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Sunday, October 02, 2011
where context is key
The season that it is cool enough to wear sweaters and scarves, but not cold enough to have to wear those big poofy winter jackets. Since we live in Atlanta, weather like this will last until, oh, just around Thanksgiving, and resume probably by the end of January. Not a bad deal.
(Also, if you're thinking that the only reason to have kids is to dress them up in cute little clothes for the fall, you're 75% right. The other 25% is to legitimize buying a lot of Halloween candy. DO IT FOR THE CHILDREN.)
Anyway, this spawned a good amount of discussion on Twitter when I first posted it, but I just wanted to open it up here in the > 140 character arena. An article in The New York Times today detailed the growing trend of non-physician practitioners (such as, to give one example, nurse practitioners) introducing themselves as "doctors" to patients in a clinical setting. One argument is that, as someone with a doctoral degree, they deserve the honorific, and earning these doctoral degrees (I'll quote directly from the article here) "can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients."
My personal take is this: indeed, anyone who earns a doctoral degree has earned the right to be called "doctor." No one is disputing that, or taking respect or recognition from anyone who has earned that doctorate. But I would also point out that the term "doctor" has a very specific meaning in a clinical setting, and that the shades of grey ("I'm not a medical doctor but I do have a doctorate in nursing,") can be confusing or simply lost on a patient or their family, especially in the setting of an already complicated interaction in the hospital.
Some people argue that there is ego involved, and I don't doubt it--and might I point out there's likely a lot of ego on both sides, from the physician side for wanting to "defend" the title of doctor, and from the non-physician side in their desire to assert their own rich and well-deserved credentials. But like with most things in medicine, context is everything, and if we can all agree that the shades of differentiation of the term "doctor" are particularly fraught in the clinical milieu (and thus confusing to patients) perhaps ego can and should be put aside in the name of transparency.
There is also the issue of responsibility. In most situations in the hospital, the physician has the ultimate responsibility for the patient and what happens to them. As the physician, I am the bottom line, and whatever happens "under" me (someone misinterprets my order, a medical trainee under my supervision causes patient injury, a medication error occurs not directly because of me but under my watch)--in the end that's my responsibility and no one else's. When I introduce myself as "Doctor Au," that's part of the implicit understanding, and patients need to enter into that doctor-patient relationship where trust and the assumption of that ultimate responsibility go hand in hand. It may not seem like more than semantics to some people, but when you present yourself to a patient as their "doctor," in a hospital, that has to mean something very specific, for the understanding and ultimately the protection of the patients under all of our care.
In my mind, if someone calls themselves "doctor" during a professional interaction in the hospital, I assume that they are a physician, and I think I'm safe to say that most patients feel the same way. Just the same way that, if I'm in a college French class and the professor introduces him or herself "Doctor Webb," I assume that they have an academic doctoral degree and don't start, you know, taking off my clothes and showing them my rashes. In medicine, context is everything.
(Incidentally, on the flip side, if a patient asks me to call them "Doctor So-and-so," I will absolutely oblige them, no questions asked. But then again, I will pretty much call a patient whatever they ask me to call them, including the one patient I had who specifically requested that, when we woke up him up from anesthesia after surgery, we address him as "Big Poppa" because it was the only name he really responded to. No problem, uh, Mr. Poppa.)
73 comments:
- Anonymous4:56 PM
I have the exactly the same views. There are many hospitals that are putting in place guidelines in the bylaws on who can and cannot use the term Dr in the clinical setting. Some hospitals are even color coding the scrubs each professional wears so people will know. I don't remember which hospital it was, but at UMaryland or JHU the anesthesiologist wear pink scrubs.ReplyDelete
Great post--love your writing!!ReplyDelete
- Anonymous6:04 PM
I am a med student. At my current rotation sites, the scrubs are color coded by job (RT, housekeeping, nurse's assistant, etc) . However, I see plenty of non-doctors wearing the same color scrubs as the medical staff.ReplyDelete
- Anonymous6:06 PM
I am a 4th year medical student. I always introduce myself as medical student over "student doctor" 1) because i think the latter sounds quite douchey and 2) because patients will simply grab onto "doctor" and run with it. I think people other than actual, licensed physicians who want refer to themselves as "doctor" in the patient-care setting are doing nothing but misleading the patient and associated family. Furthermore, as you said they still do not assume any of the malpractice and other responsibilities of a physician...A fairly important point I think.ReplyDelete
- Anonymous6:16 PM
I completely agree with you. I am yet another anonymous (first year) med student. :) I had a PhD before I started med school (in something unrelated to medicine), and I absolutely do not want people calling me "doctor" in a medical setting until I am one. I am not a doctor yet and I really don't want people thinking that I am!ReplyDelete
- Anonymous6:19 PM
I completely agree with what you wrote, and left a comment on that awful "Well" blog on the NYT (don't get me started on how much I can't stand TPP). Here it is below:ReplyDelete
I don't think physician-doctors have any problem with people who have doctorates being referred to as "Dr". I think the problem arises when there is someone in the clinical field who introduces themselves as "Dr" but is a physical therapist/nurse practitioner/physician assistant because it is misleading to the patient. The patient thinks they are seeing an MD-Dr, and regardless of whether that is presumptuous on his/her part, it is the truth.
Also, what is so derogatory/bad about referring to oneself as "Nurse" or "Nurse Practioner"? If they truly believe they can provide equal care to an MD, which they absolutely can do, then they should lobby to increase awareness of the title "NP" in the general population. The aim should be to have acceptance of the title "NP" as a legitimate health care provider, not to drop it and try to fool the pubic into believing you are the "same as an MD".
I feel that if the NPs want to call themselves "Dr", then they should be required to do residency-type training and carry their own malpractice insurance so that when the patient gets sick they can't just hide behind the MD that is responsible for them-- let them bear ultimate responsibility for a patient's care. I don't think they should be able to have it both ways-- i.e., one can't get the prestige and respect of being called "Dr" but none of the responsibility, which is what they seem to want.
- Anonymous7:45 PM
At Maryland everyone who works at Shock Trauma (no matter their role) wears pink scrubs. Not sure if anesthesia is assigned pink at JHU, but it definitely isn't an assigned color for anesthesiologists as UMD.ReplyDelete
I agree with Anon @ 6:19. The average person who doesn't work in healthcare and has had limited exposure to the hospital hierarchy will absolutely think that an NP who introduces him/herself as a "doctor" is someone who has an MD/DO.ReplyDelete
If it's a matter of pride to the NPs, then there needs to be more patient education and campaigning to make the "NP" title accepted and respected as health providers.
- Anonymous8:19 PM
I agree! As a PGY-1, I always introduce myself as "Dr V, a junior resident with X team." I figure that by saying "doctor," "junior" and then mentioning the team, I'm giving the patient as much information as I can in one sentence.ReplyDelete
I think color-coding might be going a bit far, but I DO wish that teaching hospitals would have big informative signs in the waiting rooms about all the different people involved in patient care - teaching hospitals are so confusing, and I think this would help!
- Anonymous8:44 PM
As someone outside of the medical field and without a ph.d, I don't find it confusing to address non-physician MDs as doctors. I usually read name tags to see what degrees they have. I have friends who are MDs, DOs, and Au.Ds. My friend who has her Au.D. (doctor of audiology) has every right to be addressed in the with Dr. in the clinical setting. She has earned the degree and a professional in her field. The ENTs in her office respect her expertise and training to address her as Dr. in front of the patients.ReplyDelete
Nurse here. Probably a future midlevel, who knows.ReplyDelete
Anyway, I agree with you. I'll probably get a PhD someday, but it will likely be in physiology, just for fun. I will have earned the title, yes, but I absolutely think patients take the title and run with it, missing the distinction between clinical practice. I won't be a physician, because I decided not to go to medical school. Period.
I'd like to throw out, though, that RNs get the same ire when nurse aides are addressed as "The Nurse". If I had a dollar for every family practice doc who referred to their MA as "my nurse"...
I completely agree with this post. If nurses want to call themselves doctors within the medical community, then they should be required to earn the same level of training and expertise that we, physicians, are required to go through. Most patients do not know the difference, and may simply be more confused, rather than enlightened, by the terminology.ReplyDelete
There was a great article not too long ago on Student Doctor Network, comparing the levels of training between an MD and a DNP:
The level of training of an MD vs a DNP is very very different.
- Anonymous11:10 PM
I am outside the field and have a Ph.D. so I fully understand the amount of work and sacrifice earning the degree entails. That said, in a clinical setting where my care is at stake, you damn well better have an M.D. if you're going to refer to yourself as "doctor" when speaking with me if I'm talking to you about my care. It's not that I think that medical doctors are superior beings worthy of more respect than anyone else, because I don't. Rather, receiving medical care can be stressful and serious and I do not have the time or the patience to have to worry about assuming that someone I'm speaking with about medical/surgical issues has the expertise of a medical degree when they do not.ReplyDelete
First and foremost, I should be completely transparent and tell you that I am less than a year away from graduating as an NP.ReplyDelete
The first thing that I want to clear up is the misconception that NPs do NOT have malpractice insurance and cannot be held accountable for making errors. This is not true, at least here in Massachusetts and in other states in New England. Perhaps there are other areas of the country where NPs can "hide" behind doctors, but that isn't the case here. I think we are somewhat less apt to be sued solely because we don't typically practice in the high-malpractice areas of anesthesia, surgery, and OB, but we do (unless we are very very stupid) care malpractice insurance and we can certainly be taken to court for negligence or malpractice (as was emphasized into us just last week in class).
Second, I completely agree that NPs need a residency program. While medical students have the luxury of having an official residency program to further their training after graduating with an MD, NPs are typically hired at their first job with the qualifier that they are brand-new practitioners and will need to be precepted (with no monetary compensation to the preceptor) for at least a year after hire. It is somewhat unspoken, and I for one would LOVE to have an official residency program.
Third, I have been thinking recently about the differences between medical training and nurse practitioner training. I am quite aware that the level of information taught to us is much different (and lower) than that taught to students in medical school, but at the same time, part of the reason that our clinical hours are so much lower is that we do not have exposure to all of the specialties that are out of our scope of practice, including surgery, anesthesiology, radiology, and neurology.
Fourth, I think that until a lot more education is done regarding what NPs can and cannot do (as evidenced by some of the comments here), confusion will continue to exist. The number of patients I have seen who have referred to me as Dr. (or my preceptor as Dr.) despite me introducing myself as a nurse practitioner student is large. People do not know what NPs are, nor what they do, which is somewhat unfortunate as the number of family practice doctors dwindles and the number of nurse practitioners swells. It will be interesting to see if this changes in the next decade or so, as patients seeing FNPs as their primary care provider will most likely increase during that time period.
I think that the biggest reason my radar goes up when conversations on this topic start is that, no matter where I read about it, it always feels like physicians think we (nurse practitioners) are idiots. Take this line, for instance: "Their training is so extensive, physicians argue, that they alone should diagnose illnesses." I understand that it feels like we are encroaching on "their" territory, but until the cost of med school goes down and the number of graduates who want to go into primary care goes up, I think that physicians are going to need to understand that NPs and other "physician extenders" will be helping to fill a deficit in the primary care arena that would otherwise leave patients hanging out to dry.
- Anonymous5:29 AM
I think sounds odd for a nurse to introduce themselves as doctor in the clinical setting. I hold a DNP and would not dream of calling myself dr in front of the patient. Then again, I am military and non-physicians use rank, name and then explain what part of the health team we represent.ReplyDelete
I have seen too many residents enter rooms and never explain their roles as residents. patients deserve to know the level of practice of all providers involved.
I think a lot of this is semantics within the medical comumity. I mean most people in the hospital/clinic aren't aware that a short white coat = med student or what the color code for scrubs are. My husband sees patients for clinical trials and when he enters a room (dressed in a shirt/tie) he introduces himself by his first name, but many patients assume he's a Dr (though this assumption isn't as frequent for his female colleges...). Most people don't understand the hierarchy of a teaching hosptial, so it really comes more down to educating the general public so that they can have a better grasp of their care. (and for the record I have a PhD and have yet to introduce myself as Dr. in any setting :))ReplyDelete
I have a Ph.D. and don't consider myself a doctor (though I have had as much training as an MD between my Ph.D. and my post-doc). But, where do you draw the line -- what about a D.O.? Do they get the right to introduce themselves as a doctor? Probably the easiest way is for MDs to introduce themselves as physicians -- no ambiguity there.ReplyDelete
- Anonymous12:51 PM
im a 4th year medical student and during my GI rotation I would always introduce myself as "medical student so and so" but the fellows and residents would always introduce me as "dr. so and so" when we saw the patients together.ReplyDelete
I think that most patients have no idea who is walking into their room...attending, resident, intern, nurse, nursing assistant, respiratory therapist, physical therapist, dietitian, etc. etc. The NPs with DNP degrees that I've met have introduced themselves as "Dr. Smith, the nurse practitioner," but what the patient interprets her as could be something totally different. Without fail, patients consider our male nurses to be doctors, female residents to be nurses, and anyone who is African American to be a nurse's aide.ReplyDelete
This is a tricky one. I agree with you---yes, if you have a doctorate you have a right to identify yourself as "doctor", but not sure if this is appropriate in the clinical setting where the word "doctor" is synonymous with "physician". I can see patients being misled. If this is going to become a more widespread situation (which sounds like it is) then a standardized approach to how providers identify themselves and public education is definitely necessary.ReplyDelete
Re: Leslie's comment, above. I still think Michelle's point holds true. Yes, NPs may have their own malpractice insurance but in my practice setting, at least, there is a PHYSICIAN name on every chart as the "authorizing provider" and the NP writes "patient seen with Dr X". I have to cosign each chart in our EMR. The NPs may see the patient completely on their own & do their own billing, or they can have me come into the room also (which they tend to do with more difficult cases, & difficult families---they use their judgement). Regardless, at the end of the day, all these patients are my responsibility. If any case ultimately went to malpractice, I am 100% certain that I would be involved. Not that this answers in anyway the question of self-identification, but just wanted to support Michelle's sentiment.
Non medical person here, but ridiculously educated. When I am in a clinical setting I dont want to have to ask whether the "Dr" is an MD, OD or PhD. Clinical setting Dr should be MD or OD. Dr. Whosiwhat's is a nurse...great! but I dont want think to ask. If it is about ago, lose it. If I walked into a client meeting and introduced my self as Dr. Christine, they would laugh at me. Yeah, I have a doctoral degree, big deal.ReplyDelete
100% agree. I'm always sure to introduce myself the first time as a "Physician Assistant," not even a "PA." How the hell is a patient suppose to know what a "PA" is? And if a patient mistakingly refers to me as "doctor" I will correct them once. I assume anything after that is purely them looking for some name to use, kind of like calling any nurse by "nurse" and not their name.ReplyDelete
I'm all about being proud of my profession and the profession getting credit where credit is due. I don't want people thinking I'm a physician when I'm not. That takes away credit from the PA profession. I think some of the DNPs need to take a little more pride in their profession and lose the chip on their shoulder.
- Anonymous8:56 PM
You're right. Patients do not understand what a resident or a fellow is either. Many do not understand that an anesthesiologist is a doctor (MD or DO), just like their "real doctor".
This whole business of changing the medical vernacular, is crazy and irresponsible.
- Anonymous8:56 PM
The whole business is built on ego, vanity, self-satisfaction, and it's total crap to pretend it's not.ReplyDelete
George Michael
I think it's oversimplistic to say that "ego" explains all of the rancor that surrounds this issue, though some notion of self-aggrandizement probably makes up 80% of the comments in response to this article on the NYT webpage itself. (Warning: reading the comments as a physician may cause severe depression. Surprise, everybody hates us! As you were.)ReplyDelete
Like I said above, there is likely some ego involved on both sides of the table, but it's a gross generalization to frame the issue as one in which all physicians are God-complex-fraught dismissive assholes, while no non-physician who insists on being called "Doctor" in a clinical setting is doing it for anything but righteous reasons completely devoid of self-interest.
If we're arguing (and not that we're arguing here, but like I said I've read far too many of the NYT comments than is probably good for me) that on one side, the term "doctor" when used to refer to non-physicians in the clinical setting is admittedly confusing for patients; yet on the other side insist that non-physician doctorates deserve to be called "doctors" by patients in the hospital, confusion be damned because the patients can read nametags and sort it all out later--who, exactly, is burnishing their ego and reputation in this scenario?
Anyway, that aside, my point is that if this is an issue of ego, it shouldn't be. It should be an issue of patient care and transparency, about clarification of roles and responsibility. And though by its very nature, ego always seems to rise to the top, it should be because of patient care that we're all getting so worked up about this in the first place, right?
- Anonymous9:54 PM
You're right, Michelle. Is is about patient care. And we're confusing the patients.ReplyDelete
- Nurse Bella10:29 PM
Great post, I totally agree, but the issue that really gets my panties in a bunch is the whole issue of the DNP.ReplyDelete
As a nurse, I think that the DNP is the most ridiculous, waste of time. What more can a DNP do than the NP with a Masters Degree? No hospital will want the DNP referred to as Dr., because like you said, in them medical setting they still aren't the "doctor". I know in MI, the NPs with Masters will be grandfathered in and exempt from needing the Doctorate degree to practice. That is all fine and dandy, but the Masters & Doctorate NP are still practicing at the same level - what's the purpose of going back to school to get a Doctorate when you are valued in the health system hierarchy as essentially a physician extender - NOT THE DOCTOR. I don't know if it's an attempted ego boost to nurses, but I personally think once nurses get their PhD, they are useless to the clinical world as they are too far out of touch - Keep the Masters programs for NPS, and avoid the Dr. title struggle that is bound to occur in all hospitals.
Up here in MI, I have to say I rarely here the PAs or NPs referring to themselves as Dr. in the inpatient setting. Most NPs up here will quickly correct a patient for calling them Dr. I'm sure there are a few out there that do introduce themselves as doctor, and I think it's wrong. Great Post!
- Anonymous10:48 PM
It's just false advertising, really. In the clinical setting, a patient will assume someone who introduces themselves as Dr went to medical school and residency. Speaking medical-legally, patients don't like to feel lied to. If the NP makes a mistake, then the patient finds out his/her provider in charge was not actually a physician, I wonder what that does to the malpractice lawsuit... It's about being honest with patients, even if one didn't intentionally deceit.ReplyDelete
The thing about the DNP is that starting in 2015, all new NPs will be required to have their DNP. I see no problem with a DNP introducing themselves as "Dr. So and So, the nurse practitioner," as long as they make it clear that they are not the physician. In addition, nurses themselves (not just NPs/CNSs) can be included in malpractice lawsuits--trust me, that has been made very clear in my nursing program--it's why we have liability insurance. And, honestly, I know NPs who I would rather have treat me than some physicians, and I don't just say this because I plan on becoming one after I finish my BSN and work for a few years.ReplyDelete
Dear Michelle,ReplyDelete
I think one of the major issues here, and one that NPs should be in an uproar about, is what is clearly a money-grubbing move by nursing schools and the AAN. Now NPs will be required to have another 1 to 2 years of school for what amounts to no benefit whatsoever. The nursing doctorate is not clinical- it is in statistics and epidemiology. It will not be tied to higher pay or better patient care outcomes. Its only action will be to make the current NP degree obsolete.ReplyDelete
What's the point? All it does is bring in $$ for nursing schools, an issue well illustrated by the fact that you can basically "buy" a DNP from an online school.
In my native language, such confusion is avoided easily. A doctorate "doctor" is "doktor" (with O), abbreviated "Dr." (upper-case D), whereas a physician "doctor" is "dokter" (with E), abbreviated "dr." (lower-case D).ReplyDelete
So it's possible for someone to have both titles before their name: "Dr. dr. Jane Doe".
- Pre-med chica10:45 AM
I agree with you. The only people that should introduce themselves as doctors in a hospital are actual physicians. Don't confuse the patients, people!!ReplyDelete
- Anonymous10:50 AM
DNP: Hi, I am Dr. So and So, but I'm a Nurse, not an actual physician.ReplyDelete
Patient: ?
DNP: I have a Doctorate in Nursing
Patient: So, are you a doctor or are you not?
DNP: I am not a physician, but I have a doctorate..
Patient(thinking): this is wasting my time...so you're a doctor, but you're not a doctor of medicine.
Why go through all that trouble?
Michelle, ditto everything you have said.ReplyDelete
What I find frustrating is how much this concept disrespects the title of Nurse or Nurse Practitioner. I love nurses! I love nurse practitioners! Why is it bad to be called that?
Also, where was the patient's perspective in the article? What patient wants to be sick and have to deal with his semantic nonsense? Shouldn't this be fundamentally about patient information and autonomy? Patients have the right to not be misled.
I agree with the commented above - I can't stand TPP. The entire NYT health section is crap, and doesn't deserve to be part of such an excellent paper.
My guess is that nurse bella doesn't understand higher education in nursing. And probably doesn't even agree with a BSN as requirement for RN license....ReplyDelete
And these comments are depressing.
Until physicans start respecting nurses as equals and not inferiors, this whole ridiculous discussion will continue. It is a lot about egos on both parts, but a lot of that stems from physicians whole-heartedly believing that anyone who is "smart enough" to go to medical school would have. Nurses therefore chose nursing because they clearly weren't smart enough to be a physician. And until that mindset changes, little else will.
- Anonymous3:09 PM
NPs need to define their scope of practice, and have means of proving competence in it. There are many other doctoral fields in health care (PharmD, AuD, etc.) which have a separate and complementary role in the health care team compared to physicians. Nurses are not physicians; their training and knowledge base are very different, and therefore they can't expect the same rights and responsibilities as physicians. Shouldn't that be obvious?ReplyDelete
I am a nurse, and I think NPs add value to the health care team, but there is no way I'd agree to an NP independently managing my inpatient care or placing my chest tube. Follow up clinic appointment? Maintaining protocol adherence? Sure!
Another key here is that providers in healthcare don't exist on a linear totem pole, but in a network. Different people have different strengths and are trained to do different things, with some areas of overlap.ReplyDelete
It's in this way that it's key to point out that, in a hospital, the term "doctor" is used not as an honorific, but as a job description. Perhaps some people find that archaic, but disregarding current convention seems like willful obfuscation or just an exercise in semantics.
- Anonymous4:57 PM
That's right, Michelle.ReplyDelete
I don't introduce myself to patients as Professor ______________. In a clinical setting this is useless.
- Leslie4:58 PM
I am confused by anonymous at 3:09 who claims that NPs should have a scope of practice. We DO have a scope of practice, either clearly defined at the state level or in an agreement at one's place of work, depending on the state. Could you clarify what you meant by your comment?ReplyDelete
- Anonymous8:49 PM
As a resident I introduce myself as Dr. X, your medical resident... and I don't see what is wrong with introducing yourself as what you are... I happily see an NP for my routine low risk annual exam/pap smear but take my daughter to an MD for her eye surgery... different practice with different focus. One of our NPs does a great job with our teen OB clinic and all its crazy social and social work issues and an even better job sending all of her diabetics/hypertensives/etc to our high risk clinic to get additional involvement!ReplyDelete
- Anonymous9:14 PM
Michelle, what do you think of the my now clinics? Getting medical care over the phone/Internet along with an RX?ReplyDelete
I talked about this with my dad, who is an attorney. He laughed when I asked if he thought his clients should be calling him Doctor. He said he didn't want the responsibility that came along with the title ... irregardless of the diploma hanging on the wall that confirms he is in fact a juris doctor. :)ReplyDelete
- Anonymous11:37 PM
Hi Leslie-ReplyDelete
I should have been more specific. In my state, NPs can do almost anything under their supervising physician's license if he or she agrees to it. I don't think that should be how a profession with a terminal degree defines how they practice. NPs should practice independently, but they need to describe explicitly what they ARE and ARE NOT trained to do in nursing school (and, IMO, one lecture on chest tube insertion does not cut it). Likewise, their training should mostly be from other nurses, not physicians.
Do you have a link to a defined nursing scope of practice? I'd love to see it. All I can find on the internet is very vague language and a reference to which states require physician supervision or not.
Anon 3:09, RN
- Anonymous9:49 AM
Reading your post I agreed with your position. However, with a bit more thought I am starting to lean the other way.ReplyDelete
An NP, CRNA, PT, etc.. should be using the professional designation that they have earned, if that be at the doctorate level then it is what has been earned. perhaps, additional explanation should be made to describe the role of the individual when interacting with patients.
It cannot be justified for a physician or facility to mandate that a provider not use the distinction that has been earned. Individuals spend lots of time and money advancing their own education and should not be made to sit at the back of the bus because a few physicians feel it encroches on their perceived authority.
Bottom line is that healthcare is a TEAM approach and to belittle certain members of that team is not advancing anyone's cause.
- Anonymous6:02 PM
Why are RT's, pharmacists, food service workers, and seemingly EVERYONE else who isn't a medical doctor allowed to wear long white coats? This has also confused me on a million different occasions, so I wonder how the patients feel.ReplyDelete
I guess I don't understand how it is perceived as "belittling" someone to refer to them as an NP or a PharmD or what have you, if that's indeed the designation they have earned. Why is being referred to as "Doctor" an honor, but being referred to as a "Nurse Practitioner" insulting? I have worked with and learned from many excellent nurse practitioners, as well as from many brilliant pharmacists, respiratory therapists, and physician assistants, and their positions or how they chose to refer to themselves had nothing to do with how much I respected their work, nor did it in any way detract from the good they did for patients.ReplyDelete
Transparency in team role and structure does not belittle any member of the team, nor is that my inent. And if a nurse practitioner (or other non-physician provider) feels that it lowers their worth to be referred to as such, perhaps this is more an internalized stigma than an external one.
- Anonymous8:51 PM
I am writing this while currently hospitalized. (I am also a PhD and third year med student). I actually appreciate the designation of position (I am a surgical fellow, physical therapist, anesthesiologist) more than I care about title. Each day I am being seen by no less than 5 MD/DOs. Each of my providers has a different level of skills even within the "MD/DO" world. I am at a teaching hospital and I want to know if I am seeing an intern, resident or fellow. All of those are doctors, but have no where near the level of education and experience that *my* doc has.ReplyDelete
I am seeing multiple types of doctors. Knowing exactly who they are is rather important so I ask the right question to the right person. Discussing my Orthopaedic Surgical complications with my GI Doc isn't likely to net me the information I want/need. Discussing my surgical complications with the PhD RN who is caring for me tonight (and who has worked with Med/Surg patients for 30 years), is much more likely.
So what information is the term "doctor" really supposed to give me?
I don't think it's belittling to call someone a NP, that's not the argument. I think you'd be hard pressed to find an NP who isn't proud of that title. Nursing is not the same as being a physician-- it's not meant to be. The theory is all very different.ReplyDelete
Personally, I'm indifferent to being called a "doctor" just because I would have a doctoral degree, but that's not the point. It's a matter of respect and acknowledging that all people work very very hard for that doctoral degree, not just physicians.
- Anonymous11:29 PM
I think the belittlement comes from the other providers wanting to own the "doctor" designation. I am sure it is not nurses and pharmacists clamoring for the limitation of the use of the title.ReplyDelete
- pmmasta2:00 AM
@Anonymous 6:02pmReplyDelete
Pharmacists wore long coats historically because it provided them and their clothes the best protection against whatever medicine they were trying to compound. Now that pharmacists are moving onto clinical roles on the wards, many of us are ditching the cumbersome white coat for comfortable business attire.
@ Everyone: Dentists are often addressed as Dr. So and so, but are obviously not medical practitioners. Given this debate on who should be addressed by the term "Dr", where do people stand with regards to dentists? Is there any potential for confusion, given that dental practitioners can also be found in the hospital environment?
- Wicked Wanda8:32 AM
I spent a few years teaching clinicals for a local nursing program. One day a student asked, "all the other instructors wear lab coats, why dont you wear a lab coat?"ReplyDelete
I replied, "cause I don't work in a lab".
People who wear them to keep their clothes protected, I can understand. I am way too hot natured to wear a coat while working in Florida. I also think it looks odd to wear with scrubs. Plus when they get all dirty with stains and ring around the collar it is just disgusting!
I think this whole debate can be summed up in what Michelle said (I'm paraphrasing) above: For the DNPs, dentists, lawyers, et al., "doctor" is an *honorific*. For the physicians and surgeons, it a *job title*. Think about it.ReplyDelete
Especially since the job description of a physician involves, as you mention, being ultimately responsible for the patient and the outcome, the term "doctor" implies all of the above. In addition, as a family physician in urgent care who works with many different types of providers, there is an assumption that physicians have a certain level of training and expertise. Some other types of providers have this, but the truth is that not all do.ReplyDelete
This is just a fact, that sometimes there is less required training, which can at times lead to a less... involved... medical diagnosis. Yes, some nurse practictioners or P.A.'s have as many years of training, but many do not. I have seen this many times in my 14 years of practice. This is why non-physicians are supposed to have a physician sign off on their work. It's just the way it is. But the funny thing is, I'd almost recommend my own daughters be a P.A. rather than an M.D., just because there is tremendous stress that goes along with this responsibility that we as physicians carry. If a person makes a choice to get a doctorate in nursing, wonderful- but be proud to be a nurse. I think patients are also very aware of all of this, and would make many wrong assumptions if everyone introduced themselves as "doctor".
I prefer the term doctor to be used only as a job title. Much less confusion this way.ReplyDelete
- an ophthalmolist6:36 PM
Optometrist and ophthalmologist is on the forefront of this title confusion. Ophthalmologist has a lot to lose other than title. In many states, optometrists are allowed to treat and prescribe medication even though they never went to medical school. They can see patients without a referral from the Primary care Practioner. In some states they are even allowed to do lasers. They claimed that they have six years of concentrated eye training and even though ophthalmologist went through 12 or more years (if you do a fellowship like Joe), they did not spent as much time on the organ called the EYE. Why are they gaining so much power? The answer is, they have more representation in the Congress. Ophthalmologists, wake up. We have have getting cuts in reimbursements over the years. When I first got out thirty years ago, a cataract surgery was paid at $3000.(medicare and medicaid combined), Now the reimbursement is around five hundred.ReplyDelete
- Anonymous11:32 PM
Just today a nurse practitioner called, introduced herself as the "attending nephrologist", and proceeded to demand that a repeat study --which served no purpose except exposing the patient to unnecessary radiation --be performed emergently. I know it's one thing to ask to be recognized for the doctorate-level work you put in, and another to lie outright in the name of expediency, but it nonetheless comes down to this--titles have power, and people asking for them know this.ReplyDelete
I appreciate your position on this matter, especially since you practice in the hospital where my oncologists, nephrologist and cardiologist are likely to refer me too. And god forbid that I ever end up in your operating room, I promise not to introduce myself.ReplyDelete
I am a Masters NP in emergency medicine, where I can assure all I have my own liability insurance and can expect that both I and my "collaborating physician" would be involved in a suit should there be one. Yes, they sign my charts and this suggests that they are involved directly in a patient's care. Their signing my charts is in fact a requirement of our employer and has more to do with billing than collaboration; I am fully licensed to practice and bill independently, but FYI, my reimbursement is lower for the "same" care (face it, I can take care of a sore throat or suture a simple wound as well as my physician colleagues, but would not attempt to perform or bill for a chest tube insertion). Most often are not directly involved in the care of the patients that I see, but in the interest of excellence in patient care (and a cautious, CYA attitude) I do often ask them to see a patient and add their knowledge to my assessment; in those cases they will most often write their own note. They are all trained, board certified, and experienced in ER care, whereas I have 5 years of OJT after 3 in primary care. That said, I am the go to person for diabetes care for many of them, because I have an expertise in that area of medicine; we are a TEAM.
One thing that is often overlooked in NP training is that we have a lot of experience when we enter NP education. Although there are now contiguous degree programs (student to RN to NP in 4-5 years, which interestingly most NP's who came up the traditional way don't agree with *smile*), most schools have a minimum practice requirement of 2 years as an RN before enrollment. In the program that I attended the average number of years' experience in my group was 13; I personally practiced as an RN for 16 years, 13 in a combined ICU-CCU nurse in a community hospital (on the night shift-we were the cowboys, LOL) before going back to school. So I think there should be a nod to the fact that most of us are not starting from scratch when it comes to patient assessment, care, and clinical knowledge. Most of us do have a little over the first year medical students. By the way, those fast-track RN, BSN to NP degrees are one "solution" to the primary care MD practitioner shortage; at least the nursing profession is offering one. When medical education becomes more affordable and if it continues to take the direction that is has in the last few years with more emphasis on whole patient care and disease prevention rather than disease repair (this is a VERY short version of another whole debate) then maybe more individuals will be drawn to medical, rather than nursing school education. Personally I chose nursing for what I perceived as a more holistic approach toward patient's care when I entered nursing school 32 years ago. If fact, since I admire the advanced knowledge of my ER colleagues in our environment I'd love to have the option of a residency program that was affordable, worked around my current schedule, and ended in a DNP degree. Unfortunately as my nursing colleagues have pointed out, this is not the direction the DNP programs have taken and I am personally thankful that I will not be forced to obtain this degree. I am too old to explain my (theoretical) doctorate to anyone, and already get fatigued explaining to patients that yes, I am a nurse, AND I am also trained and licensed to assess their symptoms, order tests, diagnose their illness and prescribe medications. I also tell them that I'll be arranging their follow-up and have talked to their PCP, or that I have talked to specialist XYZ about their care, or that my ER physician colleague and I have consulted about their diagnosis and that he or she will be examined by that physician if I have asked for that consult. That is how we work as a team.
For those who are interested in the policies, the ENA and the AANP both have position statements and scopes of practice for NPs in the ER setting and here are some references:ReplyDelete
ENA NP competencies: http://www.ena.org/IQSIP/NursingPractice/advanced/Documents/ENANPCompetency.pdf
AANP scope of practice statement: http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/2010ScopeOfPractice.pdf
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Repeat after us: planning my wedding is an incredible adventure. Wonderful – now that we've got that out of the way, the rest of this planning thing is cake. It's true, once you remember that between the ups and downs and busy moments every decision you make is taking you one step closer to your wedding day, everything else comes easily.
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|This article is written from a
Real World perspective.
|TRON: Uprising S01E10 Scars, Part 2
|Media Type
|Television episode
|Charlie Bean
|Bill Wolkoff
|Elijah Wood
Bruce Boxleitner
Emmanuelle Chriqui
Lance Henriksen
Paul Reubens
Guest: John Glover
Guest: Aaron Paul
|Disney Television Animation
|Release Date
|November 2, 2012
Scars, Part 2 is the 10th episode of TRON: Uprising, in which Beck must stop his mentor from getting revenge on his enemy.
Beck awakened from a stun charge to find that Tron had left his hideout and was on his way to derez Dyson. Beck rezzed the light cycle that he had previously appropriated from Zed and gave pursuit, shouting that this wasn't like Tron, but was unable to stop his more experienced and driven mentor from losing him in the Outlands.
Dyson, meanwhile, had made himself at home in Argon City, to General Tesler's disgust. Tesler ordered Paige and Pavel to keep him out of trouble. At an Argon cooling plant, Paige discovered Pavel sabotaging equipment in an effort to disgrace Tesler; Pavel urged Paige to join him, saying that Tesler was on his way out. Paige expressed disgust and left him. The plant, however, was further sabotaged by the time they reached Dyson again, with clouds of gaseous coolant swamping the floor. Dyson suspected the renegade, and headed deeper into the plant to ferret him out.
Beck had eventually tracked Tron to Dyson's location, and confronted him once again, begging him not to let the revolution end before it had a chance to start. Tron locked Beck to a railing, throwing his disc into a nearby wall so that he couldn't get free, and vanished into the recesses of the cooling plant. Dyson, seeing four white lights through the fog in Tron's familiar configuration, stalked toward them, fully believing that Tron was actually dead and that he would be fighting a novice; the lights, however, were four light grenades stuck to a wall, which exploded and caught him off guard. Tron, still in disguise, attacked. Dyson, still believing he was fighting the renegade, taunted him with comparisons to the "real" Tron, but Tron eventually gained the upper hand, unmasking himself and advancing on Dyson with an enraged, vengeful expression, all the more terrifying as one eye was blanked out by his expanding scar. Dyson, shocked, tried to convince Tron to join him as a servant of Clu, offering to repair the damage he'd caused that prevented Tron's scars from healing themselves and left him without the ability to sustain himself without constant access to a healing chamber. Tron refused, lifting Dyson by the throat and preparing to derez him.
During his hunt, Tron had from time to time reflected on his former life before the coup, including his torture by Dyson, the forced repurposing of Reeve and the rest of their security team, and Cyrus, a former sentry who had saved Tron's life after seeing what Dyson had done to him. Abandoning his post, Cyrus had bailed Tron out of the recognizer transporting them to Clu's throne ship and hidden him in the Outlands, leaving the recognizer to crash and Dyson to believe them both dead. Now, with Dyson at his mercy, he remembered Cyrus' explanation for the rescue, echoing Beck's plea from before: "I can't let the revolution end before it has a chance to start." Changing his mind, Tron dropped the terrified Dyson on the ground, telling him he was only being left alive to deliver a message.
Back in the hideout, Tron thanked Beck for recalling him to himself. Beck asked if this meant he could have some time off, to which Tron replied in amusement, "What do you think?"
In Tron City, Dyson, shaken by his encounter, brought the message he had been given to Clu: "Tron lives." Clu, his back to Dyson, asked if anybody else knew about this, and Dyson turned abruptly to derez the lone sentry who had been present, ensuring that no one else did. Clu, smiling ominously, concluded that they would keep it that way.
- When Tron confronts Dyson, he fights with two discs as he did in the flashback scenes of TRON: Legacy, and his helmet is also the same design as the one he wore as Rinzler.
- In a brief animation error during the episode, Tron advances on Dyson with his own identity disc in one hand and Dyson's in the other—and a third disc still on his back.


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The website TransitionalHousing.org is for those who are looking for transitional housing based on their current needs.
Types of transitional housing listed.
- 3/4 house: Sober living homes that help you transition back to your normal life.
- Sober Living Home: Homes where residents recover from substance abuse.
- Halfway House: Variety of homes that can assist residents with substance abuse issues, emaotional issues, physical issues and to transition back to society.
Search through our list of supportive housing below to find the transitional resource in Montgomery, AL you need. We also provide prices/rates for transitional housing when possible, on the listing details pages.


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Homes are among the most expensive purchases you'll make in your lifetime, and it's important to make it your own, both inside and out. A fence can serve a number of purposes, including keeping a rambunctious pet or child from straying too far, creating privacy for your yard, improving the value of the house or simply making your home more secure.
More than 99,000 businesses offer fencing services and products in the United States, and the industry generates about $51 billion in revenue a year. With all of these options, homeowners can team up with a fencing contractor that meets their budget and requirements.
Types of Fences
No fence is one-size-fits-all. Each home is different, with its own character and charm, and homeowners should expect their fence to reflect this aesthetic. Fortunately, there are a number of fence materials that you can choose from to add to the look and function of your home.
When people dream about a house with a picket fence, wood is often the material that comes to mind. Wood is the most popular fencing type in the U.S. because it provides privacy thanks to its build and height options, looks attractive, and will likely last for the lifetime of the home. The downside of this option is that the height and size can impact the price, and it can take time to install.
Aluminum may not provide the type of security that wood and other options might as it would need fill-in panels. It requires little maintenance and can be decorated any way you want. However, this type of fencing is not ideal for areas with severe weather.
If you like the look of a wood fence, but not the price, PVC could be a good option. PVC is much cheaper and can be used to replace wooden stakes and pickets. While it's not as sturdy as wood, it can significantly cut down on material costs and comes in a variety of heights and colors. A PVC fence can last for years and has a high resistance to the elements.
Vinyl is one of the cheapest and most durable fencing types on this list. A vinyl fence has four times the flexibility and five times the strength of comparable wood fences. Although it has a high upfront cost, it requires no maintenance and is overall less expensive than other options.
Homeowners that are looking to be green may find bamboo fencing to be an appealing option. Bamboo is grown naturally, rising up to a foot a year, and can be planted to create a fence. Rolled bamboo and bamboo cane options will be the sturdiest choices and are optimal for colder climates.
If you think that fences are an eyesore, an invisible electric fence might be the optimal choice. These are especially beneficial for homeowners with pets. A trench is dug along the fence's boundary, and a wire is buried within. A wireless transmitter can then interact with a pet's collar to warn the animal when it is near the edge. Pets will stay within your yard, and you won't have the bulky structure of a fence.
How to Know if a Fence Works for Your Yard
Now that you know what materials are available, you might have an idea of what type of fence you'd like. However, there are a few considerations you'll need to address to verify that a fence will work for your yard:
Check Your HOA Regulations
Before you can begin planning for a new fence, you'll want to double check the rules for your neighborhood. Some homeowners' associations have stipulations concerning fences including standards for what materials can be used, as well as height requirements. Using this information, homeowners can thoroughly assess their options and stay in line with HOA regulations. You'll want to refrain from building excessively tall structures unless permitted by the HOA and municipality ordinances. Without this allowance, your fence will end up costing more.
Draw the Lines
Now that you know what guidelines are in place for fences in your area, it's time to determine if a fence will work for your yard in particular. You'll need to confirm your property lines to ensure that you stay within your established boundaries. A fence consultant will need to come out and locate utilities and other obstructions that could interfere with construction. The slope and contour of the terrain can affect the measurement of your fence as well. Understanding these elements will help determine if your yard is a good candidate for a fence and make planning run more smoothly.
Lay out Your Reasons
Establishing a fence takes some time and investment, so it will be important to consider why you're installing a fence in the first place. If you have kids or pets, safety might be your main reason. You might put in a fence for privacy if your landscaping isn't enough to provide your desired level of seclusion. For those selling their home, a fence can add visual appeal and increase property value. These considerations may guide you on what type of fence will be best for your home.
Common Issues
To properly maintain your fence, you must first learn about what problems you may face:
Damaging Utilities
Utility lines must be marked before fence installation to prevent any damages. A simple visit from a professional can save you a lot of headaches down the road.
Overlooking Standards
If you build a fence that doesn't adhere to ordinances, it can cost you a lot to address. Be sure to check with your HOA and municipality for regulations concerning what is required to build a fence in your area.
Leaning Fences
If you don't maintain your fence properly, you can expect it to come down with a few problems. You may notice that your fence is leaning or sagging, and this can be a fairly expensive problem to fix. If you don't close the gate properly, your hinges might sag and prevent your gate from closing securely. Homeowners can prevent these situations by performing regular maintenance on their fences.
Fence installation often occurs in stages. First, the fence company will mark the utility lines in your yard. Then, a crew will dig posts and set them in concrete. About a week later, the company will come and install the stringers, gates, fencing material and everything else. The average installation cost is slightly more than $4,500, but it will largely depend on the materials used. It's inadvisable to try to make this a DIY project, as a high degree of skill is required, and many costly problems can result from a bad fence installation.
Aluminum, vinyl and PVC fences all require little to no maintenance. Homeowners may use soap and water to clean off these materials, but they generally don't require much more than that. These options can be good for those that want a sturdy but low-touch fence.
Wood fences, on the other hand, require a little bit more work. With exposure to the sun and the elements, wood fences are prone to cracking, warping and cupping. To prevent this, homeowners are encouraged to clean, seal and stain their fence at least every three years. Clean the fence with a specially formulated cleaner. After 15 to 20 minutes, use a pressure washer to remove any mold, mildew and debris from the fence. From there, you can seal and stain the fence to protect it and help the wood look good as new. An oil stain is recommended, as it penetrates the material and can maintain its condition for years.
Choosing a Service
With tens of thousands of fencing service companies to choose from, how do you know which one will be the best for your needs? Here are some considerations to help you make a decision:
Are There Portfolio Examples?
You'll need to do some homework on your potential contractors. First, see if they have a website and a portfolio of samples. These can indicate the provider's level of experience and highlight their capabilities.
What's Their Reputation Like?
You'll want to have a contractor that has a good reputation. Look at customer reviews as well as how long the provider has been in business. If a contractor requires an immediate decision, asks you to pay cash or doesn't provide an estimate, it should serve as a major red flag. A friend or family member may also be a good source for recommending a contractor.
Is the Work Guaranteed?
Some organizations may offer a variety of promises, such as time to completion and discounts, simply to get you in the door. It's important to question the validity of these guarantees and research whether the contractor has delivered on these commitments. If it's clear that the contractor constantly misses deadlines or doesn't meet obligations, you'll want to renew your search.
Is There a Warranty?
No matter how good a contractor is, there may be an issue with the fence a year or two down the road. You should ask about what type of warranty is offered. A warranty could help offset repair costs if you have a sagging fence, while enabling you to fix any warped or cracked panels that may occur after exposure to the elements.
Trade Associations
Homeowners should work with a fencing contractor who is certified by or a member of one or more trade organizations. Some of the biggest associations in this industry include:
American Fence Association
Since 1962, the American Fence Association has grown to be the largest and most comprehensive resource in the industry. The group aims to benefit fence-industry professionals and customers by promoting professionalism, education and certification of its members while keeping up with the latest developments, materials, standards and tools.
The AFA has created a rigorous certification program and requires recertification every three years. Professionals must prove a history of service in the industry prior to taking the certification exam and complete the multiple-choice test.
North American Fence Contractors Association
The NAFCA is a group of fence professionals who look to bring contractors and vendors together for better affordability and accessibility to educational opportunities within the industry. It's run by a number of volunteers and encourages all contractors who want to develop their skills to join.


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Bite-proof Your Dog
By The Humane Society of the United States
Q: Is there any way I can "bite-proof" my dog?
A: There is no way to guarantee that your dog will never bite someone. But you can significantly reduce the risk. Here's how:
Spay or neuter your dog. This important procedure will reduce your dog's desire to roam and fight with other dogs, making safe confinement an easier task. Spayed or neutered dogs are three times less likely to bite.
Socialize your dog. Introduce your dog to many different types of people and situations so that he or she is not nervous or frightened under normal social circumstances.
Train your dog. Accompanying your dog to a training class is an excellent way to socialize him and to learn proper training techniques. Training your dog is a family matter. Every member of your household should learn the training techniques and participate in your dog's education. Never send away your dog to be trained; only you can teach your dog how to behave in your home.
Teach your dog appropriate behavior. Don't play aggressive games with your dog such as wrestling, tug-of-war, or "siccing" your dog on another person. Set appropriate limits for your dog's behavior. Don't wait for an accident. The first time he exhibits dangerous behavior toward any person, particularly toward children, seek professional help from your veterinarian, an animal behaviorist, or a qualified dog trainer. Your community animal care and control agency or humane society may also offer helpful services. Dangerous behavior toward other animals may eventually lead to dangerous behavior toward people, and is also a reason to seek professional help.
Be a responsible dog owner. License your dog as required by law, and provide regular veterinary care, including rabies vaccinations. For everyone's safety, don't allow your dog to roam. Make your dog a member of your family: Dogs who spend a great deal of time alone in the backyard or tied out on a chain often become dangerous. Dogs who are well-socialized and supervised rarely bite.
Err on the safe side. If you don't know how your dog will react to a new situation, be cautious. If your dog may panic in crowds, leave him at home. If your dog overreacts to visitors or delivery or service personnel, keep him in another room. Work with professionals to help your dog become accustomed to these and other situations. Until you are confident of his behavior, however, avoid stressful settings.
Q: What should I do if my dog bites someone?
A: If your dog bites someone, act responsibly by taking these steps:
Confine your dog immediately and check on the victim's condition. If necessary, seek medical help.
Provide the victim with important information, such as the date of your dog's last rabies vaccination.
Cooperate with the animal control official responsible for acquiring information about your dog. If your dog must be quarantined for any length of time, ask whether he may be confined within your home or at your veterinarian's hospital. Strictly follow quarantine requirements for your dog.
Seek professional help to prevent your dog from biting again. Consult with your veterinarian, who may refer you to an animal behaviorist or a dog trainer. Your community animal care and control agency or humane society may also offer helpful services.
If your dog's dangerous behavior cannot be controlled, do not give him to someone else without carefully evaluating that person's ability to protect him and prevent him from biting. Because you know your dog is dangerous, you may be held liable for any damage he does even when he is given to someone else.
Don't give your dog to someone who wants a dangerous dog: "Mean" dogs are often forced to live miserable, isolated lives, and become even more likely to attack someone in the future. If you must give up your dog due to dangerous behavior, consult with your veterinarian and with your local animal care and control agency or humane society about your options.
Copyright © 2001 The Humane Society of the United States All rights reserved.


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Joey Brezinski came in first today, as he's known to do, at the Red Bull Manny Mania showdown in NYC. He got 10,000 dollars and nice new belt. The finals were close though, Sewa Kroetkov, Brandon Biebel, and Ronnie Creager (sick line up, right?) were nailing insane manuals left and right, and often at the same time. The crowd was roaring with each balancing act. Other standouts today were Austyn Gillette flying around the course—it really wasn't big enough for him, and Torey Pudwill doing his video part tricks on the course's ledges. Peep the gallery below and we'll have our exclusive video up ASAP!
Photos by Blair Alley
Full Results:
1. Joey Brezinski
2. Sewa Kroetkov
3. Brandon Biebel
4. Ronnie Creager
5. Joao Pedro "JP" Dantas
6. Torey Pudwill
7. Eli Reed
8. Marty Murawski
9. Walker Ryan
10. Danny Falla
11. Alex Caronio
12. Joe Tookmanian
13. Austyn Gillette
14. Zered Bassett
15. Malcolm Watson
16. Kenny Hoyle
17. Ryan Decenzo
18. Bruno Ageuno
19. Derek Fukuhara
20. Andrew Cannon
21. Ron Deily
22. Richard Angelides
23. Steve Nesser
24. Ryan Gallant
25. Kenny Anderson
26. Danny Supa


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Mark KotchEast Bay Director of Career Development
Mark Kotch has been a licensed Realtor since 2005 and joined Alain Pinel Realtors in 2009, finding success in his career in real estate by valuing the importance of and utilizing current sales and marketing techniques throughout all mediums. Mark is a Certified Buffini Mentor, Certified Distressed Property Expert, and holds SRES and e-Pro designations. He is a four year Platinum award recipient of the Quality Service Certification (QSC) for outstanding customer service as independently surveyed by his clients, and as a result, 95% of his business is referral based. With his proven sales and marketing background with companies such as Aveda Hair Care, Mark has trained thousands of hair dressers and estheticians on product knowledge and how to properly run a successful business, resulting in numerous successful sales and marketing teams.


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Gain the greatest market advantage by listing your property with APR:
- Work With the Best
Our nationally ranked sales professionals sell more luxury real estate at a higher average sales price than any other group of Bay Area agents (*RealTrends).
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We draw qualified buyers through our extensive industry relationships, international luxury affiliations, and innovative marketing.
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Our international marketing strategy enables us to dynamically represent your property to a global audience.
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If you're planning a move outside of the San Francisco Bay area, our award-winning Relocation division can help you make it a seamless transition, connecting you with the right agent and listings anywhere in the world and providing you with information on your destination.
Luxury Real Estate
International Luxury Affiliations


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It's easy -- enter as many recipient email addresses as you like separated by commas, or log in to select anyone from your buddies list, then enter an additional message if you would like. When ready, click the "Send Email" button!
(Your Name)
would like you to see the following page on WhatIfSports.com:
Gridiron Dynasty
Coach, recruit, and run your own college football program.
SimLeague Hockey
Compete in a full season with your dream team from NHL past and present. Line & pair management, goalie options, prizes, and more.


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For MIRC/IRC clients
/server irc.canternet.org
If you have any questions considering functionality of the chats, ask any of the on-duty mods (the ones with funny symbols in front of their names)
The channels short info:
#EquestriaDaily - The main channel and the front of the Ponychats, a general room for talking
everything pony... well, everything pony that is at least a little bit of PG as stated in the general
NOTE: DO NOT POST SPOILERS IN THIS CHANNEL. Episode discussion is disallowed until approximately six hours after an episode airs, in order to allow everyone the opportunity to enjoy an episode. POSTING SPOILERS WILL RESULT IN A BAN. If you want to discuss spoiler content, see #EquestriaSpoilers.
#EquestriaAfterDark - welcome to the dark side of ponydom. This channel disregards the PG
rule from General Rules, so pretty much everything can be posted here. From Grimdark to the
more "saucy" pony pictures and fiction. Only for mature audience!
#EquestriaDailyRP - Channel dedicated to roleplaying with ponies! So if you have an OC that
you want to immerse with or want to see the Mane Cast in action, this is the place for you. Our
staff will work hard on delivering a high quality experience for all of the willing players.
#EquestrianGamers - Equestrian Gamers is, well, a channel for reading poet-- Wait, wrong
script. Equestrian Gamers is a gaming channel for gamers talking about the games they enjoy, a
place to find others who play your favorite games, as well as a place to just sit and chat. We are a
mature channel, just don't bring anything really adult into it!
#EquestriaSpoilers - Channel dedicated to discussions of new episode filled with spoilers! This
room is usually busy right after and during a new episode airing, when too many too enthusiastic
bronies must share their excitement to others as soon as it is technically possible. Because of the
"no spoilers" policy in the other channels, this place was made.
#EquestriaTheater - Channel dedicated to discussion of episodes as they air. Not to be confused with #EquestriaSpoilers, as this channel is kept free of future episode spoilers!
#EquestriaDailyArt - A room dedicated to all of the ponies with a creative spark, be it drawing, painting, sculpture, customization, poetry or expressive dance (wild outdoor performance included!). Share your works here, await crits and comments and rejoice in some artsy brainstorming with others over here. Our mods will not be too harsh on the criticism, I swear.
#EquestrianStudy - The channel for aspiring writers, this is the place to discuss characterization, plot, world building, and all of the other facets of story telling. If you need assistance, constructive criticism, or just somewhere to bounce ideas, consider checking us out.Friday, June 3, 2011 op 5:00 PM
Labels: News, Not-Fanfiction
Chat Embed


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Find scriptures by:
Keywords (Holy Ghost)
Reference (Alma 32:21)
The fundamental principles of our religion are the testimony of the Apostles and Prophets, concerning Jesus Christ, that He died, was buried, and rose again the third day, and ascended into heaven.
The family is central to the Creator's plan for the eternal destiny of His children.
The Book of Mormon is the word of God, like the Bible. It is holy scripture, with form and content similar to that of the Bible.
Scriptures are available for purchase online in a variety of covers, colors, and sizes and with a variety of features.
The scriptures are available on the Gospel Library mobile app, now on iOS, Android, and Windows devices. Additionally, they are available in a variety of other formats.
New resource to support your family scripture study.


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© 2011 Rutgers, the State University of New Jersey
- Last Updated:
May 17, 2011
The NJ Green Building Manual is not intended to be exhaustive and all-inclusive and the enclosed guidelines are not to be considered the only method of green building. The guidance and strategies presented do not supercede applicable building codes, laws or regulations and are not a substitute for the judgment and services of competent or licensed professionals. Nothing in this manual should be construed as policy, an endorsement, warranty (express or implied) or guaranty by the project's managing partners (NJ DEP, NJ DCA, NJ HMFA, NJ BPU, NJ EDA, Governor's Office of Policy) or any persons or organizations involved in the creation of this publication, or of any technical descriptions, systems, details, requirements, materials, or products. The mention of a particular product, business or manufacturer does not constitute an endorsement, expressed or implied, by managing partners, the Rutgers Center for Green Building or the State of New Jersey. The managing partners, the Rutgers Center for Green Building expressly disclaim any responsibility for any damage arising from the use, application, or reliance on the recommendations and information contained herein.


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My paternal grandmother, Dorothy Louise Harris, grew up in Appleton, WI, the daughter of Orville and Katherine (Katie) Harris. She obtained her teaching degree in 1920 from Oshkosh Normal school, and taught first and second grade in Clintonville, WI from 1920 until 1923. She then taught 2nd grade at McKinley school in Appleton from 1923 until 1929, when she married my grandfather, Russell Weller, and moved back to Clintonville.
I'm very fortunate to have found many mentions of my grandmother in the Appleton Post-Crescent in the years from 1925 to 1929. Dorothy was very involved in her church, and seemed to be a very energetic school teacher.
The following newspaper excerpts are listed in chronological order and give a special glimpse of my Grandma's early adult life. I've added some photos taken of her during that time period.
August 6, 1925 – Trip to Omaha
Mrs. O. D. Harris and daughter, Dorothy, 224 E. Winnebago St., left Tuesday for Omaha, Neb., where they will spend a few weeks with Mr. and Mrs Harold Cook. Mrs. Cook is a daughter of Mrs. Harris.
August 19, 1925 – Teaching Staff District 4
Teaching Staffs of City's Schools Are Almost Completed Now
Fourth District Schools – Pearl Fellow, Dorothy Harris, Marjorie Hood, Agnes Tracy, Katherine Tracy, Margaret Stebensohn, Dott Smith, Elizabeth Wadsworth, Aurilia Whittlinger. Ungraded Room – Esther Rock, Lydia Schottler. Deaf Room – Edna Aderman, Ida Gleason.
August 28, 1925 – Returned from Omaha
Mrs. O. D. Harris and daughter Dorothy have returned from a three weeks' visit at the home of Mrs. Harold Cook, Omaha, Neb. Mrs. Cook formerly was Miss Belle Harris of this city.
January 9, 1926 – Chi Tau Meeting
Memorial Presbyterian Church
Virgil Bryant Scott, Minister.
Sunday school 9:45 A.M.
Morning worship 11 o'clock. A grain of Wheat.
Christian Endeavor 6:30 P.M.
Evening Service 7:30 P.M. Subject of Sermon, The Way Out.
Prayer meeting Thursday at 7:30 P.M.
Monday at 6:30 P.M. Monthly Teachers' meeting of the Sunday School.
Chi Tau meet on Tuesday of this week at the home of Miss Dorothy Harris, 224 Winnebago St. at 6:30 P.M.
Monthly missionary meeting at the home of Mrs. S. W. Murphy on Tuesday of this week, January 12 at 2:30 P.M. The devotional service will be conducted by Mrs. Rhoades. The topic for the meeting is Utah. The committee in charge of the meeting consists of Mrs. W. D. Mason, Mrs. William Burbank, Mrs Stewart Leuchars, Mrs. David Ogelvie, and Mrs. O. D. Harris.
January 11, 1926 – Chi Tau Upsilon Meeting
Chi Tau Upsilon of Memorial Presbyterian church will meet at Tuesday evening at the home of Miss Dorothy Harris, 224 E. Winnebago St. A supper will be served at 6:30 after which the business session will be held.
September 24, 1926 – Geography Committee
Committees Are Appointed to Work Out Educational Problems.
Committees to work out educational problems were appointed at the meeting of first and second grade teachers with Ben J. Rohan, superintendent of schools Wednesday afternoon. Other business include the distribution of programs for the Northeastern Teachers association convention in Oshkosh on Oct. 8 and a discussion of Better Teaching booklets which have been planned in order that teachers may measure their ability and development through the year.
Members of the geography committees are: Second grade, Miss Katherine Tracy, chairman, Miss Dorothy Harris, Miss Ruth Taylor, Miss Erma Temple…
December 18, 1926 – 2nd Grade Christmas Program
Class parties were held in the grades at McKinley school Friday afternoon before the closing of school for the Christmas holidays. Miss Elizabeth Wadsworth and Miss Agnes Tracey were in charge of the party for the kindergarten and first grade children. The second grade had it's program alone. This was directed by Miss Dorothy Harris.
February 5, 1927 – Chi Taus Meeting
Memorial Presbyterian Church
Chi Taus will meet on Tuesday at 6:30 P.M. at the home of Miss Dorothy Harris, 224 E. Winnebago St. Miss Evangeline Wirick, Miss Ruth Mielke, Miss Mararet Miskimin will act as the committee.
March 3, 1927 – Visual Education
Visual education as a part of geography teaching was demonstrated at the "go to school night" of the second, fourth, fifth and sixth grades of the McKinley school Wednesday night. About 100 parents attended the model classes.
Stereoptican slides and stereographs are used in the supplementary work of the children. Other subjects demonstrated were silent and oral reading, spelling, mathematics, including examples of the true and false test method of teaching, and oral English.
Teachers in charge of the classes were Miss Pearl Fellows, Miss Josephine Sexton, Miss Elsie E. Sandberg, and Miss Dorothy Harris.
April 20, 1927 – Chi Tau Society Officers
Election of officers was the principal business at the meeting of the Chi Tau Society of Memorial Presbyterian church Tuesday evening at the home of Miss Dorothy Schenck, N. Leminwahset. A supper was served at 6:30 preceding the business session. Miss Schenck was assisted by the Misses Margaret Miskimmin and Vivian Viel.
Miss Olga Heller was elected president for the coming year. Miss Ruth Mielke was elected vice president and Miss Dorothy Harris was elected secretary and treasurer. Patronesses for the year will be Miss Jessie King, Mrs. J. E. Bond and Mrs. Virgil B. Scott.
September 12, 1927 – Chi Taus Meeting and Womens Missionary Society
Chi Tau Upsilon society of Memorial Presbyterian church will resume its meetings for the season with a supper at 6:30 Tuesday evening at the home of the Misses Helen and Jean Paterson, 319 E. Lawrence St. The Misses Dorothy Harris and Margaret Ritchie will be the assistant hostesses. Miss Olga Heller is president of the society for the coming year. As social will be held following the supper.
A meeting of the Womens Missionary society of the Presbyterian church will be held at 3 o'clock Tuesday afternoon at the home of Miss Marian Smith, 210 N. Park Ave. Miss Kate Schneider will lead the devotions. Mrs. H. H. Clausen, Mrs. Orville Harris and Mrs. G. A. Ritchie will have charge of the programs which will be on new literature for the coming year. Study books for the season will be chosen.
September 14, 1927 – Womens Missionary Society and Chi Tau Study Book
Miss Agnes Gale Hill, a missionary from the Presbyterian church to India, told about the people in India and her work at the meeting of the Womens Missionary society of the Presbyterian church will be held at 3 o'clock Tuesday afternoon at the home of Miss Marian Smith, 210 N. Park Ave.
"The Twelve Test of Character" by Foedick was chosen as the study book of Chi Tau Upsilon society of the Memorial Presbyterian church at the first meeting of the season Tuesday evening at the home of the Misses Helen and Jean Paterson, 319 E. Lawrence St. Miss Ruth Mielke read a paper. Supper was served at 6:30. The Misses Dorothy Harris and Margaret Ritchie were assistant hostesses.
October 1, 1927 – Womans Club Solicitors
Solicitors Start Campaign to Raise $10,000 to Meet Current Expenses
Workers for the Womans Club will have a supper meeting at 6:15 Monday evening, opening a campaign to raise $10,000 to defray current expenses of the club during the coming year.
The club, entering its ninth year of existence, is planning a comprehensive program of work for the coming year. Its principal purpose is regular club work and to sponsor recreation for women and girls.
The club has a nominal membership fee and an woman in Appleton or Outagamie Co. is eligible for membership. A squad of women soliciting memberships for the club started work last Monday and the two efforts will be carried on together next week.
Woman who will canvas the schools for pledges are Mrs. Mable Meyer and Misses Ruth Mielke, Magdalene Kohl, Mable Welter, Hilda Kippanham, Rose Helm, Selma Mallmann, Jenn Jackson and Dorothy Harris.
August 16, 1928 – Prize Winner
Mrs Emory Greunke and the Misses Marie and Irene Greunke entertained at a miscellaneous shower at the latter's ohm, 709 N. Morrison St. in honor of Miss Emily Greunke, who is to be married hearty in September to William Brydenhagen of Sturgeon Bay. Miss Greunke is the daughter of Mr. and Mrs. Charles Greunke, 70 N. Morrison St. Bridge furnished entertainment for the evening and the prizes were won by Miss Dorothy Harris and Mrs. Marie Boehm.
September 21, 1928 – Geography Outline
A meeting of the first and second grade teachers of the public schools was held at Lincoln school Wednesday afternoon.
The committee selected to work on the geography outline includes Mrs. Leila Mortimer, general chairman; Misses Katherine Tracy and Marion Uebele, second and first graid chairmen, and Misses Dorothy Harris, Ruth Taylor, Ruth Hartig, Emma Schwandt, Agnes Tracy, Viola Weber and Lois Smith.
February 11, 1929 – Teaching Reading
A man with a red hat seen on the streets of a civilized community might cause a ripple of excitement and shop window full of men's red hats bring forth a few gasps, but it is doubtful if any red had could cause as great a stir as the one in the second grad at McKinley school. In this particular instance a red hat marks the crowning achievement – for the pupils of class B it means victory in the art of reading.
The idea is this. To stimulate greater interest in perfect reading the teach, Miss Dorothy Harris, intimated a contest inbreeding. Each time a child reads well, he is permitted to take one more step in the drawing of a snowman and when the snowman is finally topped with a red hat, the pupil has completed the contest. None steps re involved – three balls for the three parts of the snowman's body, the eyes , nose, mouth, buttons, broom and finally the red had.
This who have completed their snowman are Harold Bertsky, Donald Own, Doris Jean Rhoder and Oscar Moderson.
July 15, 1929 – Dorothy Harris and Russell Weller Wedding
The marriage of Miss Dorothy Harris, daughter of Mr. and Mrs. O. D. Harris, Winnebago St. and Russell Weller, Clintonville, took place at 7 o'clock Monday morning at St. Rose church, Clintonville. The Rev. Father Dietrich performed the ceremony. Miss Helen Weller, Clintonville, acted as bridesmaid and Emil Tanty, Neenah, was best man. A wedding breakfast for immediate relatives was served at the home of the bride's parents following the ceremony. After a tour to Niagara Falls and other points of interest in the east and Canada, Mr. and Mrs. Weller will make their home in Clintonville where Mr. Weller is in the hardware business.
July 17, 1929 – Marriage License
Waupaca – The following applications for marriage licenses were received in the office of County Clerk L. F. Shoemaker during the week ending July 9: Guy J. Schmahl, Manawa, and Ivy L. Reinheimer, Cecil; Russell B. Weller, Clintonville, and Dorothy L. Harris, Appleton; Joseph S. Lolosso, Manawa, and Esther Swenson, Iola; Bernard L. Schults, and Irma M. Roenz, Manawa.
Unfortunately, I didn't know my Grandma Weller as well, or for as long, as I would have liked. She passed away when I was 11 years old. We didn't live near Wisconsin when I was a child, so we saw our Grandparents once or twice a year. I'm thankful to have found these tidbits about her life before she married my Grandpa.


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Raising a child with desirable character traits in today's society can present many challenges.
Raising a child with desirable character traits in today's society can present many challenges.
Impatience and intolerance emerge at an early age, bullying is an everyday term, and a sense of entitlement is common, even in young children.
A family must-have is "The Children's Book of Virtues," by Wm. J. Bennett (Simon and Schuster). In it, Bennett describes moral education as "training of the heart and mind toward the good," he also includes "the do's and don'ts of life."
Bennett underscores the 10 most important virtues — self-discipline, compassion, responsibility, friendship, work, courage, perseverance, honesty, loyalty and faith — through simple storytelling. These — and all other character traits — are taught by example and practice, which shape and develop the moral values we most admire.
Many of these values were encompassed in one phrase that was shared with my teen years ago. It has carried with us both ever since.
As a high school student studying professional performing arts in New York City, her acting coach said, "You are enough." She explained that, once you learn your lines, you study your character until you fully understand your character's emotions. Combined with training, skill and talent, "you are enough."
Capitalizing on that phrase, I repeated it whenever my daughter struggled with peer pressure, our divorce or goal setting challenges. It reminded her that, if she did what she knew to be right, she would prevail because she is enough.
We crafted a beautiful wooden plaque, lettering her phrase carefully, and hung it as a reminder by a satin ribbon in her bedroom. That simple phrase has taken her far in life.
Recently, I came across an extended version written by Molly Mahar.
While working with a group of women who were striving to develop parenting skills, I shared my daughter's story and then read the following:
"I am enough. I am full of sparkle and compassion. I genuinely want to make the world a better place. I can accomplish difficult things. I practice kindness. I'm not afraid of the truth. I am loyal, adventurous, supportive and surprising. I am enough. I make mistakes, but I own them and I learn from them. Sometimes I make a lot of mistakes."
Inspire your child by modeling those traits.
Reinforce "If it's wrong, don't do it."
Teach your child to find value in others, with encouragement to reach out to help another.
Minimize negativity, and be the positive influence.
Teach your child to sparkle.
Diana Boggia, M.Ed., is a parenting coach who lives in Ohio. She is author of "Parenting with a Purpose." Send your child-rearing questions to firstname.lastname@example.com or The Repository, c/o Family Matters, 500 Market Ave. S, Canton, OH 44702. Find parenting resources at her website, yourperfectchild.com.