
"Hey @ppppolls saw a post that had this on Scribd…any comment?" wrote one user.
"Yes," PPP's Twitter account replied. "It's really a commentary on the credulity of Trump supporters that so many think this memo could be real."
Monmouth Polling, when faced with a RealTrueNews "leak" of its own, took it a lot more seriously. Chacon's fake Monmouth memo had Hillary Clinton losing in the polls to "a potato."
One alumnus, an assistant campaign manager for the Republican Party in Pennsylvania, demanded answers from the university for a memo it didn't create.
"If it's true then it's a disgrace and there needs to be action," said Tyler Vandegrift. "He is potentially sacrificing the academic reputation of my Alma Mater in favor of partisan politics. People need to have faith in polls."
"For the record, the purported Monmouth University poll memo being circulated is a photoshopped fake—and not a very good one at that," the Monmouth poll's Twitter account wrote. The Washington Post even wrote the whole thing up, calling RealTrueNews a pro-Trump site. Scribd forced Chacon to pull the memo down.
He felt bad about that one. And the Megyn Kelly story, which happened a month later.
After all, Chacon is a guy with young kids writing truly ludicrous fanfiction on the internet. It's only being construed as fact by people who really, desperately want to believe the world is run by a shady, nefarious cabal.
There's no better proof than the source material for one of his latest "leaks," focused on a failed "coup" attempt by Mike Pence and Paul Ryan to take over the Republican ticket. One pro-Trump message board posted about 100 messages about the "leak" until an anonymous user noticed something fishy.
"He signed one email '-Chase, No Job Is To [sic] Big,'" wrote the user. "Chase is a character from a popular kids show called Paw Patrol, their motto is 'no job's too big, no pup's too small.'"
Chacon's kids watch Paw Patrol, which is on Nickelodeon.
The countless pages of commenters agonizing over his leaks on websites like 4chan and Reddit have started to make more sense to Chacon over the course of the last few weeks.
"I'm sympathetic. I have family that are Trump supporters. This makes people's lives more exciting. From reading these posts, it seems like people get energized and kind of excited," said Chacon, who said he was a lifelong Republican until the party "lost him at [Sarah] Palin."
"They're researching them all as sort of an augmented reality game, and the goal is to catch the bad guys. Like Hillary Clinton and the Illuminati."
But Chacon's goal isn't just to get the people who fall for it on Facebook to be discerning, although he admits that would be nice. He's trying to catch websites who play to their userbases' wildest fears on Facebook and Twitter—and do it for profit.
Chacon has only twice ever seeded his documents to websites like 4chan, an anonymous white supremacist message board where Trump is referred to as "God Emperor." But screenshots of his documents frequently wind up there and on Reddit's /r/The_Donald anyway, where they're met with reverence and not much skepticism.
A screenshot of Chacon's latest "leak" appeared on those sites before landing on conservative news sites and prominent alt-right Twitter feeds earlier this week. The document appears to show a "confidential memo" from pro-Clinton super PAC Correct the Record imploring staff to flood Reddit and Twitter with "high-frequency recent polls."
In the memo, he calls the practice "poll-flogging."
"I thought 'poll-flogging' would be a pretty obvious joke, but I guess it wasn't," said Chacon.
Duped by this, again, was Paul Joseph Watson, an editor at the alt-right conspiracy website Infowars. His tweet of the screenshot received thousands of retweets and, hours later, that same screenshot appeared on conservative blogs like YoungConservatives and Gateway Pundit, who later corrected their stories. Watson pulled the tweet about a day later.
Eleven months ago, Trump himself appeared on Infowars' daily online video show to give the website a half-hour interview and sing its praises.
"I just wanted to finish by saying that your reputation is amazing. I will not let you down," said Trump. "You'll be very, very impressed, I hope, and I think we'll be speaking a lot."
But this wasn't the first time Infowars fell for Chacon's intentionally fake news. The website also fell for "Bucket of Losers" before wiping the story off its website without a correction. (The story still appears on Watson's Infowars sister site, PrisonPlanet.)
The Daily Beast repeatedly asked Watson if he had time to be interviewed on the phone.
"No, I don't. I'd rather boil my own nuts in a pan of steaming hot water," Watson responded via email. "If you'd have been honest in the first email and admitted it was a hit piece, I would have done it. This is why no one trusts the media. You suck, you lie and you mislead people. You're dishonest, smarmy and two faced."
The Daily Beast then asked if he didn't "want [his] readers to know information that you can prove was incorrect."
"I'll correct it when your publication corrects itself and admits that Clinton is a warmongering, continent destroying, ISIS-arming, migrant crisis starting, Saudi Arabia money taking, fake feminist, child molester defending, corrupt as fuck, Wall Street owned, career politician cunt," said Watson.
"Compared to that, a mistaken tweet about a hoax story pales."
He then screenshotted the exchange, and posted it on his Twitter account.
Chacon had always been into elaborate pranks, Klasfeld remembers. When Chacon and his identical twin brother, Eric, used to work at the same white-collar job in their 20s, Klasfeld said, there was one guy who acted like he was better than the place and didn't much like either of them.
So they decided to drive him insane.
Chacon confirmed this account. "He was a slightly arrogant guy who went to MIT," he said. "We made it look like there was some mysterious force sending messages from inside the network directly to him."
"It kept escalating and escalating, but this guy didn't have a clue," said Klasfeld. "At one point in time, he actually thought it was them, but he said something like, 'This is beyond your abilities.' And that just coaxed them into making it all the worse."
That's basically how it went, Chacon remembers.
"He did say, 'I suspect you guys are doing this, but you're not smart enough,'" he said. "When it was all over, he was kind of pissed for a couple of days. Then he was like, 'Damn, that was kind of cool.'"
And RealTrueNews, Chacon said, isn't much different from that prank. It was a gag with a mission of dragging people away from their own extreme self-importance by deploying brilliant stupidity. Chacon called it art.
The website, Chacon said, will end after the election, but he has one more big story in him. If Clinton wins, he says, this will be the headline:
On Wednesday, 13 days before the election, Infowars already beat him to it.
Its headline? "DONALD TRUMP HAS WON THE 2016 PRESIDENTIAL ELECTION."


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Welcome to the Age of Open-ish Technology
Last week, as Tim Cook took the stage to unveil the iPhone 5, I tweeted snarkily that unless he was announcing a reversal of corporate philosophy to support a more open computing environment, I wasn't interested.
That led, perhaps predictably, to a conversation with a developer friend who's deeply committed to open-source, about how Google's Android is hardly a case study in openness. He argued that the difference between Android and iOS was smaller than is commonly appreciated in the media; I argued that the ability to fork Android still matters. For me, the result of that debate was simply the reminder that Android is an open-source project controlled (rather than supported) by a corporation.
Fitting, then, that only days later news dropped about Google objecting to Acer's partnership with Alibaba, as Google alleges the Chinese company's new mobile operating system is an Android fork. Whether or not that claim is true, the point is that Open Handset Alliance members like Acer have to play by Google's rules.
So is "technically open but tightly controlled by one company" better than closed? I'd still argue yes, and Tim Wu makes what is to me a compelling case for Google's commitment to openness compared to Apple in his book The Master Switch. But for the sake of argument, I want to ask if it's possible that the mostly-kinda-sorta-open might be crowding out truly open-source development.
Just over a month ago, blogging and RSS giant Dave Winer wrote a post in which he accused venture-backed companies of being predatory to the open development community. Those companies, he wrote, "feed off open development work, destroy the value of its open-ness, and put little or nothing back."
After reading this, I reached out to several entrepreneurs, startup developers, and VCs for their takes, and what I heard was that startups often take great pride in their contributions to open-source, and that while they may gain advantage from open-source software, they don't bleed value from it. That's the beauty of nonrival goods, after all.
And yet I can't help but worry about the impact that open-ish software might be having. Whether it's a nominally open-source project under a single company's control or a now-ubiquitous service like Twitter unilaterally determining just how "open" or not its API will be, we live in an age when private companies are readily acknowledging the many benefits of some kind of open mentality. There's a recognition that you should let lots of other people contribute to your product or platform, but this decentralized activity is in many cases still coupled with centralized control. If there's damage here, it's less to open-source projects that exist, and more to the ones that never get a chance to.
I'd still take a more open API over Twitter's new, more tightly controlled ecosystem, and I prefer a Google-controlled openly licensed mobile operating system over a proprietary one. And most of all, I believe deeply in the transformative power of the two economic models mentioned here: venture-backed entrepreneurship and commons-based peer production. How those two should interface with one another, I'm not sure. At the very least, in this day and age it's clear that the question to ask isn't Is it open? But, rather, Is it open enough?
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Baucus, Hatch expand IRS probe
Top lawmakers on the Senate Finance Committee are broadening their probe of the Internal Revenue Service's practice of targeting conservative groups, asking the agency to turn over an extensive batch of communications detailing who was involved in the program.
In a letter sent Monday to acting IRS Commissioner Steven Miller, Chairman Max Baucus (D-Mont.) and ranking member Orrin Hatch (R-Utah) sought details on how the agency reviewed applications for wide range of tax exemptions — not just the requests for 501(c)(4) status at the center of the current scandal.
The lawmakers also want to know whether any elected officials influenced employees as they decided which applications for a tax exemption deserved extra review.
( Also on POLITICO: Who knew what when?)
"Was the decision to target any tax-exempt applications for review and subject them to full development or heightened scrutiny influenced or prompted in any way by political pressure directed at the IRS from any members of the Congress or other elected officials?" Baucus and Hatch wrote.
Since news of the targeting program surfaced on May 10, the IRS has insisted that political bias played no role in the extra review given to nearly 300 groups seeking tax-exempt status.
But Republican have blamed President Barack Obama and other Democrats for publicly demonizing 501(c)(4)s and creating a culture that encouraged IRS employees to crack down on the organizations. Democrats have rejected such arguments.
( PHOTOS: 10 slams on the IRS)
The letter requests all communications between any White House officials, including Obama, and IRS workers that mention targeting 501(c) organizations.
Meanwhile, the senators are also pressing for the names and dates that any individual in the White House or Treasury Department became aware of the targeting.
Deputy Treasury Secretary Neal Wolin learned last summer that an inspector general was probing the IRS for targeting conservative groups but he wasn't provided any details of the investigation.
The Wall Street Journal reported late Sunday that White House counsel Kathryn Ruemmler learned in April that the inspector general investigation found that the IRS wrongly targeted conservative groups. There's no indication yet that she told President Barack Obama about the investigation or its results.
Miller, who stepped down last week at the Obama administration's request, will testify before the Senate Finance Committee on Tuesday. Wolin will appear before the House Oversight and Government Reform Committee on Wednesday.
Baucus and Hatch also specifically asked the agency to explain why officials have repeatedly blamed a spike in nonprofit applications as the impetus for centralizing reviews when data from the inspector general found that the volume of requests increased long after the IRS already began scrutinizing conservative groups.


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Scientists at Karlsruhe Institute of Technology (KIT) have succeeded in encoding data at a rate of 26 terabits per second on a single laser beam, transmitting the data over a distance of 50 kilometers, and decoding the information successfully. This is the largest data volume ever transported on a laser beam. The process developed by KIT enables the transmission of 700 DVDs' worth of content in just one second.
The advance is reported in the journal Nature Photonics.
In this experiment, KIT scientists led by Professor Jürg Leuthold beat their own record in high-speed data transmission of 2010, when they exceeded the magic limit of 10 terabits per second -- i.e. a data rate of 10,000 billion bits per second. This success of the group is due to a new data decoding process. The opto-electric decoding method is based on initially purely optical calculation at highest data rates in order to break down the high data rate to smaller bit rates that can then be processed electrically. The initially optical reduction of the bit rates is required, as no electronic processing methods are available for a data rate of 26 terabits per second. Leuthold's team applies the so-called orthogonal frequency division multiplexing (OFDM) for record data encoding. For many years, this process has been used successfully in mobile communications, based on mathematical routines (Fast Fourier Transformation).
"The challenge was to increase the process speed not only by a factor of 1,000, but by a factor of nearly a million for data processing at 26 terabits per second," explains Leuthold, who heads the Institutes of Photonics and Quantum Electronics and Microstructure Technology at KIT. "The decisive innovative idea was optical implementation of the mathematical routine." Calculation in the optical range turned out to be not only extremely fast, but also highly energy-efficient, because energy is required for the laser and a few process steps only.
"Our result shows that physical limits are not yet exceeded even at extremely high data rates," Leuthold says, noting the constantly growing data volume on the internet. According to Leuthold, transmission of 26 terabits per second confirms that even high data rates can be handled today, while energy consumption is minimized. "A few years ago, data rates of 26 terabits per second were deemed utopian even for systems with many lasers." Leuthold adds, "and there would not have been any applications. With 26 terabits per second, it would have been possible to transmit up to 400 million telephone calls at the same time. Nobody needed this at that time. Today, the situation is different."
Video transmissions consume much Internet bandwidth and require extremely high bit rates. The need is growing constantly. In communication networks, first lines with channel data rates of 100 gigabits per second (corresponding to 0.1 terabit per second) have already been taken into operation. Research now concentrates on developing systems for transmission lines in the range of 400 Gigabits/s to 1 Tbit/s. Hence, the Karlsruhe invention is ahead of the ongoing development. Companies and scientists from all over Europe were involved in the experimental implementation of ultra-rapid data transmission at KIT. Among them were members of the staff of Agilent and Micram Deutschland, Time-Bandwidth Switzerland, Finisar Israel, and the University of Southampton in Great Britain.
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text: To test drive this 2017 Ford Explorer in St-Jérôme, in the Laurentians, please fill-out this form and a specialist from St-Jérôme Mitsubishi will contact you shortly. It will be our pleasure to book an appointment at the date and time of your best convenience, when you will have all the necessary time to test drive this 2017 Ford Explorer at St-Jérôme Mitsubishi in St-Jérôme, in the Laurentians. Don't wait any longer, test drive it now!


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By BENJAMIN E. SASSE & CHARLES HURT
Only this isn't some little fund from shadowy private sources; this is taxpayer money, redirected to help Obama win another term. A massive amount of it, too — $8.3 billion. Yes, that's billion, with a B.
Here is how it works.
The most oppressive aspects of the ObamaCare law don't kick in until after the 2012 election, when the president will no longer be answerable to voters. More "flexibility," he recently explained to the Russians.
But certain voters would surely notice one highly painful part of the law before then — namely, the way it guts the popular Medicare Advantage program.
For years, 12 million seniors have relied on these policies, a more market-oriented alternative to traditional Medicare, without the aggravating gaps in coverage.
But as part of its hundreds of billions in Medicare cuts, the Obama one-size-fits-all plan slashes reimbursement rates for Medicare Advantage starting next year — herding many seniors back into the government-run program.
Under federal "open-enrollment" guidelines, seniors must pick their Medicare coverage program for next year by the end of this year — which means they should be finding out before Election Day.
Nothing is more politically volatile than monkeying with the health insurance of seniors, who aren't too keen on confusing upheavals in their health care and are the most diligent voters in the land. This could make the Tea Party look like a tea party.
Making matters even more politically dangerous for Obama is that open enrollment begins Oct. 15, less than three weeks before voters go to the polls.
It's hard to imagine a bigger electoral disaster for a president than seniors in crucial states like Florida, Pennsylvania and Ohio discovering that he's taken away their beloved Medicare Advantage just weeks before an election.
This political ticking time bomb could become the biggest "October Surprise" in US political history.
But the administration's devised a way to postpone the pain one more year, getting Obama past his last election; it plans to spend $8 billion to temporarily restore Medicare Advantage funds so that seniors in key markets don't lose their trusted insurance program in the middle of Obama's re-election bid.
The money is to come from funds that Health and Human Services is allowed to use for "demonstration projects." But to make it legal, HHS has to pretend that it's doing an "experiment" to study the effect of this money on the insurance market.
That is, to "study" what happens when the government doesn't change anything but merely continues a program that's been going on for years.
Obama can temporarily prop up Medicare Advantage long enough to get re-elected by exploiting an obscure bit of federal law. Under a 1967 statute, the HHS secretary can spend money without specific approval by Congress on "experiments" directly aimed at "increasing the efficiency and economy of health services."
Past demonstration projects have studied new medical techniques or strategies aimed at improving care or reducing costs. The point is to find ways to lower the costs of Medicare by allowing medical technocrats to make efficient decisions without interference from vested interests.
Now Obama means to turn it on its head — diverting the money to a blatantly nonexperimental purpose to serve his political needs.
A Government Accounting Office report released this morning shows, quite starkly, that there simply is no experiment being conducted, just money being spent. Understandably, the GAO recommends that HHS cancel the project.
Congress should immediately launch an investigation into this unprecedented misuse of taxpayer money and violation of the public trust, which certainly presses the boundaries of legality and very well may breach them.
If he's not stopped, Obama will spend $8 billion in taxpayer funds for a scheme to mask the debilitating effects on seniors of his signature piece of legislation just long enough to get himself re-elected.
Now that is some serious audacity.
Benjamin E. Sasse, a former US assistant secretary of health, is president of Midland University. Charles Hurt covers politics in DC.


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Harem van de Farao
Téjlor is the pseudonym of a comic artist from Hungary, who started to work for international publishers in 2004. He made comic strips for the Virtuagirls homepage, and cartoons for the Polish Dobry humor magazine. His ten albums were published by Sombrero Media in The Netherlands.
These included books like 'Harem van de Farao', 'Graaf Vlad' and 'Donau Girls', as well as sexy comics about erotic stars like Sunny Leone, Kim Holland and Hot Marijke. Tejlor also made installments in the 'Rooie Oortjes' series (2011-2012). He also works for E.F. Edizioni in Italy and the DarkBrain webcomic site.


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Speakers and attendees - Next Generation VLA Workshop
Orlando, FL - AAS 2016 - Speakers and attendees during the Next Generation VLA Workshop at the American Astronomical Society's (AAS) 227th annual meeting at the Gaylord Palms hotel here today, Monday January 4, 2016. The American Astronomical Society (AAS), established in 1899 and based in Washington, DC, is the major organization of professional astronomers in North America. The annual meeting is the premier astronomical event with more than 2,300 astronomers, educators, industry representatives, and journalists in attendance and at least 1,600 oral and poster presentations scheduled. Photo by © CorporateEventImages/Phil McCarten 2016
Speakers and attendees Next Generation VLA Workshop AAS 2016


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As a courtesy and convenience for our community, Barton Health is providing this Directory of Physicians on the Medical Staff at Barton Memorial Hospital. You may search our Physician Directory by Name or by Specialty. If you do not enter or select any information, but just press the "Search" button, you will receive a list of all physicians on staff at Barton Memorial Hospital. You may also download the Physician Directory for a listing of physicians on staff at Barton Memorial Hospital.
This physician directory is provided as a convenience to you. It is not intended as a recommendation, referral, or endorsement of any particular provider. Physicians are not employees of Barton Health or its affiliates. Barton Health is not responsible for any loss or damage caused by your reliance on this information. You should verify the accuracy of the information directly with the physician's office.
All doctors on this site are affiliated with Barton Health's network of care - members of the medical staff of Barton - affiliated hospitals, affiliated medical groups, and independent practice associations that participate in clinical initiatives. Doctors do not pay a fee to be included in this directory.