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We are excited to announce that this year's CVHS Class of 2018 Grad Night Celebration will be at Main Event starting at 11 PM on Tuesday, May 22nd, and ending Wednesday morning at 6:30 AM . . just in time to head over to the mandatory graduation rehearsal at 7 AM on the football field.
Campo Verde graduating seniors have exclusive access to everything Main Event has to offer, including bowling, billiards, ropes course, laser tag, and arcade games. You can spend some time taking photos with friends in the photo booth, dancing to tunes spun by a California DJ, and being entertained by a nationally known hypnotist during his show….where you just may get chosen to become part of the entertainment!
You will be well fed at Grad Night…..pasta and salad upon arrival at 11 PM and a 2 AM pizza party. Snacks will be available throughout the night and as well as a light breakfast in the morning.
And if that's not enough, the Grad Night party will have lots of prizes to be raffled off like bicycles, printers, gift cards, dorm fridges, TVs and other fun stuff to help launch you into the next phase of your life.
The registration form is attached and must be signed by a parent. Turn in the registration form and payment at the bookstore. The cost is $70 until the Senior Banquet on Wednesday, May 9th, and $80 after the Senior Banquet.
Don't miss out!
The Grad Night celebration is sponsored by the CVHS Project Graduation boosters.


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Q: Virginia introduces law prohibiting WHAT demographic from marrying?
No, not gays.
A: girls age 13 and under.
Yes, it was previously legal. Yes, this happened. Over 200 girls under age 14 have been married since 2004 in Virginia. The current law allowed it when 1) the parents consented, and 2) the child was pregnant.
This is a question you won't hear on the show. Sorry, just not a good fit for a show that is about having some fun with the law. But it was interesting enough to warrant a quick post.
Read more from the Independent. http://www.independent.co.uk/news/world/americas/virginia-introduces-law-to-stop-12-year-old-girls-from-getting-married-a7119091.html
Tagged disturbing, marriage, state laws, unusual laws

subset: commoncrawl


text: This part of the grounds has been known by many names including the star garden and the union jack garden. Interestingly the area dates from 1713-1719 and would originally have been a formal wilderness garden. The terms wilderness probably brings to mind wild planting schemes but in fact in the eighteenth century it was a term used to describe an area that was densely planted with trees and shrubs. To gain a sense of what this looked like at the time it is possible to consult engravings that date from the 1730s where it is possible to see the extent of the original structure. Two areas were designed in the shape of a union jack flag (hence one of the names for this part of the grounds). These beds contained oak and were edged with yew, holly and laurel, trimmed to ensure that it kept its original shape.


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ARTEMIS, named after the Greek goddess of the hunt, is a wine that truly reflects its name. It's the culmination of our hunt for the finest grapes from Napa Valley which, when combined with estate-grown fruit, combine to create a Cabernet Sauvignon that expresses the regional character of Napa Valley with the signature style of Stag's Leap Wine Cellars. "Dry and herbal, with dried berry, black cherry, cedar and dill flavors, straying into dryer territory on the finish. Drink now through 2020."
Wine Advocate: 90


text: LightWave has just about everything you need for quality character animation work. Its methods, however, might not be suited for you. If that's the case, there is another program that works with LightWave, but it is a standalone application. Magpie Pro, from Third Wish Software, offers the user an integrated set of tools for lip-syncing characters. It uses prerendered thumbnail images and also can reference an AVI file. You can even load 3D objects into Magpie Pro as well. Figure 12.29 shows the Magpie Pro interface.


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Worried you might not be able to watch Microsoft's E3 Press Conference live on June 9th at 12:30 pm EST? No worries, we've got you covered here on Gamers Xtreme! We'll be live blogging the whole event and you, as the community, will be able to interact with us throughout the whole conference! The blog is also mobile friendly so for those of you with smartphones, you'll be able to still catch every minute of the conference through your phone. Enter your e-mail address below to be reminded of when the event is about to go live and get involved with E3!
Microsoft's E3 2014 Press Conference Live Blog
June 7, 2014 by Leave a Comment


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Register or login to save your shortlist.
A buzzword among weight watchers is metabolism. Slender women who seem to eat anything without gaining excess weight credit such good fortune to a good metabolism. Overweight individuals aim to their increase metabolism in their efforts to shed unwanted p
There are some great natural remedies and tricks available to help us boost our concentration and memory.
Everyone has overeaten at some point or another but binge eating is different to overeating from time to time. Learn more about this disorder and find out some strategies to help overcome it.
There is no magic number when it comes to the amount of calories that you should be eating to either lose or maintain weight.
Cardiovascular disease continues to be the leading cause of death among middle-aged men and women. Studies confirm that heart disease may be developed early in life although its symptoms begin to surface only when the disease is at an advanced stage.
Congestive heart failure is a condition suffered by many Australian people but, while it is scary, it can be managed by natural therapies in conjunction with standard treatments. Natural therapies can help to make your life more comfortable if you have t
More Articles Related to Personal Trainers


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The Professional Car Detailing Company
Exclusive Car Care is owned and operated by Justin Lawrence and was established with the fundamental aim of providing an alternative to the overwhelming number of traditional and often sub standard car cleaning services available in the UK.
Despite the large number of car detailing/valeting companies throughout the UK, we pride ourselves in having the knowledge, endless patience and passion to perfect the appearance of any vehicle that is given to us to detail.
Quality without Compromise
We work on a limited amount of vehicles so that we can focus on each vehicle and customer's specific needs, and take the proper amount of time needed to get the job done right.
The boutique level of services and skills that we provide simply cannot be achieved by volume-based car valeters/detailers found throughout the UK.


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This flavorful braised cabbage is an easy preparation, and it makes a tasty side dish. Serve the dish with ham, corned beef, or a pork dish. The apple and apple jelly combined with the vinegar gives the dish a nice mix of sweet and sour flavors. If you like the taste of caraway seeds, they make an excellent addition.
What You'll Need
- 4 tablespoons butter
- 1 large onion, quartered and thinly sliced
- 1 large tart apple, peeled, cored, finely diced
- 1/2 head of cabbage, coarsely chopped or shredded, about 8 cups
- 1/4 teaspoon freshly ground black pepper
- 3 tablespoons cider vinegar
- 1/4 cup apricot preserves or apple jelly
- Kosher salt, to taste
How to Make It
- In a large saucepan or Dutch oven, heat butter over low heat. When the butter is hot, add onion and apple and cook, stirring, for about 7 to 10 minutes, or until soft.
- Add cabbage, black pepper, vinegar, and the preserves or jelly. Stir to mix well. Cover the pan tightly and simmer slowly over low heat for about 1 to 1 1/2 hours, or until cabbage is very soft and tender.
- Add salt to taste.
Tips and Variations
- Cook 2 to 4 slices of bacon. Drain, crumble, and then toss with the cabbage just before serving.
- Add 1 teaspoon of caraway seeds to the pan along with the cabbage.
|Nutritional Guidelines (per serving)
|Total Fat
|12 g
|Saturated Fat
|7 g
|Unsaturated Fat
|3 g
|31 mg
|135 mg
|32 g
|Dietary Fiber
|10 g
|5 g
(The nutrition information on our recipes is calculated using an ingredient database and should be considered an estimate. Individual results may vary.)


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Watch Montgomery Week in Review (VIDEO)
Don Mooers hosts the latest episode of Montgomery Week in Review. His guests include Dr. Carol Garvey, Jenny Crawford, Jessica Fuchs and Barbara Goldberg-Goldman.
Topics discussed this week include the gap in life expectancy between rich and poor, the National Children's Mental Health Awareness Week, the upcoming Traumatic Brain Injury in Veterans seminar for mental health professionals and the upcoming Affordable Housing Conference.
You can watch the show in its entirety, below:
Montgomery Week in Review airs on Montgomery Channel 21 Thursdays at noon and 8 p.m.; Sundays at noon and at 1 p.m. on Mondays.


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- Worldwide Rank #222,909,901
- Follower/Following Ratio 0.38
- Daily New Followers 0
はるさん Twitter Stats
@0116gaga - Tracking はるさん Twitter profile since August 21, 2014
はるさん's story
はるさん, also known as @0116gaga has a reasonably significant presence on Twitter and is ranked by us in the 30% percentile for account strength. Active on Twitter since December 2013, はるさん made it to having a respectable 3 Twitter followers and to being ranked 222,909,901 for number of followers among all Twitter users.
The plot thickens when considering はるさん's follower-to-following ratio, which is 0.38.
@0116gaga doesn't tweet all that much, with an average of 0 tweet(s) per day in the past 30 days. That's pretty consistent with a total of 13 since @0116gaga joined Twitter.
This account is tracked by us Only August 2014. As of August 14 2018 we track 290722354 Twitter accounts, so feel free to search for other accounts you're interested in and reveal their Twitter story!
はるさん Tweets
@0116gaga has posted 0 tweets in the last 8 days, which translates to an average of 0 tweets per day.
はるさん Twitter Followers
@0116gaga has 3 followers on Twitter.
This account is #222,909,901 in the worldwide rank of the most popular Twitter users.
はるさん Following on Twitter
@0116gaga is following 8 Twitter accounts.
Last month this account stopped following 1 users.
はるさん Predictions & Milestones
@0116gaga will hit 3 followers in the next 3 months, and 3 in one year.
You are on はるさん's Twitter stats page
We track these Twitter stats since August 21, 2014 . You can see how many followers はるさん lost or gained and what the prediction is for tomorrow or the next 15 days, together with all kinds of other stats like rank compared to all Twitter users, tweets etc.
Why don't you give it a try and compare はるさん to yourself ? Or if you are はるさん get even more feature rich & up-to-date stats with our premium Twitter Stats.
Twitter Counter is the #1 Twitter stats site powered by Twitter. It all started in June 12, 2008 and we grew rather rapidly because of our Twitter Counter badge. The button is a nice small image that shows your visitors how many followers you have on Twitter. Within a year the button was on many many blogs around the world and we displayed more than 100 million buttons in one month. We track follower stats for over 290.722.354 users now.


text: The Count of Monte Cristo is a 1934 American adventure film directed by Rowland V. Lee and starring Robert Donat and Elissa Landi. Based on the 1844 novel The Count of Monte Cristo by Alexandre Dumas, the story concerns a man who is unjustly imprisoned for 20 years for innocently delivering a letter entrusted to him. When he finally escapes, he seeks revenge against the greedy men who conspired to put him in prison.


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On the reversibility of transitions between closed and open cellular convection
The two-way transition between closed and open cellular convection is addressed in an idealized cloud-resolving modeling framework. A series of cloud-resolving simulations shows that the transition between closed and open cellular states is asymmetrical and characterized by a rapid ("runaway") transition from the closed- to the open-cell state but slower recovery to the closed-cell state. Given that precipitation initiates the closed–open cell transition and that the recovery requires a suppression of the precipitation, we apply an ad hoc time-varying drop concentration to initiate and suppress precipitation. We show that the asymmetry in the two-way transition occurs even for very rapid drop concentration replenishment. The primary barrier to recovery is the loss in turbulence kinetic energy (TKE) associated with the loss in cloud water (and associated radiative cooling) and the vertical stratification of the boundary layer during the open-cell period. In transitioning from the open to the closed state, the system faces the task of replenishing cloud water fast enough to counter precipitation losses, such that it can generate radiative cooling and TKE. It is hampered by a stable layer below cloud base that has to be overcome before water vapor can be transported more efficiently into the cloud layer. Recoverymore »
- Publication Date:
- Grant/Contract Number:
- Type:
- Published Article
- Journal Name:
- Atmospheric Chemistry and Physics (Online)
- Additional Journal Information:
- Journal Name: Atmospheric Chemistry and Physics (Online); Journal Volume: 15; Journal Issue: 13; Journal ID: ISSN 1680-7324
- Publisher:
- European Geosciences Union
- Sponsoring Org:
- Country of Publication:
- Germany
- Language:
- English
- 1213807


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Our Delegation once again returned to one of our flagship conferences: EuroMUN 2017!
6 of our dashing delegates had an amazing time in Maastricht, The Netherlands defending their respective countries' positions. Notably, two of our members successfully participated in the Joint Cabinet Crisis.
Outside of our dangerous little game in the Crisis Room, EuroMUN promised and delivered. I have always believed Maastricht to be one of the premium locales for a conference and stand by the society's decision to make it one of the flagship events our delegation attends every year. It provides a very enjoyable balance of debate quality, a beautiful city, a professional venue and amazing attendants. Despite some hiccups with both the suggested accommodation and the food provided during the conference, our delegation's experience was quite positive.
I for one can say I'm looking forward to attending next year!
– Arturo, Crisis delegate representing Portugal
See you next year!


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Faculty: Medicine
Potential Start Date: August 1 2017, with first rounds of interview beginning no earlier than July 17th.
Job Summary:
Full-time position to manage the behavioral core facility within Roger Guindon Hall at the University of Ottawa.
The Behavior Core Facility provides a state-of-the-art facility equipped to serve the research community at the University of Ottawa, its affiliated Research Institutes, as well as researchers across the scientific community. The Core provides a time-efficient and cost-effective service for the design, execution, analysis, interpretation, and presentation of data resulting from use of the Core's facilities.
The equipment enables a full battery of assays relevant to learning and memory, social behavior, sensory gating, motor function, and mood disorders. In addition, the core offers equipment in order to perform in vivo optogenetics, as well as measure various physiological outcomes using small animal telemetry (EEG, EMG, pressure) and non-invasive determinations of body composition and metabolic parameters.
The primary responsibility of this position will be to directly interact and train researchers to plan and execute behavioral and physiological testing in experimental animal models, including rats and mice. Other responsibilities include assisting the Director in managing the usage, acquisition and setup of equipment, fee structure, and planning activities to ensure sustainability.
Essential Qualifications:
PhD Degree in Biological Science or related field and/or minimum of 1-3 year experience as research technician or specialist
Practical experience in animal care and models
Experience using computer systems and software related to biomedical research
Excellent written and oral communication skills (prefer Bilingual in French and English) are essential due to the interactive nature of the position.
Support is in accordance with University of Ottawa standards and a competitive package of salary and benefits will be offered to the successful candidate based on qualifications and experience.
Qualified candidates should send a short letter of introduction describing their career path and previous expertise, CV, and the names of three references to: Christina Sardella (email@example.com)
Download a pdf version of this advertisement
Posting end date: 2017-07-14


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in this section
NSF CAREER Award, 2016-2021
The prestigious CAREER Program, which was launched in 1996, provides support to junior faculty members and encourages the combining of research and education. Applicants submit a proposal that includes research and education plans. Awardees receive various amounts of funding, typically ranging from around $400,00 to $500,000, for a period of five years.
Professor Singh received a 5-yr, 500,000 award from the Division of Materials Research, Biomaterials Program, NSF.
See more online: Cornell Chronicle


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House Leased
- About this property
1 Weeks Free Rent on Stunning Family Home with Private 1 Bed "Granny Flat"Property ID 1838622This stunning home is located in the heart of the blue ribbon suburb of Wilston, including 1 weeks free rent!
Upstairs features include
Open plan living and dining with polished timber floor boards
Fantastic spacious kitchen with ample storage and brand new gas cook top and dishwasher
Large second carpeted air conditioned living area featuring stunning french doors opening onto the deck
Three spacious bedrooms
Bed one features built in wardrobes, air con and fan
Bed two features built in wardrobes and fan
Bed three features built ins
Extra sun room, perfect to use as a home office or nursery
Neat and tidy bathroom with separate shower and shower
Separate toilet
Large spacious laundry with ample storage
Entertainers deck with sensational city views
Storage shed
Double carport
Downstairs Features
Completely separate granny flat featuring the below
Fourth bedroom is spacious with tiled flooring and built ins
Great sized air conditioned living area, perfect as a teenage retreat
Kitchenette with ample storage and double sink
Good sized courtyard, perfect to catch the afternoon sun
Great sized yard, perfect for the kids - FULL garden maintenance included
Extra features
Wilston primary school catchment area
Internet high speed cable available, up to 100Mbps
Air conditioning upstairs and downstairs
VJ Walls and high ceilings throughout upstairs
Solar Photo voltaic System
Solar hot water system
Freshly painted throughout
New carpets throughout
New curtains throughout
Excellent storage facilities throughout the entire home
Sensational city views (east and north)
Plenty of off street and on street parking
Close to public transport, ICB, Clem 7
Just a short stroll from the Wilston cafe strip and a quick drive to the local shopping precinct, a home of this calibre will not last long. Book now for an inspection!


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Meeting at Berlin Lodge in Pouch Camp, Seaview, the Aquehonga District Committee of the Boy Scouts of America held its monthly meeting on Tuesday evening. It was called to order by Chair AnneMarie Borriello.
Rich Ricco, District Commissioner, said that the commissioners were working with units to make sure all Youth Protection courses are being completed. Leaders should have received an 18-month calendar from GNYC. He urged leaders to both use the calendar to avoid conlicts and to located training opportunities off-Island when Scouters cannot attend local courses.
The Camping committee reported that overall more Scouts went camping this past summer than in 2013. They also reminded attendees about the specialty camps that might be of interest to more experienced Scouts. Possible future improvements to Pouch Camp were also discussed.
It was noted that a new website will be coming on-line shortly to replace the current Aquehonga website. Margaret Collord was thanked for coordinating the effort.
There are many activities coming up, including the Webelos-a-ree October 17-19, the Order of the Arrow Ordeal October 24-26, the annual Ghost-a-ree for Cub Scouts & siblings on October 25 (new location – the Camporee field opposite the JCC,) and Scouting for Food on November 8. There are also training courses, including Cub Leader Specific on November 1 and BALOO on November 15. December will be the Bowl-a-thon and the Pouch tree lighting. Klondike Derby planning is already well underway for the February event. It was also noted that Merit Badge counselors are available at the monthly Staten Island Geological Society meetings. Their next meeting will be Friday, October 10 at the Father Hicks Center at St. Clare's.
Eagle Board of Reviews continue to be held at the Richmond County Courthouse the first Monday of the month. Last night three Eagle candidates were examined, bringing the calendar year to date total to 41. Attendees were reminded that any Eagle candidate that began his work in 2014 must use the 2014 workbook and application forms.
The Catholic Committee noted that Cub Scout workbooks for the Religious emblems must be turned in by the December 8 Roundtable, and the Mass will be on January 25. A one-day retreat is planned for January 24, and the Board of Review for Boy Scout Religious emblems is February 4.
For information about joining Scouting or about any Scouting event or program, contact District Director Greg Mustoe at (212) 651-2863. Information is also available at www.beascout.org. The new name for the local Staten Island Scouting website will be announced shortly.
The next District meeting will be November 4 at Berlin Lodge, Pouch Camp. The next District Roundtable will be this coming Monday – October 13 — at New Dorp Moravian Church.


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#TheHaloWay (noun): The passion, values and customs associated with Angels Baseball that affect all aspects of the lives of fans and players; A typical pattern of behavior when Angels Baseball is life.
#TheHaloWay signifies a common pride shared by our fans and our players that extends far beyond the diamond. Those raised on The Ryan Express, trips to Wally World and the '02 Championship Team have adopted #TheHaloWay of life - Win or lose, we remain devoted.
When you live #TheHaloWay, you don't just experience an incredible Mike Trout Catch or helmet nachos. You experience the common thread that brings us together as a family, a love of the game that is passed down generation to generation.
When you believe in #TheHaloWay, in life as in baseball, you are rooted in tradition, you are compassionate, you put your team first and you are committed to competing with honesty, respect and a desire to win, whether you are on or off the field.
Baseball is more than just a game. It's a way of life.


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Things to Do
Greensboro is a vibrant community that offers a selection of cultural and entertainment options. Visit our downtown attractions and historic sites or take a self-guided walking tour of the town. Listen to podcasts of tall tales and local lore. Plan to be in town for one of our exciting downtown events or take in a show at Festival Hall.


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Healthcare – Its Personal
The Great Healthcare Debate
Healthcare is personal and front and center in our minds not just because we all intersect with it in some way but it employs 1 in 9 people in the United States. With the current state of our media and political system with polarized debates, he said she said talking heads on the media, the echo chamber of social media and the 24/7/365 barrage of news and fake news it can be hard to see a pathway out of the quagmire we find ourselves in. But we all want to see that path. I just don't believe that people get up in the morning wondering how they can decimate the healthcare services and the lives of their fellow human beings. We don't get up out of bed every day wondering how best to punish people who may have made bad choices in their lives or who find themselves in unfortunate positions though geography (the zip code effect) or genetics. I know I don't and I don't think you do either.
Yet the stream of coverage and what we read, see and hear online and sometimes even in person suggests that this is the case. I can't answer the reasons why but I've read a string of articles and reporting that variably suggests its always been like this to this is the fault – and then insert the name of your favorite whipping horse. Ultimately it does not matter – unless you believe that people wake up with malintent every morning it's better to start with an understanding of the problem and then thinking about possible solutions and how we can apply them quickly and effectively
So Let's Start with some of the fundamental problems in our healthcare system – to be clear we are not alone in the world. I have seen and heard from many others in different countries who are all struggling to varying degrees and with different focus and priorities the same issues. If I had to boil it down to one issue I would say
It's a familiar equation to anyone trying to balance their budget or allocate their time. If you are like me you may find there are just not enough hours in the day for the task list you created in the morning and wishing either to stretch time (time dilation) or perhaps be able to turn time back with the Wizarding world's Time Turner. There are two basic options available – reduce the inputs or reduce the outputs. In the vernacular of budgeting – either spend less or make more money. Both may be viable and depend on personal circumstance but undoubtedly there will be easier and harder solutions. Ultimately we all have to make our own personal decisions – so one solution or size does not fit all.
It would be foolish to suggest that this covers all the complexity of the healthcare system as we all know healthcare is incredibly complex and always reminds me of the game Jenga.
This does not cover everything and there are many other elements in play but it is certainly a start and one that individuals and organizations can focus on to start to make incremental improvements.
As one Chinese proverb states:
Every journey starts with a single step
And turning that step into a habit is one of the best ways of setting a path to improvement.
Demand Side of Healthcare
This is the access and use of the system and the burden does not just fall on the individual. But it does start there as it is out personal choices to access and use available services that creates demand. Historically in the United States, the cost and payment of this access have been disassociated from the individual. When you visit the doctor or pharmacy you don't pay the actual cost of the service – your insurance carrier does. Ultimately we do all pay for this through our insurance premiums and for many the contributions made on our behalf by our employer that is part of the compensation we receive for working for them but at the point of care, we are disconnected from the price and cost of a service.
Patient Accessing Care
To a varying degree individuals have some form of co-pay – a personal cost that is defined by the insurance coverage and is shifting increasingly to the individual under the new insurance plans called High Deductible Health Plans (HDHP). One of the intentions of this policy is to make the individual responsible for this cost in an attempt to influence behavior and decrease unnecessary access. But this comes with the inevitable unintended consequences with cost avoidance strategies by individuals who knowing they will be held responsible for the full cost of a visit, drug or test may elect to decline to have or use the service.
I'd count myself in that crowd having been on a HDHP plan for several years. I can point to several decision where I have declined tests, treatment and access to care because of the nature of my personal responsibility – I have an associated health savings account (HSA) which should cover the capped amount of cost for the year. But the crippling nature of potential costs associated with a catastrophic medical problem – a serious accident, cancer, heart attack are all so terrifying that I see the HSA as a buffer against the potential of medical insolvency that might result especially when you consider the impact on a family with one source of income that would be impacted by any medical disability.
Insurers Paying for Care
Insurers want to reduce their costs – and even the non-profits have to make money so are focused on the bottom line if they want to continue to serve their customers and population. So they look to find ways to reduce the unnecessary access to care imposing barriers and limits. There was a gate keeper concept that requires a referral letter from a primary care physician before you can access s specialist – that service by the way costing you additional fees to see the primary care provider. There are formulary requirements that exclude certain drugs from coverage and attempts to limit access to specific doctors and networks to strengthen the buying and negotiation power of the payor with the providers in the system.
Providers Delivering Care
On the provider side the clinal professionals delivering the care all arrived at this point having selected the expensive assault course of education to train and qualify to be able to deliver care. For doctors, it's persistence and endurance that win out. The barriers to entry are high and tied to economics. They all have the same desire to help patients – but economics and the burden of the educational system can overwhelm just about anyone and they have bills to pay both for their education but also the infrastructure they must use to be able to both deliver care but also bill and be paid for delivering. They want to reduce their overhead and spend as much of their time and resources on the delivery of care but to survive in the system must allocate significant amounts of money to non-clinal systems and activities. Estimates of these costs suggest that at least 30% of the healthcare costs we as a society pay in the United States are tied to administrative and billing functions. The data's still lagging but projections for 2016 put the total healthcare bill at $3.207 Trillion (thats $3,207,000,000,000 or more than $10,000 per person in the USA)
Reconciling the Differences
The difference of opinion often centers on what is unnecessary – in the eyes of the patient they need and want the care they think is appropriate to them. Some of this is fed by a constant stream of information that even for an well informed clinically experienced specialist can be difficult to comprehend and make informed decision. We want wants best for our personal health and the health of our family and loved ones. But sometimes what the patient may think is best may not be – a great example is the steady stream of requests for antibiotics for treatments of minor infections. Not every sore throat or cough demands the use of antibiotics and in fact, in many cases, their use is damaging as we face a future where this line of defense is increasingly being overrun with smartly adaptive bacteria who develop resistance with terrifying speed.
Payors Perspectives
The same is true of payor and insurers – they face a rising tide of costs associated with care that is increasingly complicated and expensive and struggle to balance their budget.Faced with one patient who's costs for treatment might be hundreds of thousands of dollars or more so they limit or decline this in favor of treating multiple other patients where their cost of treatment is thousands of dollars or less? The utopian answer is treat everyone but we they like each of us do not have unlimited budget or resources and have to make hard decisions. And the problem with healthcare fundedfor the population but access individually.
Clinicians Perspectives
Clinicians also have a view on what's appropriate – and the vast majority act with total integrity (I would like to say all of them but sadly there are occasional stories of clinicians and healthcare professionals who game the system – sometimes with simple prescription based fraud or other times over treatment of stenting in cardiac cases). Sadly for a profession that is so dependent on trust the rare cases of fraud and abuse unfairly tar everyone with the same brush. As I said above – I believe everyone gets up in the morning with the best intentions and this is true of the clinal professionals who each and every day battle a system to deliver the care and compassion they set out to deliver when they took the path into healthcare. They want to say no to unnecessary treatment but the personal pressures applied and the underlying compassion and the innate drive that was the foundation of why they entered the profession can influence them to order and prescribe because they are unable to explain the lack of value and offering this option makes their patient happier and comfortable.
So how do we reconcile these differing opinions
Economics and Making Choices
There's a sad fact in the US healthcare system – we do not talk about cost effectiveness. Its not just a taboo subject but also a forbidden topic, As Aaron Carroll (The Incidental Economist) noted in his piece Forbidden Topic in Health Policy Debate: Cost Effectiveness we avoid talking about cost-effectiveness in the United States.
Some think that discussing cost effectiveness puts us on the slippery slope to rationing, or even "death panels."
As he points out – if there was a pill available that could extend your life by one day but costs a billion dollars, most would accept this as an unacceptable trade off and decline it. But that' extreme – as you decrease the cost where does that line become blurred?
what's to stop us from deciding that spending a couple hundred thousand dollars to extend grandma's life for a year isn't worth it either?
More troubling is the shackles that have been placed on the Patient Centered Outcomes Research Institute – who were founded but explicitly prohibited it from funding any cost-effectiveness research at all! How can an outcomes institute assess healthcare if cost effectiveness is not part of the equation?
"We don't consider cost effectiveness to be an outcome of direct importance to patients."
In fact, we in the United States are so averse to the idea of cost effectiveness that when the Patient Centered Outcomes Research Institute, the body specifically set up to do comparative effectiveness research, was founded, the law explicitly prohibited it from funding any cost-effectiveness research at all. As it says on its website,
PCORI was established to fund research that can help patients and those who care for them make better-informed decisions about the healthcare choices they face every day, guided by those who will use that information.
Quality-Adjusted Life Years
As he points out there is actually a fairly robust strategy and measure that can offer insights into the value of measuring health outcomes – QALY's (Quality-Adjusted Life Years) which the National Health Service has been using fro some time in the National Institute for Health and Care Excellence (NICE) that provides guidance, advice, quality standards and information services for health, public health and social care. Also contains resources to help maximise use of evidence and guidance. There is no doubt they are imperfect but very little in life is perfect and perfection should not be a barrier to progress. The use of this is not a sole determinant – but offers some measure of science and data to making what are incredibly difficult tdecisions
So in the current debate of what health system we need to put in place I would advocate the inclusion of cost effectiveness as one of the factors that must be considered and the QALY and perhaps even the Incremental cost-effectiveness ratio (ICER) as part of this difficult discussion.
I'm all about incremental changes and while including a cost effectiveness as a measure may seem a bigger stretch I feel it is a smaller step in the right direction. Can we achieve this? Is there a better incremental step we can take to resolve the challenges of our healthcare system? Leave your thoughts below.
Healthcare – Its Personal was originally published on Dr Nick – The Incrementalist
Patient Centered Systems
What will it take to move our healthcare system to a truly patient-centered system? We know based on multiple data points that engaged patients have a big impact on the successful outcome of treatment. Leonard Kish cited the phrase back in 2012
Patient Engagement is the Blockbuster Drug of the Century
Referencing a 2009 Kaiser study of coordinated cardiac care and comparing to those not enrolled in the study
"patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program."
"clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent."
And this study in Telemedicine and e-Health. Dec 2008; Vol.14 (10): 1118-1126 that showed impressive results for chronic disease management:
- 19.74% reduction in hospital admissions
- 25.31% reduction in bed days of care
- 86% patient satisfaction
- $1,600 average cost per patient per year, compared to $13,121 for primary care and $77,745 for nursing home care
- 20% to 57% reduction in the need to be treated for the chronic diseases studied, including diabetes, COPD, heart failure, PTSD, and depression
Patient Data Ownership
I believe as do many others that the patient is at the center of everything we do and deliver in healthcare. By placing the patient and their information at the center of care and allowing them access and control we empower them and enable a model that moves away from the historical paternalistic delivery of healthcare to patient-centered and enabled care. It does come with challenges since many people contribute to that care and the current administrative and financial configuration focus the management and ownership of data with providers, healthcare systems and payors. While many patients want access to their data and some even want to own and manage it, many do not and are ill equipped to be responsible for this data. Perhaps what we need are some independent services and providers who aggregate, manage, secure and maintain patient data on behalf of patients – much as banks do with our money. There was some hope when Google and Microsoft jumped into healthcare offering Google Health and Microsoft Health Vault respectively. Microsoft's version continues to this day – google withdrew theirs and Sergey Brin was widely quoted when he said
"Generally, health is just so heavily regulated. It's just a painful business to be in, I think the regulatory burden in the US is so high that think it would dissuade a lot of entrepreneurs."
But while complex, not insurmountable and as he rightly points out
"I am really excited about the possibility of data also, to improve health"
I am too and while there remain many challenges associated with securing and sharing that data the "entrance" of these alternative participants into the healthcare space – some perhaps looking at this from a simple employee perspective, is an opportunity for new ideas, insights, and people applying the collective brain power to one of our most pressing problems. I continue to hear from colleagues and friends of companies that are exploring and looking at healthcare. UPS highlighted their healthcare focus and the potential for 3-D printing in a recent tweet:
@drnic1 Can #3Dprinting help address the issue of rising #healthcare costs? UPS believes it can: https://t.co/nqFG67jKB1
— UPS (@UPS) April 9, 2017
And I heard from a friend that Dyson even has a healthcare "focus".
Protecting Patients
There are some major concerns as these data-focused companies offer access but do so with agreements that contain so much legalese as to be unintelligible and opaque to the consumer who may well be giving up much more than his own personal data but potentially giving up his future health. The GINA act offers some protection to individuals who in sharing personal genomic data that tag them with a "pre-existing' condition could have found themselves unable to access care. But the act did not go far enough failing to address the issue of other insurance and employers who can use this data to deny access or coverage and perhaps even employment?
We need the combined power of this patient data to create the insights into diseases but not at that personal expense. There are many technologies on the horizon that offer a potential path to help achieve this and blockchain represents an interesting innovation of decentralized secured data that offers individualized control and dynamic revocation options for access. If you are interested in learning more about Blockchain this article in HealthcareIt News is a good primer for its potential in Healthcare: How does blockchain actually work for healthcare?. It is not a panacea and the fundamental rights and ownership still need to be addressed without giving away the farm to corporations and businesses.
The existing healthcare system incentivizes behavior that is in opposition to a scalable nationwide vendor neutral interoperable patient-centered data. Our model has multiple groups who have a vested interest in the control and ownership of data (for example Payers, Providers, Patients and even employers). Each has their own economic and commercial drivers and in many instances, these do not coincide with open sharing of data. In a system that is driven by activity and delivering care (Fee for Service) sharing data could mean a reduction in work and income. Until our reimbursement system moves to a more holistic care model that focuses on wellness and outcomes and incentivizes behavior that delivers better health and outcomes for patients through cooperative and coordinated care and ultimately equitably rewards all the contributors to these outcomes we will remain stuck in the quagmire of limited interoperability.
The key to a patient-centered interconnected care model is the free flow of data between all the areas responsible for delivering care. We moved away from the single index card medical record held by your personal physician who was the focal point of care and care coordination to a distributed team-based model of care that encompasses multiple areas and people. In some instances, thatcher coordination may be carried out, at least in part by the patient or their family members, and they need to be included and ultimately in control of the data and its flow. The only way this team can deliver excellent care is through the frictionless flow of enhanced data and knowledge. This information flow must include the patient and all their family members that are authorized, interested and engaged in their care. Data should be shared with the patient's consent with everyone concerned and available for as long as it is needed to deliver care but this access should be flexible enough to allow it to be revoked or removed when it is no longer needed or necessary
Welcome to the Fray
I am a big fan of learning from other industries and perspectives and spoke about this at HIMSS Conference in Orlando
The Best Exotic Marigold Hotel and I am excited to see the rush of companies and people into the healthcare space but for those stepping in and thinking about data and the ownership and control of this data, I would suggest this requires a new way of thinking. Much like security – patient access and control needs to be baked in from the start. Taking ownership and rights away from patients will stall progress and anger your constituents and community. As ePatient Dave would say or better yet sing:
Give me My Damn Data
Here's hoping that these new players see the value of the engaged patient and include some of these principles in their march towards our common goal of better more cost effective healthcare. For the large organizations thinking about the data, remember you and your family members are patients too. The following thoughts are offered as some basic guiding principles on data stewardship:
- Patients want control of their own data,
- Patients want to be able to share safely and securely share their data with all their care providers and participants (this will include family members and friends)
- Patients want granular control of some elements of the data limiting individual access to certain elements and areas
- Patients requires a full audit capability tracking who has access and has accessed their data
- Patients want to be able to easily and dynamically revoke access
- Patients will share their data for research and benefit of others but their contributions need to be recognized and accounted for
- Data cannot be used against Patients to deny coverage or increase their costs
What have I missed – what controls or limits would you place on your data that would make you more willing to share your data. What would stop you from sharing your data and why?
Patient Centered Systems was originally published on Dr Nick – The Incrementalist
Wise Up to Hidden Healthcare Fees
It's perverse but the healthcare system in the United States is making you sick. Don't believe me – then maybe you have a high-end plan with no deductible and full access and no ceiling. But there are not many of those and for the rest of us, I imagine your interaction with the system is as frustrating and stressful as mine – probably on a spectrum depending on your plan (High deductible plan or the more traditional Preferred Provider Organization (PPO) and co-payments.
Fee for Service Healthcare
The cynical view might be this is deliberate since our system remains firmly stuck in a fee for service model – healthcare providers are paid to do something…anything. From its original development, this made sense – our capacity to treat conditions was limited and the cost of these treatments in line with our ability to pay for them. But along this journey science and in particular the incredible progress of medical research got involved and we have been on a veritable tear of progress and innovation, or as the Exponential Medicine group would say Exponential progress.
There is a continued push towards a more robust and accountable model – Accountable Care Organizations have been set up and these models of total care and coverage and responsibility tested for effectiveness and economic effect. There is lots of disagreement on the success or failure of ACO's and it is fair to say that the jury is still out. But intuitively we know that taking care of the complete picture and being responsible for the total care of patients health is better for the patient and for outcomes. I have seen it time and again where individual mandates or focus induce unwanted/unexpected/unintended consequences elsewhere in the whole system.
Discharging Patients Early – Unintended Consequences
Discharging patients from the hospital early typically results in better outcomes. Early programs that incentivized this behavior and rewarded programs that got patients out of the hospital early were deemed successful but failed to take account of the downstream impact of readmissions resulting from too early a discharge and subsequent complications for that patient that could have been avoided.
Fixing a Broken System
The recent book "American Sickness" by Dr Elisabeth Rosenthal "An American Sickness" takes on the existing system and is filled with strategies for patients faced with mounting medical bills, an intractable and aggressive healthcare system that is unflinching in seeking payment and by many estimates the leading cause of personal financial crisis and insolvency. While the figures remain under debate my own personal reality living with a High Deductible Plan that has found me
- Self-treating Fractures
- Becoming my own compounding pharmacy and
- Spending months and many hours fighting multiple bills
In the case of one screening procedure, that under the current regulations are fully covered but thanks to either mistaken coding or perhaps even deliberate coding, remains outstanding and in two of the three cases, the billing organizations despite my attempts at regular communications, response and protests were handed over to debt collection agencies.
So I am with Dr. Rosenthal and "breaking down the monolithic business".
The situation is far worse than we think, and it has become like that much more recently than we realize. Hospitals, which are managed by business executives, behave like predatory lenders, hounding patients and seizing their homes. Research charities are in bed with big pharmaceutical companies, which surreptitiously profit from the donations made by working people. Americans are dying from routine medical conditions when affordable and straightforward solutions exist.
Employer Sponsored Insurance
Central to the challenges is the arcane concept that you access to healthcare and health insurance should be linked to your employment. As one friend of mine commented, "There are some who believe this is a deliberate policy on the part of employers to lock in employees to jobs they may not want but have to take because they need the health insurance and can't afford the challenge or cost of changing (health insurance". I don't quite go down that rabbit hole and think Dan Munro's explanation in his great book "Casino Healthcare"
that detailed the history linked to the war effort and the need to find other incentives after they introduced: "An Act to further the national defense and security by checking speculative and excessive price rises, price dislocations, and inflationary tendencies, and for other purposes." (EPCA) in 1942 – wages were frozen to stop inflation but as is so often the case left the door open for unintended consequences that found employers looking for ways to compete for a shortage of labor. And as they say what follows is history – Employer Sponsored Insurance (ESI) was born.
History of the NHS
It is interesting to note that the NHS model was also a product of the war that found the wounded servicemen and women in need of healthcare. A need that was serviced by the "Emergency Hospital Service" (aka Emergency Medical Service) that provided a model and experience to the country that became the model for what is now the NHS established in 1946.
But whatever the history, reasons, and background – this remains a millstone around American's. It can add to job reductions and General Motors have stated that their employee healthcare costs add $1,500 – 2,000 to the price of every car they produce. It makes us less competitive internationally and crippling many with overheads that add to the cost of goods sold. It also puts employers at the table on healthcare decision making for their employers that present potential conflicts of interest given their need to service their share holders and remain profitable.
Finding a pathway to resolving this big intractable healthcare mess is going to take some major re-thinking and compromise on all sides. In the meantime, I suggest focusing on individual incremental approaches locally.
Incremental Steps to Coping With Healthcare
The list of 6 Questions to ask your doctor before your appointment and 5 questions to ask before you stay in a hospital are excellent resources from Dr. Elisabeth Rosenthal, that are featured in the book and on the website. So in the spirit of the incremental approach, I offer up two credit card size templates containing the
- 5 Questions to Ask During Your Hospital Stay
- 6 Questions to Ask Before Every Doctor's Appointment
Formatted in a handy Avery 5371 White Business Card Template that can be printed – double sided and put in your wallet: Questions When Using Healthcare Avery Template 5371
Do you have any tips or suggestions in dealing with the healthcare system? Disagree with any of this – feel free to leave your comments or reach out.
Wise Up to Hidden Healthcare Fees was originally published on Dr Nick – The Incrementalist
Digital Health for the Undeserved
A recent report published by Jane Sarsohn-Kahn for the California Health Foundation: Digitizing the Safety Net Health Tech Opportunities for the Undeserved offers some deep insights into reaching the population most in need of help but often left out in the discussions of the latest and greatest technology to break into the news cycle.
As pointed out low-income households have access to mobile technology with 8 out of 10 sending and receiving text messages – in fact mobile phone usage and ownership mirrors the experience in Africa where many of the communities have little choice given the paucity of existing infrastructure and have bypassed the traditional communications systems in favor of mobile networks
and gave rise to a whole innovation of mobile banking that originated that pre-dated, is more flexible and is more widely used than anything developed in the west (The M-Pesa system) – servicing the unbanked people of Africa without requirements to have a smart phone nor to use an app. I've written about the opportunity we have of learning from our African friends in the past)
In the case of the undeserved here in the US many of these people mirror these experiences and providing easy access using simple tools is effective not just from a cost standpoint (as Healthcrowd showed $1 for mobile messaging vs $34 for paper mailing) – and that's even before you consider the engagement/response rate we find with mobile applications and interactions…think about it, when you want to reach your children do you send them an email or text them
Take the time to read about the multiple projects that are reaping big benefits and doing so cost effectively. These are real working projects with a range of technology that has demonstrable impacts and could be applied to many more groups and environments. The extensive piece takes you on a journey from everything as simple as text messaging from Healthcrowd to the medication adherence and tracking concepts of Proteus Digital Health of digestible sensors that track your pill from manufacture to ingestion.
There are a few guiding principles to help steer you to success
- Meet people where they are – widely varied and none are typical
- Build Trust – under promise, over deliver; everything is fragile for this community and failure can be far more catastrophic for them than "average" users
- Address social determinants of health – just providing a ride to get to the clinic could mean the difference between success and failure and an Uber Ride is a lot more cost effective than an ambulance required for the crisis that could have been averted
- Consider the cost of data service – data is expensive on many plans treat it like memory used to be in the days of 640K
- Recognize the many layers of health literacy – not just comprehension but basic literacy and even language
- Speak in the Vernacular – and make it culturally sensitive too
As Aman Bhandari said
"The new sexy is scaling what can work"
Proven solutions that have been effective provide great opportunities for those looking to make that impact on their own area.
Digital Health for the Undeserved was originally published on Dr Nick van Terheyden, MD
Healthy Living Starts with You
Human capital – the stock of knowledge, habits, social and personality attributes embodied in the ability to perform labor so as to produce economic value.
When reading the above definition of human capital, a particular word jumps out… habits. I am passionate about habits because poor lifestyle choices—or bad habits—are the number one driver of today's health crisis. Chronic illnesses—such as heart disease, stroke, asthma, diabetes, and obesity—are responsible for 7 of 10 deaths each year, and treatment of chronic diseases accounts for 86% of U.S. healthcare costs. However, while they are among the most common and costly of health problems, chronic diseases are also the most preventable and manageable, because they often result from choices we make in our daily lives. To conquer chronic illness, we have to change our bad habits. And that's not easy.
If I had to prescribe one medication to cure bad habits, it would be patient engagement. When we are effective at engaging patients to participate in their care, they begin to take more responsibility for their own health and adopt healthier habits. Effective engagement of chronic disease patients can lead to reductions in hospital visits, decreased morbidity and mortality and improvements in treatment adherence and quality of life.
To truly influence positive behavior changes, health goals must fit meaningfully in patients' everyday lives. People must be surrounded by opportunities to embrace healthy lifestyles, and that requires the involvement of the entire community – care providers, governments, businesses, and of course, the people living there.
It's no surprise that 7 of the top 10 Future-Ready cities overlap with the American Fitness Index's list of healthiest U.S. cities. These developed cities are arguably some of the most connected and most educated, and they have infrastructure that supports recreational activity. But health is not only an outcome of development, it is a prerequisite for it, and never before have communities had such an incredible tool to engage people in making healthy lifestyle changes… technology.
Just as technology is giving providers more ways to care for and engage their patients in more places, it's also providing the means for governments to reach constituents, businesses to tailor wellness programs for their workforce, and people to take charge of their own health.
Care providers
Technology gives caregivers unprecedented opportunity to engage patients and provide excellent care, anywhere, while also giving both patients and doctors a valuable feedback loop. Telehealth, remote biometric monitoring, and technology-assisted health coaching are powerful tools in the fight to improve chronic care outcomes because they provide in-the-moment support to patients struggling with diet, exercise habits, and medication routines.
For example, an FDA-cleared mobile app that delivers real-time motivational messages, behavioral coaching and educational content right to the mobile devices of patients with Type II diabetes has demonstrated significant drops in their A1C levels.
Even simple text message programs can make a difference. Text2Breathe, a program of the Children's National Medical Center, sends care information and reminders to parents of children with asthma and has helped help reduce emergency room visits.
State and local government
State and local government agencies have immense power to use technology to spearhead healthy lifestyle and disease prevention programs. For example, in response to Philadelphia's high rates of chronic disease, city officials recently launched PhillyPowered, a multi-media campaign designed to encourage Philadelphians to become more physically active. The campaign features a mobile-friendly website, which lists free or low-cost places to get fit in the city, provides educational information, and includes a social media component that enables Philadelphians to share tips on how to fit exercise into their busy lives.
Portland University, in conjunction with the Oregon Department of Transportation, is piloting a smartphone app called ORcycle
designed to collect data and feedback about bicycle routes, infrastructure and accidents in order to improve infrastructure suitability for bicycling in Oregon.
Businesses suffer from the impact of chronic illness through absenteeism and retention problems, yet they are uniquely positioned to promote healthy lifestyles for workers and their families. Employers can work with their health plans to identify need for wellness programs and services such as preventive screenings, tailored to lowering both health risks and costs.
Companies are increasingly integrating technology into their wellness programs. For example, Dell's Well at Dell program includes a virtual wellness portal that imports numbers from onsite health screenings and provides employees with an action plan, educational information, and email and text reminders to stay on track. Some companies are adopting wearable technology as part of their wellness programs to incent employees to get fit. It is worth noting that data security and privacy is paramount to protect employee health information and need to be designed in as part of all of these initiatives to maintain the trust that is essential for an effective healthcare system.
Technology today gives communities in all geographies the means to invest in the health of human capital and very real opportunities to shape the future of healthcare… now.
This article previously appeared on Future Ready Economies site
Healthy Living Starts with You was originally published on DrNic1
Doctors and Patients – Who Knows Best
The Power of Knowledge
Life has changed and access to information is no longer the definition of value – we have seen these changes in the past as far back as 1494 when the printing press was introduced making books and knowledge more widely available:
And proceeds through newspapers, the steam engine, photography and the death of painting, the telegraph, movies and the death of theaters, the telephone, phonograph, radio, television, computers and the internet and if anything the speed of change is accelerating. So too in medicine have things changed with a shift away from paternalistic experts to wide knowledge access and cooperative systems of healthcare delivery.
The Sorry State of Medicine
But the physician is still a key part of healthcare delivery and for many in the profession there is a sense of despondency and even despair with profession and their ability to deliver the care they aspire to deliver each and every day. This recent piece in the Wall Street Journal Why Doctors Are Sick of Their Profession captured the spirit – only 6% of doctors surveyed describe their morale as positive and that's not just bad for the doctors – its bad for patients too.
The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade
Physician suicide remains high with doctors the most likely to commit suicide with a rate of 1.87 times that of the average population (the US alone loses ~400 physicians to suicide per year) and their "success" measured as a completion rate is far higher than the general population (x 1.4 – 5.5).
As this piece The Painful Truth: Physicians Are Not Invincible highlighted (South Med J. 2000;93(10) ):
Physicians fulfill a special role within our society. While they are given many privileges and rewards, they also carry serious responsibilities. Physicians are expected to be healers, available to others whenever a crisis occurs or a medical need arises. They are expected to have unfailing expertise and competence, to be compassionate and concerned, and to provide universally successful care in a cost-effective manner. Such idealized expectations emanate from patients, from families, from society (including payers and regulatory and accreditation agencies), and from within the profession of medicine itself. Self-imposed expectations inhere in the institutions of medicine — medical colleges, clinics, hospitals, professional associations, and collegial relationships — and are internalized by students of medicine as they are socialized to become practicing professionals. These expectations become a part of how physicians define themselves.
So when I came across a picture of this mug:
I posted it to my social media feed with a commentary
Great reminder for #RSNA15 of the value of clinicians in #healthcare pic.twitter.com/Mew9Rkg836
— Nick van Terheyden (@drnic1) November 30, 2015
I wanted to highlight that clinicians are still an essential part of the healthcare system and their contributions are valued. This mug captured a strength of feeling that caught me by surprise.
It is available for purchase from a British eBay store and has been subject to several posts including this one from ePatient Dave – here and here and plenty of likes, dislikes, tweets, and even some fairly hefty criticism including one comment about starting a holy war.
Doctors Under Siege
I know many of my colleagues feel besieged. The system has drained every last ounce of empathy and compassion out of many with overhead requirements that detract from direct patient care and turn highly qualified, talented and well intentioned clinicians into data entry clerks and automatons. I have always believed and still do that every clinician gets up in the morning with all the best intentions to deliver high quality, compassionate car. There may be a small percentage of individuals who do not but if they exist are a tiny minority.
We selected the career because we care. We selected the career because we want to offer support and compassion to our fellow human beings. We get our reward from these actions and there is no replacing the privilege of the trust that is placed in our hands in a personal and intimate relationship with our patients.
To get into medical school required an incredible climb up an academic mountain that was littered with others who did not make it. The experience tends to reinforce the sense of importance and verges on narcissism for some as the course and hurdles demand a level of self confidence in our own skills and knowledge. It is little wonder that what emerges from the medical school sausage machine can appear devoid of compassion, over confidant and unwelcoming of other opinions. It is any wonder that there is any compassion left by the time a doctor emerges with his degree and board certification – and that's before he steps into a the healthcare quagmire and finds himself unprepared for healthcare as it is delivered today.
But many patients and patient advocates perceived this negatively and as an affront to their place in participatory care. The perception from patients appeared negative and there were multiple reports of patients who had been blocked when bringing information to their doctor and Dave even cites the sad instance in the UK of the 19 year old girl who had fibrolamellar hepatocellular carcinoma (a rare cancer that with ~200 cases diagnosed worldwide annually) that was treated and then returned. Despite her pleadings to the contrary the Hospital and clinical team refused to believe her and told her to "stop googling"
There were even a few physicians who saw this mug negatively – as Bryan Vartabedian a pediatrician at Baylor said:
This mug reflects a dated mentality https://t.co/cUeELJOtUZ — Bryan Vartabedian (@Doctor_V) December 1, 2015
and he posted this piece "Doctors and the Google Threat". I don't disagree with him that information access brings huge value and makes healthcare more accessible to a wider population but the systems in place don't support the time aspect that this new sometimes unfiltered and unscientific data brings to many of the clinicians I talk to. One of the main challenges with this was captured by one friend who said:
You came in to see me with 9 minutes of reading material but I only have 7 minutes of time to care for you
And James Legan said:
@jimmie_vanagon @drnic1 @tugger723 Web is a blessing & curse tons of info but w/o med training more noise than meaning — Jim Maughan (@tugger723) December 1, 2015
And the deluge of information that arrives on everyone's phone is replete with snake oil and pseudo science oftentimes amplified by celebrities who's impact with their millions of followers can be incredibly damaging to individuals health.
Dave did take a constructive approach to the participation of patients
I personally am completely opposed to a patient going in and saying "I've decided I have condition X, and I want you to prescribe 42mg QID of medication Y." I mean, have you ever seen the things medical students have to learn to get their license?? But I'm all in favor of a patient saying, "I have symptoms A and B, and from what I can tell from websites J and Q, that sounds like it could be M." Explain your thinking, identify your source, and try to solve the diagnostic puzzle together: Collaborate.
While there are still doctors who see this as a challenge to the traditional model of care and the paternalistic distribution of knowledge and care, most do not. I leave it with these two tweets that for me captured the underlying spirit I felt when I posted the original image:
@drnic1@tugger723 I like to google with my patients at the point of care with #ProjectedEHR a great place to meet on common ground– — James Legan MD (@jimmie_vanagon) December 1, 2015
and this one
@harshybar @drnic1 you're absolutely right and I love when my #patients are informed and ask questions #imaging3 — Geraldine McGinty (@DrGMcGinty) December 1, 2015
Everyone on the Same Side
Most physicians say the best part of their jobs is taking care of people – its the human moments, the taking care of people that make our jobs so satisfying. We are all on the same side – the structure of the system forces behavior that is not always ideal but despite this physicians do want participatory interactions – we love patients, especially ones that are engaged in their own health and care and we do not (and cannot) know everything.
You may well bring information to us that we are not aware of or have not read or heard about and we hope there will be enough time and opportunity to review this and help include scientific knowledge, no matter the source, in our review and guidance on the best course of treatment for you.
Doctors and Patients – Who Knows Best was originally published on DrNic1
Personal Healthcare Management
This piece by Aaron Carroll detailing his personal experiences with the healthcare system for what should be an easy and simple activity represents the frustration and challenges everyone faces on a daily basis including myself
I have the exactly the same challenges with renewal of what is a long standing formulation
I know this is not good for anyone and as pointed out it is not good for personal health – in my case as my wife and family will attest it definitely raises my blood pressure as I spend countless hours on the phone fighting with systems.
Everyone's story will be different and in my case I don't love the drug company who have taken long standing medication mixed them in a standard way and patented this to make it extraordinarily expensive for a formulation that contains one over the counter medication (OTC) and one generic prescription medication. And because of the artificial limits placed on supplies (90 days supplies with a maximum 1 year) behavior is modified attempting to reduce unnecessary costs. Ultimately everyone is behaving in the way the system incents.
Imagine that experience in the store – CostCo refusing to allow you to buy your supplies in bulk limiting your purchase to 3 months supply of toilet paper
and having to keep going back to an external party to require approval for purchasing when CostCo offers a special deal to purchase 12 units that might cover you for a year. Costco want you to purchase more and if you have the space and storage and will use it you want to buy in volume because it saves you money and the manufacturer wants purchasing their product. Costco is focused on making the process and cost as efficient as possible.
Before the deluge of complaints that buying drugs is not the same as buying toilet paper – true but take many maintenance drugs with excellent efficacy and safety. Even if it does require regular blood tests forcing the workflow to link the two in an sequence that tortures everyone in the process makes no sense. Engaged patients want an efficient process, will follow sensible and safe treatment guidelines and don't need to be squeezed into a sequential process that includes steps that are linked for clinical reasons but remain disconnected in real life and difficult and expensive to follow for everyone concerned
As the costs shift to the individual the frustrations rise with the process and the necessary costs and waste – expect a rising voice of complaints and frustrations that might hopefully start to effect change
Personal Healthcare Management was originally published on DrNic1
Dunkirk Spirit: How physicians support patients overcoming adversity
One in eight U.S. women will develop invasive breast cancer over the course of her lifetime. In 2014 alone, an estimated 295,000 new cases of invasive breast cancer are expected to be diagnosed. That's approximately 808 cases per day.
But these statistics don't matter. Whether it's one-in-eight or one-in-3 million, the impact of the illness is what matters—not the numbers. It immediately becomes a reality to you. We can never forget that healthcare is personal, something my colleague, Melissa Dirth, articulated beautifully in her recent post "When 1 in 8" was no longer just a statistic to me."
As a physician, sharing unfavorable findings and test results is always a sobering moment, no matter how many times you've done it before. We all struggle to find the right words, and look for ways to be supportive as you allow your patient to handle the shock that accompanies such news. We all have different viewpoints and our perspective on the disease is colored by our own life experiences and the individual circumstances.
What never ceases to amaze me, however, is the strength of the human spirit. Despite the hard road stretching before them, so many of our patients face breast cancer with what the British would term "Dunkirk Spirit," that inner strength that helps patients and their families overcome tremendous adversity.
|Dunkirk Spirit
It is, in my opinion, one of the reasons that make cancer sufferers and survivors such an important and compelling tableau of courage.
Unfortunately, one of the essential elements that quickly becomes lost in the morass of technology is the Art of Medicine, and our ability as doctors to spend the time focused on our patient and their relatives. As clinicians, we intuitively know the statistics associated with the disease and can interpret them to understand the impact the diagnosis we have just communicated with the patient is likely to have, but there is so much more to providing care. We don't just treat the condition, the physical body—we are caregivers and healers, and we seek to help the whole patient.
Technology can help in healthcare, but it is not the goal nor should it ever be the focus. Yet, in some cases, it has detracted from our ability to provide care and compassion. To deliver on the promise of great healthcare we have to return to the Art of Medicine and enable, not disable, our clinicians with the technology we develop.
To learn more about the role technology plays in the Art of Medicine, read: "There's no room in technology in end-of-life care decisions"
This article originally appeared on WhatsNext: Healthcare


text:
Police: 19-year-old's overdose death highlights growing heroin problem in Maine
Augusta man, who graduated last year from Cony High School, was found dead in McDonald's bathroom, police say.
By Craig Crosby email@example.com
Staff Writer
AUGUSTA — Jordan Ellis couldn't sleep. Listening to his uncle, the career military man, all of a sudden Ellis had a vision of his future, the one he'd been chasing without ever getting closer.
Leslie Ellis comforts her daughter, Amber, Wednesday at their Augusta home as they grieve for their son and brother, Jordan Ellis. A 2012 Cony High School graduate, Jordan died last Friday in Augusta from a presumed heroin overdose.
Staff photo by Andy Molloy
2012 senior photo of Jordan Ellis.
Contributed photo
Ellis believed the Army would bring it all within reach. He couldn't wait to tell his mom and sister.
"Finally we said, 'You have to get up at 3 tomorrow morning. You have to go to bed,'" his mom, Leslie Ellis, recalled Wednesday. "He came into our room and gave Amber and I both a kiss and said, 'I love you guys.'"
Less than 24 hours later, 19-year-old Jordan Ellis was dead. He died, police and Leslie Ellis believe, of a heroin overdose.
"The last text I got at 6:35 p.m. was, 'I'm on my way home,'" Leslie said.
Jordan's final moments were spent inside the bathroom at the Bangor Street McDonald's restaurant,
Article source: http://www.kjonline.com/news/Suspected-heroin-overdose-highlights-growing-problem-in-central-Maine.html


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Cllr Joe Caluori, Executive Member for Children, Young People and Families, blogs about how Islington Council is improving education and social mobility in the borough
Yesterday (22nd November) in Parliament, Labour MPs led a debate on education and social mobility. According to a recent report, Islington has a child poverty rate of 38%, one of the highest rates in London. In Islington, we know how important a high quality education is in determining the life chances of young people.
In order for our young people to unlock their true potential, education is the key to helping young people exceed the educational achievements of the parents and move out of poverty.
Since 2010 Labour-led Islington Council has made education one of the centrepieces of our vision of creating a fairer, more equal Borough. In Islington we have seen rapid improvement in educational achievement. Not too long ago 70% of parents chose schools outside Islington, but now that statistic has been reversed.
Islington's primary schools are in the top 10 in the country for helping children from poorer backgrounds achieve good results. GCSE results in the borough have massively improved in recent years, meaning more young people living in Islington have the chance to go on to further education or enter the world of work with the skills they need. All of our secondary schools are rated 'Good' or 'Outstanding' by Ofsted.
Islington is ranked fifth in the Government's Social mobility Index, which shows our hard work is paying off. However, there is no room for complacency. The aim of increasing social mobility through education is challenged by Government policy.
The Social Mobility Commission recently warned that low and middle-income families are being held back by a "deep social mobility problem", pointing to an unfair education system, a two-tier labour market and unaffordable housing as key causes. These are also areas that the Tories have done nothing to address, and even worsened through their own policies, in recent years.
The cost of housing plays a significant role in child poverty and social mobility. This is why Islington Council has pledged to deliver a further 2,000 affordable homes, including 500 council homes by 2020. We are also actively campaigning against the Tory Government's Housing and Planning Act, which will force councils to sell off housing stock and make finding an affordable home in Islington harder.
Government policy on Housing will increase overcrowding, which is already a huge problem for us. Imagine trying to do your homework or revise for exams in a two bedroom flat with two siblings and parents.
We will continue to fight to remove any barriers to our young people reaching their true potential and take action to provide the jobs, housing and education that enables people to live a life beyond the parameters of the one they were born into.
Public meeting on Ladbroke House
As the DfE have no plans to consult the community over their controversial plans to open a free school sixth form with luxury flats on the Ladbroke House site in Highbury, local people have come together and arranged a 'Community Consultation'. The meeting will take place at 6.30pm on Monday 5th December at Highbury Fields School and is open to anyone with an opinion on this proposal.
Pictured – Cllr Joe Caluori, Executive Member for Children, Young People and Families


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Aired: Apr/24/2009
When Adelleâ's wealthy friend is murdered, Adelle imprints Echo with the womanâ��s memories and personality to solve the case. Ballard looks into Mellieâ��s past, and Topher secretly programs Sierra for an engagement.
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I love the whimsical nutcrackers and thought I would try my hand at refurbishing a couple of my old ones. I didn't think about the time it would take me so I forged ahead. It was daunting at first because of the small features and the conditions of the nutcracker. I love adding a touch of whimsy to each one.
I used acrylic paints to enhance the colors of red, gold, black and white checks. My favorite store is Mackenzie-Childs and I longed for decorations to relate to their inventory. Little by little, I brought each Nutcracker back to life with new-found character. At times I added small adornments like stripes, waves, dots and whatever I dreamed up. I painted my signature on the bottom and dated them.
I got the idea to start offering them on Ebay and before you know it I had sold over 5o to on-line auctions. I also sold the nutcracker in several holiday craft shows that were successful. I was even featured in several local papers showing my love of nutcracker.
I submitted my portfolio to Lowe Mill Arts & Entertainment locally and I opened my studio, Queen's Closet, in 2013. There I met various artist that had a passion for art similar to mine. I felt accomplished and happy that my nutcracker took me to a whimsical world that let me inspire others. I love being around inspiring artist because they have a fresh way of looking at life and their surroundings.
I learned though, having a studio is just that. You are busy at being an artist but you don't make money. It's just a title with backing and responsibility.
Therefore, I contracted a special friend to build a studio on my back deck where I can work and play and be close to home. I love this studio where I can do all the things I love without the cost of monthly rent and travel expenses.
Do you have an inspiring art that you want to share? Take the time to drop me a line and we can connect our views and likes right here on this page. I look forward to hearing from you!
I hope you like my whimsical Nutcrackers!
Queen Rose


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Click the link below to create a Work Order Request for issues with your room (such as: lights out, ceiling tiles missing, desks needed, etc.).
Stovall Middle Work Order Request
Click the first link to create a Technology Request for issues with your technology or for training. Use the second link to request Chromebooks for your classroom.
Stovall Tech Request
Stovall Device Request


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St Peters Cricket Club is continuing in it's efforts to establish a thriving girls and womens section. Our Womens 1st XI play in the EACA & SCB Women's T20 League and we have two colts sides/age groups - Girls Under 15's and Girls Under 13's. These sides play in the EACA & SCB Junior Leagues.
We are currently looking for new ladies and girls players. Whether or not you have played before or are totally new to the sport you would be more than welcome at our thriving family friendly club. If you are interested in getting involved then please contact David Corney, Chairman and Colts Coordinator.
The signs are particularly encouraging with the current crop of girls colts sides containing county representatives and providing the club with silverware, which you can read about below.
In 2014 the Under 13 girls team won the Lady Taverners competitions where in the final of the south east competition having been made to bat first and scoring 60-2 off their 8 overs they bowled Old Buckenham CC, from Norfolk, out for 28 in 7.2 overs with Tilda Chambers taking 3 wickets in one over. They made it to the final by getting out of a group including Bexley CC from Kent and Hutton CC from Essex. In the first match Bexley CC scored 38-2 off their 8 overs, St Peters reached 59-1. In their second match against Hutton CC it was more of a closer match with Hutton scoring 36-1 while St Peters scored 39-3.
They then followed this up with more success by winning 4 out of their 5 matches to top the indoor league. So the future looks very bright for this group of girls who will hopefully stay together and get stronger and stronger.


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Akaroa Day Trip
dan itibaren NZD 500,00 NZ$
- Süre: 1 Gun (Tahmini)
- Lokasyon: Christchurch
- Ürün kodu: AKA
Travel with your driver/guide in an SUV to the scenic village. Included in your itinerary is pickup and drop off from airport and or accommodation in Christchurch. Photographic stops along the way with commentary. Scenic route taken to or from Christchurch according to your schedule or booked activity in Akaroa. Assistance from your driver/guide throughout the day.


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Theme4Press › Forums › alora › Height of social icons › Re: Height of social icons
I didn't upload any new images, which is why this is so puzzling to me.
Also, is there any way to show the social sharing box on pages as well as posts?
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Oil Prices and the Keystone XL Pipeline (video)
Video of Jack Gerard, President and CEO of American Petroleum Institute, talked about falling oil and gas prices and efforts by the US Congress to approve the Keystone XL Pipeline.
House OKs Keystone XL pipeline
Defying a presidential veto threat, the House of Representatives passed a bill approving the construction of the Keystone XL pipeline.
Nebraska court tosses suit over Keystone pipeline
Nebraska's highest court tossed a lawsuit Friday challenging a proposed route for the Keystone XL oil pipeline, saying the landowners who sued didn't have legal standing to do so. The Nebraska Supreme Court decision could remove a major roadblock for the $7 billion cross-continental project.
House Plans to Vote on Keystone XL Bill Friday
The US House of Representatives is planning to vote Friday on legislation approving the Keystone XL pipeline, It will be the tenth time since 2011 that the GOP-controlled chamber has passed measures approving the pipeline, which has been under review by the Obama administration for more than six years. The Senate is expected to begin consideration of a similar bill on Wednesday...
What's Your Energy Wish This Year
See what our veterans are wishing for America's energy.
An Oil Boom Is a Power Boon
OPEC met on Nov. 27, and openly recognized that the United States' oil technological revolution - driven by enhanced oil recovery methods including hydraulic fracturing (known as fracking) and horizontal drilling - has undermined the cartel's economic and political power.
Program launched for job-seeking vets
Job searching just became simpler for veterans, and region employers will reap the benefits.
Veterans expect pro-energy leaders
What has made the Middle East a geostrategic focal point for so long but its possession of vast reserves of the oil we and our allies need to sustain our economies? If there were any adequate alternative sources of this precious fuel, we would have to be mad not to take advantage of them. And yet, there are.
Shale Revolution: Opportunity To Jump-Start Economic Growth
Will the U.S. shale boom turn out to be a bust? The recent decline in oil prices has left some questioning whether it can be sustained.
Thank you for Keystone XL attempts
Just a short note to thank every Veteran who worked on the attempt to get Keystone XL pipeline legislation through the Senate. Unfortunately, our efforts came up one vote shy of passage.


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The leaders & disruptors changing private brand.
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EXPIRED: Early bird tickets must be purchased by Friday, July 13, 2018. All tickets give attendees access to all presentations, meals and cocktail parties during the conference.$1,395 REGISTER TODAY
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MBD's private label team produces more than 10,000 SKUs every year under a wide variety of brands, in every conceivable category. Branding is consistency. MBD will ensure that your brand is accurately and consistently represented from the first to the ten thousandth SKU.Marketing By Design
The number of Private Brand projects is growing fast; you need to keep up with brand management, category reviews, packaging, artwork and much more to meet "on shelf" dates. Our Total Workflow Solution gets products to market faster, reduces chaos, and puts resources at your fingertips.Workflow by Design
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We help private brands to grow and succeed. We help retailers to evolve their private brand products, ensuring quality, consistency and competitiveness, while improving the efficiency, accuracy and cost effectiveness of their interactions with suppliers.Solutions for Retail Brands (S4RB)
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As a global brand consultancy, we know that growth is achieved through clear strategies, exceptional customer experiences, and world-class capabilities.Interbrand
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We make shopping for bulk easy, convenient and fun, so you can focus on the things that really matter.
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Women Impacting Storebrand Excellence (WISE) is a non-profit professional development organization, founded by women, to champion the power of diversity and inclusion which drives profitable growth within the store brand industry.Women Impacting Storebrand Excellence


text: This stunning Perrelet Moonphase A10396 automatic watch has a subtle silver dial with a contrasting blue dial for the oversized moon sit on. This particular moonphase watch not only displays the lunar positions accurately for more than 100 years, without needing correction, but also shows different constellations. The unique case design features ridges along the side of the watch. The watch is 5 atmospheres water resistant and comes on a gorgeous matte crocodile band with an engraved deployant buckle.


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Error 633: The modem is not installed or configured for Dial-Up Networking.
Had this error when putting a sim card on a Toshiba Laptop for the first time. It is solved the editing the registry...
1. Open Registry editor.
2. Navigate to H_Key_Local_Machine\Software\Microsoft\Windows\Current Version\ Telephony\Providers.
3. Change the Providerfilename0 to TSP3216L.TSP
4. Restart computer.