text:
XomeDx (Whole Exome Sequencing)
XomeDx and XomeDxPlus test reports will include secondary findings, if present in the proband, as published in the American College of Medical Genetics and Genomics Recommendations for Reporting Incidental Findings in Clinical Exome and Genome Sequencing. We actively look for variants in these genes, as recommended by the ACMG, and confirm reportable secondary findings by Sanger sequencing. Patient samples sent for XomeDxSlice will not be evaluated for secondary findings and therefore will not receive secondary findings as part of their result.
GeneDx honors patient preferences and offers the choice to opt-out of receiving secondary findings. If a patient chooses to opt-out, patients must select the opt-out option on the test requisition form.
XomeDx/XomeDxPlus: Whole Exome Sequencing with or without mtDNA Sequencing and Deletion Testing
Patient Guide Spanish Patient Guide Test Requisition Family Member Requisition XomeDx FAQs LOMN
|Test Name
|More Information
|XomeDx, or whole exome sequencing (WES), can be used to identify the underlying molecular basis of a genetic disorder in an affected individual and is best suited for patients who have a genetic condition that routine genetic testing has not been able to identify. The XomeDx test targets exons, which are the protein-coding regions of the human genome. Exons are captured and sequenced using massively parallel sequencing.
|XomeDxPlus includes whole exome sequencing as well as mitochondrial genome sequencing and deletion testing. For more information on the mitochondrial genome sequencing and deletion component of the XomeDxPlus testing, please visit our neurology/mitochondrial genetics page on our website. XomeDxPlus is best suited for individuals with clinical features suggesting a mitochondrial disorder.
|Test Name
|More Information
The XomeDxXpress test is whole exome sequencing with an expedited turnaround time (TAT) of approximately 2 weeks. A verbal result is given within 7 calendar days after the start of testing and will include pathogenic and/or expected pathogenic variants in known disease-causing genes (Human Genome Mutation Database genes). A written report including all clinically relevant, confirmed variants will be reported within approximately 2 weeks after the start of testing. Because of the rapid TAT, blood or DNA samples on the proband and both biological parents must be submitted at the same time, along with clinical information, in order to begin testing. This test requires approval by GeneDx; please email firstname.lastname@example.com to discuss prior to sending in samples.
XomeDxSlice: A Phenotype-driven Targeted Exome Test
Please visit www.genedx.com/xomedxslice or more information on how to order XomeDxSlice
|Test Name
|More Information
(A phenotype-driven targeted exome test)
|XomeDxSlice captures and sequences the whole exome, but analysis is targeted to a limited and specific phenotype-driven gene list. The phenotype-driven gene list must be submitted using the XomeDxSlice online submission tool (link) by the ordering provider. Please review the instructions below.
XomeDxSlice is best suited for individuals with a clearly defined, oligogenic phenotype where a comprehensive gene panel is not available, or the patient has a single gene disorder for which clinical testing is not currently available.
|Test Name
|More Information
XomeDxPrenatal is an expedited whole exome sequencing (WES) test for ongoing pregnancies with abnormal fetal ultrasound findings. There are two reporting options that offer patients a choice on the types of results that will be returned: XomeDxPrenatal Targeted and XomeDxPrenatal Comprehensive. Patients have the option of opting out of the ACMG secondary findings.
With a turnaround time (TAT) of 3-4 weeks, the fetal specimen and specimens from both biological parents must be submitted at the same time, along with clinical information, in order to begin testing. This test requires approval by GeneDx before ordering; please e-mail firstname.lastname@example.com to discuss cases prior to submitting samples.
GeneDx Policy on Secondardy Findings
GeneDx will report out known or expected pathogenic variants in the genes recommended by the American College of Medical Genetics and Genomics (ACMG). GeneDx is currently evaluating probands for ACMG SF v2.0 (Kalia et al., 2016). The presence or absence of the proband's identified secondary findings is available for relatives who underwent whole exome sequencing or targeted segregation analysis as part of the proband's test. ACMG secondary findings are not reported for relatives that opted out of receiving ACMG secondary findings. Variants that may be present in a relative, but are not present in the proband, would not be detected and therefore are not reported. Only variants that have been previously reported and are a recognized cause of the disorder (known pathogenic; KP) or variants that are previously unreported but are of the type which is expected to cause the disorder (expected pathogenic; EP), as specified in the ACMG recommendations are reported (Kalia et al., 2016; Green et al., 2013; Richards et al., 2015). Known or expected pathogenic variants may be present in a portion of the gene not covered by XomeDx and therefore would not be detected. The absence of reportable secondary findings for any particular gene does not mean there are no known or expected pathogenic variants in that gene, or other variants that may confer susceptibility to the disorders listed.
A current list of genes and disorders for which findings may be reported can be found here.
GeneDx offers other services for patients who have undergone XomeDx, XomeDxPlus or XomeDxSlice tests. There is a charge for these services.
|Service Available
|More Information
Carrier/Mutation-specific testing
|GeneDx can provide Mutation-Specific Testing for known familial mutations, in any gene, for families that have had previous XomeDx or XomeDxPlus testing at GeneDx. Mutation-Specific Testing is offered for both symptomatic and asymptomatic individuals, and for dominant or recessive mutations. Mutation-Specific Testing is less costly and more rapid than diagnostic analysis of the whole gene. Pricing is dependent on whether testing is done for one or two mutations. For XomeDx mutation specific testing, please click here to fill out the XomeDx form.
|Informed Consent
Release of Exome Aligned Sequence Data
|GeneDx is able to release whole exome sequence (WES) data for individuals who have undergone XomeDx, XomeDxPlus, XomeDxXpress, or XomeDxPrenatal testing. Data is available as CRAM (compressed BAM file) or VCF files with the signed consent of the patient and applicable family members. GeneDx has generated this sequence data using massively parallel (NextGen) sequencing to target exon regions. The targeted regions were sequenced on an Illumina sequencing system with 100bp or greater paired-end reads. GeneDx has evaluated the data generated by the XomeDx test for the purpose of a genetic diagnosis based on the reported clinical features. GeneDx does not provide interpretation or confirmation by an orthogonal test method for variants unrelated to the patient's clinical features as indicated to GeneDx at the time of testing. Variants not included in the GeneDx report should be considered research results and should not be used for medical management without appropriate confirmation and interpretation by a qualified genetics provider.
GeneDx Consent for Release of Data
|Required Forms
|Additional Forms and Useful Information
1. When is whole exome sequencing useful?
Whole exome sequencing (WES) is a powerful diagnostic tool in 20-50% of patients (Yang, et al. N Engl J Med. 2013 Oct 17;369(16):1502-11, and GeneDx, unpublished data). GeneDx offers three different whole exome sequencing tests: XomeDx, XomeDxPlus (which includes mitochondrial genome sequencing and deletion testing) and XomeDxSlice (a phenotype-driven targeted exome test).
WES can be used to identify the molecular basis of a genetic disorder in an individual with:
- A genetically heterogeneous disease in which no single gene or group of genes makes up a significant percentage of the mutation spectrum,
- A long differential diagnosis for which sequential genetic testing is cost prohibitive
- An atypical presentation
- No molecular diagnosis after exhausting currently available genetic testing
2. What are the different WES tests that GeneDx offers and how do they differ?
There are three types of XomeDx tests:
- XomeDx is whole exome sequencing (nuclear genes only) with a phenotype-targeted report. Unless the patient opts-out in writing, we will report, if present, known and/or expected pathogenic variants in a specific subset of genes as secondary findings. This policy follows the policy statement by the American College of Medical Genetics and Genomics (ACMG) regarding the reporting of secondary findings in clinical exome sequencing.
- XomeDxPlus is a combined test including whole exome sequencing with sequencing and deletion testing of the mitochondrial genome.
- XomeDxSlice captures and sequences the whole exome, but analysis is targeted to a limited and specific phenotype-driven gene list. A list of genes to be analyzed is determined prior to testing by GeneDx and the ordering provider, please click here.
|Capture and sequencing of the exome (i.e. the exons of 20,000+ nuclear genes). Variants in genes that cause, or may be associated with, the patient's phenotype are described in each report. All variants included in the report have been confirmed using a different test method.
Variants identified in the proband are evaluated and reported in the familial samples that have been submitted.
Secondary findings as recommended by the ACMG are reported as a default,but patients can opt-out, as indicated below.
|Capture and sequencing of the exome with reporting similar to XomeDx, PLUS sequencing and deletion testing of the mitochondrial genome (mtDNA).
Next generation sequencing of the mitochondrial genome can detect mtDNA mutations as low as 1.5%-5% heteroplasmy and large deletions (2 kb or larger) as low as 15% heteroplasmy.
Targeted testing by Sanger sequencing to determine the presence or absence of a mtDNA variant in the proband's mother is performed (when a maternal sample has been submitted) and results are included in the proband's report.
Other aspects of XomeDxPlus, including reporting variants in family members and incidental findings, are the same as XomeDx.
|Capture and sequencing of the exome with targeted analysis of genes chosen based on known associations with the patient's phenotype.
The gene list must be reviewed and approved by GeneDx prior to the submission of a sample. Submit a gene list online using our online XomeDxSlice tool.
Specimens Required
|Singletons are accepted. Sending the proband and both biological parents is strongly recommended, whenever possible. Other relatives that may be helpful for analysis are: affected and/or unaffected siblings, and affected 2nd and 3rd degree relatives.
|Same as XomeDx
|Proband only
Specimen Type
|Blood: A single tube with 1-5 mL whole blood in EDTA. Ship overnight at ambient temperature, using a cool pack in hot weather. Specimens may be refrigerated for 7 days prior to shipping.
Purified DNA: High quality extracted DNA can be accepted. At least 15ug is requested (with a minimum concentration of 50ng/ul).
We cannot accept buccal brushes for this test.
|Same as XomeDx
|Same as XomeDx
Information Required
|Medical records, including indication for testing, history and physical exam, review of systems, and results of prior testing performed. Unusual features, even when not the primary indication for referral, are often helpful in making a diagnosis. Please include as much detailed information as you can!
|Same as XomeDx
|Prior to testing, ordering providers must submit a gene list online based on the patient's phenotype through our online XomeDxSlice Tool. The gene list will be reviewed and approved or declined by the GeneDx medical specialists within 1-2 business days. Reasons for declining a gene list for XomeDxSlice include: poor coverage, significant homology to other regions of the genome, and the availability of more sensitive testing.
An approved gene list will be emailed to the ordering provider with the average percent coverage at 10X for the genes requested. This email will contain a unique tracking number that must be submitted with the patient's sample and requisition form.
Incidental Findings
|Genes listed in Green, et al (2013) will be evaluated and known and/or expected pathogenic mutations will be reported as part of our standard reporting protocol.
Patients may choose not to undergo this part of the analysis and reporting by signing the Request to Opt-Out of Receiving Incidental Findings section of the consent form (Click here to download the requisition).
|Same as XomeDx
|Incidental findings are not evaluated or reported in patients who undergo XomeDxSlice testing.
Only the genes agreed upon between the ordering provider and GeneDx will be evaluated and analyzed in XomeDxSlice.
Test Limitations
|Whole exome sequencing does not identify some types of mutations (e.g. trinucleotide repeats, some insertions and deletions)
Exome capture and sequencing has areas of low coverage and/or low quality data. Variants in these regions may not be detected.
Pseudogenes or regions of homology may reduce our ability to detect variants.
While we do our best to interpret variants using the literature and a variety of databases, this can be challenging when the scientific data are limited or conflicting.
|The limitations of exome sequencing are the same as XomeDx.
The mtDNA sequencing and deletion test is expected to detect greater than 98% of known pathogenic mutations and deletions of the mitochondrial genome. Very low levels of heteroplasmy may be missed with this test.
|Same as XomeDx. Because the analysis for XomeDxSlice is targeted, variants present in genes not included on the pre-selected gene list will not be identified or reported.
Regions of any given gene not covered by whole exome sequencing will not be filled in with Sanger sequencing.
3. What does GeneDx need to perform XomeDx testing?
- Proband's specimen (blood, DNA or frozen tissue)
- Completed submission form and consent
- Medical records, including prior test results, consult notes, pedigree, etc.
- Specimens from additional family members, if available.
4. What is the cost of XomeDx?
GeneDx can bill all commercial insurance and the patient is responsible for only the co-pay, co-insurance and unmet deductible as dictated by his or her insurance carrier. GeneDx will perform a benefit investigation and contact the patient if the patient's out-of-pocket cost is expected to be greater than $100. We will work with the patient if the patient has financial difficulty and offer a financial assistance program based on their income. Additional information can be found on our billing page (www.genedx.com/xomedxbilling).
5. What is the turn-around-time for this test?
Please visit the individual test page for turn-around-time information:
6. Whose specimens should be sent for XomeDx and what testing is performed?
Biological parents are typically the most informative samples and are accepted whenever possible. When a trio is sent for XomeDx and XomeDxPlus, whole exome sequencing is always performed on each member of the trio. This improves the sensitivity of the analysis when compared to testing only the proband. In some cases, siblings of the proband will be requested. Sometimes testing distantly-related family members can be helpful. GeneDx will decide, in consultation with the ordering provider, the individuals who can optimize our ability to identify a genetic cause of the patient's phenotype. We will also discuss the type of testing that is most useful and cost-effective (i.e. whole exome sequencing or variant analysis to determine segregation). All individuals' samples should be submitted at the beginning of testing. If additional relatives are indicated to be coming separately from the proband, testing will be on hold until all samples are received. In general, only a single report will be issued for the proband. However, the report will describe the inheritance and segregation of variants for all tested individuals.
7. What if extended family members want to be tested for a variant identified in a patient by XomeDx testing?
Family members can be tested for the mutations/variants identified in the initial patient. Please refer to the information about Carrier Testing for details.
8. Can you use WES to screen the parents for carrier status of recessive diseases?
A test designed for universal carrier screening (such as Inherigen by GenPath: Women's Health) is a better way to obtain this information than reporting them from WES. This recommendation follows the American Academy of Pediatrics (AAP) guidelines recommending carrier testing not be performed on children.
9. How does GeneDx identify variants that are associated with the patient's phenotype?
WES identifies hundreds of thousands of variants. Variants are filtered using a variety of factors including population frequency, presence of gene and/or mutation in HGMD or other database, inheritance pattern, phenotype, severity of sequence change, and function in pathways.
10. Will GeneDx report the parental genotype when a proband has a mutation or variant associated with the proband's phenotype?
Yes. The proband's report will indicate if a parent or other family member who has been tested also has that mutation or variant.
11. Are there any findings that will NOT be reported?
A single report will be issued on the proband (the affected individual in the family). No report will be issued on the parents or other unaffected relatives. Variations known to be benign (not associated with any disease) and/or commonly seen in many other healthy people will not be reported.
If a patient opts-out of receiving secondary findings, we will not analyze or report variants in the ACMG-recommended genes unless they are related to the patient's phenotype.
12. Will the analysis identify mutations in disease-associated genes that are not associated with the patient's reported phenotype?
Over 20,000 genes are being analyzed by the XomeDx and XomeDxPlus tests, which may reveal pathogenic variants in genes that may be medically significant, but not associated with the primary reason for having the test. We follow current recommendations of the ACMG and actively look for and report known and/or expected pathogenic variants in the genes outlined in these recommendations. Pathogenic variants will be reported in these associated genes unless the patient chooses to opt-out by selecting the opt-out option in the patient consent box of the test requisition form. In rare cases, GeneDx may also report an incidental finding in a gene that is not one of the genes recommended by the ACMG. These findings are pathogenic variants identified in the coding exons of genes that are considered medically actionable and the results are significant for your health.
13. Are there genes that are not well covered by this method?
Although there are some entire genes that we may not be able to capture and sequence in a particular patient, in general we expect that there may be small portions of different genes that are not amenable to evaluation. Some exons have low or no coverage because no probes are designed or available for these regions. It may be challenging to get good, usable sequence data for some regions.
14. Does WES detect copy number variants?
WES may detect copy number variants (deletions and duplications) that are three exons or larger. Smaller events may also be detected but with less reliability (Retterer et al., Genet Med. 2014 doi:10.1038/gim.2014.160). As with other types of mutations, any mutation that is included in a GeneDx report has been confirmed. The sensitivity of WES to identify CNVs compared with other methods in a diagnostic setting is not known.
15. Is it possible to reflex to XomeDx if XomeDxSlice is negative?
Yes. You will need to submit a completed add-on form for "Reflex to XomeDx", a completed XomeDx consent document, and submit additional family member samples if possible. For billing information regarding reflex testing to XomeDx if XomeDxSlice is negative, please contact the GeneDx Billing department at 301-519-2100.
16. Will GeneDx offer re-analysis of WES data and what is the cost?
The ordering provider may request a re-analysis of the exome sequencing data for XomeDx and XomeDxPlus one year after the test report was issued. The first re-analysis can be requested at no charge.
17. What platform is GeneDx using?
The exome capture is performed using massively parallel (NextGen) sequencing to target exon regions. The targeted regions are sequenced on an Illumina sequencing system with 100bp or greater paired-end reads.
18. What are the statistics for coverage/quality?
Approximately 95% of the targeted region of an affected individual's exome will be assessed with the XomeDx test at 10x coverage, while >98% of the target region will be covered at a minimum of 1x. We will provide detailed information about how much of the exome was evaluated in the patient on the report you receive.
19. Can we get access to the aligned sequence data?
The sequence data generated by the XomeDx test can be requested by the ordering health care provider. Please see the Consent for release of aligned sequence data form in the "Additional Forms and Useful Information" above for directions and fees.


text:
"It's just a corporate basketball league game and I need the exercise anyway."
"What could possibly go wrong?"
(At the game – Whistle blows – Game starts)
Like any other basketball game, you hear the basketball bouncing, sneakers screeching, players yelling when suddenly …
a loud *CRACK*
… elbow meets face …
… my face, his elbow …
… nose breaks.
Now broken noses in basketball are fairly common but what makes this particularly frustrating is that it is 2 weeks before I leave for a 2 month trip around the world. A classic example of Murphy's law:
"Anything that can go wrong will go wrong."
Has anything ever gone wrong for you?
Perhaps your biggest client left you for someone else right before your performance review.
Maybe your train was delayed on the morning of an important interview.
Or just when you finished paying off your credit card bills, your car breaks down causing you to go back into debt.
In life, things will go wrong and there is usually nothing you can do to stop it (just like there was nothing I can do about my face meeting that elbow) but what you can do is control your actions after.
Unfortunately, most of us react the wrong way when things go wrong. Here is a common list of what NOT to do:
Blame Others
It is common to blame others for our misfortune. When I was injured, my gut reaction was to blame the other person for being so reckless (who throws elbows during a fastbreak). If your train is delayed, you may naturally blame the city for its poor subway system or the sick passenger who had the nerve to get on the train and then get sick.
This desire to blame others comes from a feeling of injustice when things go wrong. We don't deserve it so why is this happening to us. It's not our fault so why are we being punished. Someone else must be causing this.
This is a dangerous way of thinking because blaming others will not solve the problem. It will actually make it worse because when we see ourselves as victims, we tend to feel entitled. We expect others to fix it and we give up responsibility for the issue. We become jerks to anyone not making us their first priority or sympathizing with our issue. This leads to others not wanting to help us and makes the situation worse.
What you might consider doing instead:
Take responsibility.
Things went wrong because of something you did. My nose is broken because I went to play basketball. You were late for your meeting because you didn't give yourself enough time to account for train delays. Once you take responsibility, you stop acting like a victim and waiting for others to help you. You decide to rely on yourself to make the situation better which in turn will make it better. You become grateful to anyone that helps you which makes them want to help you even more.
When things go wrong, it's very natural to regret our decisions that led up to the situation. As I was waiting at the urgent care center with a bloody nose, I thought to myself,
"I shouldn't have played in this game. Why did I go 2 weeks before my trip?"
I started to blame myself for my poor decision. It's the same when you lose a big client. You may regret not calling on them more often or not recognizing the signs that your relationship with them was deteriorating.
We regret because we judge our actions with hindsight bias – seeing events that already occurred as being more predictable than they were before they took place. We spend all our time in the land of "if only" and thinking of what we could've, should've and would've done differently. This usually makes us feel even more frustrated because the "right" choice always seems so obvious after the fact.
What you might consider doing instead:
Focus on the present moment.
It is a waste of time to think about changing the past because there is no way for you to do so. What matters is what you can do now. Regret can be defined as unhappiness with your past choice. You regret because you've lost sight of one important fact:
You made the best decision you can make at the time you made it.
Of course, if you knew the future, you could make a better decision but you don't and you never will.
Don't waste your time on regrets. Acknowledge that, at the time, it was the best decision you could have made despite the outcome. Now focus all your energy on what you will do next to make the situation better and to prevent a similar situation in the future. Learn from your mistakes but don't dwell on it.
Be Depressed
One of the most common reactions to misfortune is to feel down. This happens because we worry about the future. When the doctor told me that my nose was broken, I was worried.
What if I can't go on my trip?
What are we going to do about all the money we spent on tickets and excursions?
What if my nose ends up looking strange for the rest of my life?
Why does this always happen to me?
If you just got out of financial debt and your car breaks down, you may be depressed because you worked so hard just to end up right where you started. I call this the "dark cloud syndrome" because we begin to take our misfortune personally. We feel that there is a dark cloud following us around and that bad things "always happen to us". We just can't seem to catch a break and it leads us to stop trying to make the situation better. We resign to our cursed status and imagine only a gloomy road ahead.
According to the American Scientist, Edward Tryon,
"Thoughts lead on to purpose, purpose leads on to actions, actions form habits, habits decide character, and character fixes our destiny"
- So if you have self-defeating thoughts,
- your purpose will be to defeat yourself,
- which leads to actions that will do just that,
- which form habits where you are constantly defeating yourself,
- until you build up a self-defeating character,
- which results in you being repeatedly defeated in life.
Not a very good outlook.
What you may consider doing instead:
Our realities are based on our perceptions and our perceptions are based on what we focus on. When things go wrong, we tend to focus on all the other times where things have gone wrong and we start to generalize that things always go wrong for us. A better approach when things go wrong is to say to yourself,
"That's interesting because things usually work out for me."
Then spend some time thinking about how lucky you are (if you're living in the US or if you're able to read this article, you are already luckier than many people out there).
I was able to avoid worry and being upset because I thought about how lucky I was. I also spent my time focusing on what the next step should be and creating contingency plans if I had to cancel part of my trip due to surgery. This experience made me realize that it's possible for things to go wrong without feeling frustrated, angry, depressed or worried. Handling this setback in this resourceful way created a very positive experience for me and it inspired me to write this article.
I am grateful to experience firsthand the power of changing my thoughts and its effect on changing my actions and my destiny. I hope my articles can open up possibilities in thoughts and actions for you that you didn't realize existed.
Do you have helpful ways for overcoming bad times? If so, please share them below in the comments section.
Photo by BikeRanger
Robert Chen
Robert Chen is the founder of Embrace Possibility and author of The Dreams to Reality Fieldbook. He helps people who feel stuck move forward by guiding them to see other possibilities for their lives. He specializes in working with high performers get to the next level. If you're going through a tough time right now, check out Robert's article on How to Feel Better Right Away and if you're having trouble getting what you want out of life, check out How to Always Achieve Your Goals.
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15 Responses to What NOT to Do When Things Go Wrong
Glynis Jolly says:
Hi Robert. I've been reading many posts that all seem to say pretty much the same thing. It was refreshing to read yours. Although the topic is not new, your slant on it was. Very enjoyable and your advice on how to really take respnsibility was helpful..
Hi Glynis,
Thank you for reading and for your kind words. I focus on practical advice that I've tested using my own life and I find that it resonates with others as well.
tearoomdelights says:
I like your attitude, it's so tempting to wallow in being a victim instead of taking responsibility for our actions. When these kinds of things happen to me, I usually automatically blame someone else and feel very sorry for myself, but I try to remind myself to take responsibility for it and that helps me to feel better. I have control over some parts of my life, if not all of it, and all I can do is try to make the best decisions I can at any one time. Naturally, sometimes I make bad decisions and I wish I could hit 'undo' (I often wish life had this button when I spill a cup of tea all over the carpet or something like that), but it's just life, things do sometimes go wrong. I think the best thing you can do is exactly what you're advocating, accept that it's happened and look for the good things in the present. I can imagine breaking your nose just before a trip would get you down, it certainly would if it were me, but you have your trip already planned and you have amazing opportunities coming your way. I know you'll make the most of them and I hope you have a fantastic time!
Hi Lorna,
Thanks for the comment. I used to be a master at making excuses and blaming everyone else when things go wrong but I've found that even though it may bring short-term relief, it almost always does long-term harm. I've found to take responsibility and to focus on the solutions has always been the fastest way to not only feeling better but also to make the situation better. Let me know if they ever make the "undo" button. I'll be very interested in getting one.
Thank you for reading and for your good wishes.
R Hariharan says:
Hi Robert,
Your article is straight forward and has helped me come out of blaming others and feeling self pity……. Wish you all the best.
I'm glad that this article was able to help you R Hariharan. Happy New Year and good luck!
Angela HicCups says:
Hello Robert,
These articles(especially this one) are truly amazing,I am actually able to understand these! I've got to be honest when i say I was easily able to relate to these topics with the personal experiences and the lessons we tend to meet up with. And for that I thank you kindly for highlighting the positive outlooks on things like these, I can never think of anyone who hasn't had something go wrong in their lives without picturing the DARK CLOUD as you mentioned and the pain of depression.I'm sure glad i found this because i have recently had something that didn't go the way i planned.I wanted to go to a convention to meet and try to befriend my favorite actor of all time,even though he retired from acting awhile ago,it didn't stop me from trying to accomplish what i thought would be a big change in my usual actions. So, when i went on their website to check in on their guest list, he appeared to have cancelled…I was devastated when i found out, i could hardly bare the tears…That is when i started getting angry at myself,the workers at the convention,and god which i terribly regret doing..i just couldn't help but to think someone was laughing at me which made me angrier and much more sensitive about the way i acted, it still hurts me to think about it.I don't know what final task i would do if i were to choose to give up.Anyway thank you again.
Hi Angela,
Thank you for your comment. What has really helped me to overcome situations that don't go my way is to understand that it is not personal. Things happen for many reason but rarely if ever does it happen to spite us. It has worked for me so far. I wish you the best of luck.
[…] is going to lose readers, my business is going to lose momentum, what is my family going to do if something goes wrong. Maybe I shouldn't […]
Robert Fernandez says:
A more effective perception of mistakes rather than "when things go wrong," is by learning to perceive them as great opportunities presented by life in order to increase strength whether emotional and/or physical.
Agreed: when things go wrong = opportunities for growth
101 Ways to Build Trust with an Employer - Dental Hygiene Resumes - Samples, Tips, Ideas and More says:
[…] blame– when things go wrong, don't point fingers. Empower yourself by taking responsibility and then determining what […]
Wilbur Spivens says:
When things go wrong, I get angry immediately. Never mind blame or regret or depression. As for "What you may consider doing instead," it's a non-starter. I'm already fuming and cursing, and the idea of "consider doing _______ instead" is impossible.
Thanks for sharing Wilbur – not sure if working on your knee jerk reaction to anger is something you want to work on, but if so, you might want to check out this article:
[…] Stay positive and be optimistic […]
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subset: commoncrawl


text:
A federal jury has awarded $100,000 for pain and suffering to a former director of special education for the Malverne School District, who claimed she was fired for reporting sexual harassment.
The director lost her underlying sexual harassment suit, but prevailed on the wrongful-firing claim.
The verdict serves as a reminder that an employer's response to a sexual harassment complaint is as critical as the incident prompting it.
Even if no harassment took place, employees who can prove they were targeted as troublemakers because they complained may win a retaliation claim.


text: Show Hide image Politics 30 October 2008 Round table: Access all areas? Sign up for our weekly email * Speakers: Richard Armstrong Head of Primary Medical Care Contracting, Department of Health Ben Bradshaw MP Minister of State for Health Services, Department of Health David Haslam National Clinical Adviser, Healthcare Commission Jeannette HoweHead of Pharmacy, Department of Health Steve Poulton Commercial Operations Director, Pfizer David Pruce Director of Policy and Communications, Royal Pharmaceutical Society David Colin-Thomé National Director for Primary Care, Department of Health Steve Field Chairman, Royal College of GPs David Furness Health Project Leader, Social Market Foundation Branwen Jeffreys Health Correspondent, BBC TV News Julian Le Grand Richard Titmuss Professor of Social Policy, London School of Economics Martin Roland Director of the National Primary Care Research and Development Centre, University of Manchester Sue Sharpe CEO, Pharmaceutical Services Negotiating Committee David Stout Director, Primary Care Trust Network, NHS Confederation Branwen Jeffreys (chair) I would like to start by getting everybody to make a contribution from the perspective of the patient. Once, patients would have gone to their family doctor as the sole gatekeeper for the NHS. Now the white paper on pharmacy envisages that they might also go to a health advice centre at their local community pharmacy. They might get information online or at the end of a telephone. Ben, why do patients need more options? Ben Bradshaw The options that have been offered to them hitherto have been rather restrictive and have not kept up with changes in healthcare provision, changes in emphasis towards prevention and changes in the way people lead their lives. For example, over the past 18 months we have been having discussions with the British Medical Association (BMA) over GP opening hours. Almost uniquely of public services and healthcare in particular, and in spite of record investment, the public are telling us very firmly that GP surgery opening hours were not convenient to them and to their families. When it comes to pharmacy, there has been a perception for a long time that pharmacy has not been able or given the space to develop its full potential and contribute to a more comprehensive primary-care offer, a more convenient one that a lot of people feel very comfortable with accessing in their local high street. Branwen Jeffreys Professor Roland, is this what patients want? Martin Roland I think they want better options, and better options might include more options. One of the things driving the need for better care is increased complexity, both of medicine and of people's problems as they get older and have multiple conditions. We need to drive a path between better options and not making the system so complex that care becomes more fragmented and made worse by trying to make it better. Sue Sharpe We are seeing the development of pharmacists to help people keep well and manage their own health. As pharmacists develop the services and their interventions with patients around medicine taking, they will help patients feel more in control of their health and their treatment. Patients can get access to pharmacists, talk informally and it allows them options as to how they access the level of care they need. Some will need specialist help; some will need GP help. But increasing numbers will be able to manage their own health needs with better information. David Stout Patients using pharmacists is not a new option. Patients have always gone to pharmacists for advice. However, there are issues around how we make a complex range of services understandable to patients. How do they navigate through this potentially complex field in which some pharmacists offer some services and others do not; some GPs offer some services and others do not. Are the people offering the services properly trained and equipped to give good-quality diagnosis or advice? We need to be confident that we have proper systems in place to ensure quality of care and address this navigation issue. Branwen Jeffreys The Healthcare Commission highlighted that confusion recently. Do people simply turn up to A&E because there is a big sign saying, "This is where you come for help". David Haslam Absolutely. I am a GP as well as an adviser to the Healthcare Commission and it is absolutely clear that there is a need for clarity, logic and simplicity; that patients understand where to go. Healthcare language is confusing - the term "primary-care access" does not mean much to most people. Steve Field Access is important. Pharmacists have been around for years and there is potential in expanding their role, particularly on prevention and on minor illness. As we move more towards roles-based care, protocol-driven care, we need to free up GPs to have longer appointments to deal with illnesses. GPs have to be brave in this, hand over a fair amount of what we do at the moment and extend the length of consultations to deal with the ageing population and so on. However, it will only work if pharmacists are part of the team and what I am worried about is fragmentation and pharmacists doing things that they are not trained for, just as GPs doing things that they are not trained for is also a problem. So the issue is how it fits into the jigsaw. Branwen Jeffreys David Colin-Thomé, do you think that some GPs might be anxious about the changes? David Colin-Thomé Of course, any change causes anxiety. I have probably been a GP longer than most of you here put together and my job was to be available for my patients when they perceived they had a need to see me. That relationship is the important bit and that tends to be confirmed by lots of studies. I was happy to see people with minor ailments because they were Mrs Jones or Mr Smith rather than because it was a minor ailment. Many of them did come with minor ailments because I was their clinical adviser but next time they might come with something major. It depends on your relationship, I think. However, we have to accept that patients might also want to see somebody else and that sometimes causes tension. Branwen Jeffreys David Furness, how well equipped are different types of patients to navigate their way through the system? David Furness The pitch is very mixed. While young people may be very adept at accessing information through electronic resources, they may be less familiar with the landscape of healthcare compared to their grandparents who are better at getting the appointment they want or the service they require. We need to recognise that diversity and hopefully we will end up with a system that reflects it. I am quite sceptical about claims that moving more work into pharmacy would reduce the workload of GPs because we know that demand for healthcare has a way of expanding to fill the available capacity. However, we have to recognise that this diversity of patients may choose things that do not look efficient or effective. They may be more expensive. People may choose to turn up at A&E for their first presentation with particular symptoms. We cannot want both to give people choice and to expand the range of things available to them but then also try to manoeuvre people down a particular path when we know that identical people make different choices. Branwen Jeffreys Julian Le Grand, should we be curtailing people's expectations of what they can make demands on the health service for? Julian Le Grand In general, I have been in favour of expanding the pharmacist's role as they have skills that seem to be underutilised. The caveat is that it might lead to patients thinking that a pill will solve every ailment, whereas if you had gone to the GP, you might have got a recommendation to go to the gym. David Pruce Actually, we have quite a bit of research to show that a lot of people that turn up at a pharmacy expecting to buy a tablet are actually sent away because either they need to go and see their GP or they need a different solution. So that is already part of our philosophy. We need to get to a place where GPs and pharmacists are able to work together more as a team and to learn each other's skills and where the boundaries lie - when pharmacists need to refer a patient on to the GP and when the GP has a complex patient with multiple medicines who would benefit from the advice and expertise of the pharmacist. Steve Poulton Medicine is only effective if it is taken properly and in accordance with the directions of the clinician who has prescribed it. We are trying to work much harder with pharmacies to give them access to information about the medicines we produce. We would like to think we probably know more about our medicines than anybody else does but, for me, this debate is really about the shifting need of what primary care should be delivering. The NHS is absolutely wonderful as a national treatment service. What it is not very good at is preventative medicine, catching people before they get broken. Extending the remit of the broader primary care team to include some of the skills and accessibility pharmacists have could really help that. Ben Bradshaw Since 2004, primary care trusts (PCTs) have been required to publish an annual "Your Guide" and these have been of variable quality, so we have been doing work on this and we are about to issue new guidance. I think you are right that people do not know about services at local level. This should make it much clearer about the offer locally from the pharmacy - what sort of services you can go to your pharmacist for as well, and more and clearer information about GP access. We will also be addressing the issue of PCTs. We need to start calling it "NHS Devon" and "NHS Hammersmith and Fulham" so that most people understand what that name means. Branwen Jeffreys David Pruce, where do you see the boundary between this new role that could develop for pharmacists and what GPs can do? David Pruce GPs have particular skills around diagnosis, but pharmacists do not. If a patient comes into a pharmacy with a minor ailment, we are usually able to say, "This is something that you can treat yourself" or "This is something you need to go and see your GP about". Pharmacists have specific expertise around medicines and our expertise is likely to be better than that of GPs because we have spent more time on it. So we each need to recognise our limitations and see where we can work together. The whole makes more sense than each of the parts does. I do not want to be a mini doctor. I want to be a maxi pharmacist. That is something that most pharmacists would agree with. Branwen Jeffreys Do you think the predictions in the white paper are right that as many as 60 million consultations a year could shift out of GP surgeries into pharmacies? David Pruce I do not think that is how people behave. You are likely to see a shift if the care that is provided in pharmacies is part of the NHS and is free to the same extent it is in general practice. Currently, there is a barrier in that people have to pay for things they buy from pharmacies, whereas at the general practice you get it free of charge. David Colin-Thomé As I say, a lot of primary care is about relationships and some will have a strong relationship with pharmacists and then move on to the GP. Some may have a relationship with a community nurse they are working with. We need flexibility. Even though that might seem more inefficient, primary care is much cheaper than going to secondary care. I think we shouldn't be too mechanistic about the cost efficiency of primary care because you will damage the actual relationship if you make it too simplistic. Steve Poulton I think the danger is that we are not going to see a shift, we will just see a massive expansion. Steve Field I think Ben is right that when you talk about access, access is not just to a human being but to information. Diabetes used to be the realm of endocrinologists and now really is much better managed by patients on their own with some advice. In future, many patients will get that advice from pharmacists, hopefully working with GPs. As things become more roles based or the patients do the investigations and monitoring at home, then they need access to information. For me, it is about how we empower the patient to manage their own care. They might manage it through using the internet for information or by popping along to the pharmacist. Prescription charges are an important point. In inner-city Birmingham, where I work, many patients come to us for cough mixture and things that I would not prescribe and David would not advise as a pharmacist. So we need to work with patients to understand what is best for them. That is more important in the long term. Branwen Jeffreys Some PCTs have started playing around with commissioning a wider variety of services from pharmacies. How is that working? David Stout It is anything from minor ailments services being commissioned as an alternative to general practice for minor ailments through to designated specific services which are additional to what is already in place - contraceptive services and anticoagulation services and so on. So it is working very variably, I suspect. Generally, people see this as a useful addition in terms of choice for patients. However, there is a fundamental value-for-money question that as we offer more services people start to shop around. Can we afford all of these choices, ultimately? Is this the best use of resources? In what PCTs have put in place so far, I think they have seen these services as useful, value-for-money additions. Ben Bradshaw One of things I have been picking up is a lethargy on the part of PCTs, for example, with the vascular screening that is supposed to be rolled out in the New Year by a range of providers, including pharmacists. David Stout I have not picked that up so if that is people's perception it would be interesting to know. Sue Sharpe I think that is right. We have PCTs that are very varied in their ability to look at and think of ways of engaging pharmacy. Some pilots in London are working well in the early stages but we have tremendous inconsistency across the country and I think, as we develop better use of pharmacy, we need to tackle this consistency of offer around the piece so that patients can become much more aware of choices. I think the "NHS Devon" that you cited, that clear branding of where patients go for help, rolled through to pharmacy, will be helpful. Branwen Jeffreys Do you see a distinction in the uptake of these new ideas between the larger pharmacy chains and the many thousands of individual community pharmacists who may feel less able to cope with all of these changes? Will they gradually be edged out? Sue Sharpe Yes. I think the larger chains have seen the strategic direction and have organised themselves to make the change rather more consistently, as you would expect, than the independents. There are some excellent examples in independents but there is more variation. Martin Roland It just strikes me that it is tinkering around the edges. If you came down from Mars you would not do it like this. You would not have one bunch of people who are particularly skilled diagnosticians and another bunch who are particularly good with complex medication regimes and stick them in different places with records and tell them to get on with it. In my practice in Manchester, we employ a pharmacist four days a week. She works with repeat prescriptions, with the doctors coping with patients. It is hugely beneficial. How can a pharmacist help a patient with a complex medication regime when they do not have their medical records? So we need to think more radically if we are going to make the best of what the two professions have to offer. Jeannette Howe I think it is important to think about pharmacy as a mixed model because there are models where pharmacists can work very closely with general practice and we want to encourage that. But, being on the high street, pharmacists are very accessible and can provide services to people who do not actually use the health service regularly. Our conundrum is to balance both of those things. In the white paper, we said we would work with the leading edge PCTs around access to patient records because it is a very sensitive issue. We need to develop exactly how pharmacists will get access to the care-record service and then we can develop services further. Where services are developing, GPs do give pharmacists access to their patient records, so we need to make that more general. We are trying to make pharmacy mainstream within PCTs' commissioning. That is why we are consulting and doing a pharmaceutical needs assessment as the basis for decisions around the commissioning of pharmaceutical services. The white paper recognised the need to support service development with commissioning to the public. We are working particularly with people with long-term conditions, to find out what they understand about pharmacy, how they want to access pharmacy, terminology and so on. David Haslam From a regulatory point of view, for the Healthcare Commission and, from next year, the Care Quality Commission, the real drivers are going to be both quality and safety, and safety is absolutely key. It is absolutely spot on about the communication issues and the illogicality of the gaps. We have to find a way, realising that we cannot completely restructure the health service. Medical records are part of that but, as the population ages, and we have more people with multiple problems and multiple comorbidities, all the simple disease guidelines cease to be as valuable. It is absolutely key that pharmacists, GPs and secondary care are working coherently together. David Furness It seems we have identified the tension between wanting to create solutions with locally commissioned services involving pharmacy and the problems of lack of uniformity. Sometimes we want to have our cake and eat it - to have uniform national standards across the country but then encourage local autonomy and decision-making appropriate for a local population. That circle has not been squared in the NHS over 60 years. Perhaps the variety in services is something we need to start promoting the benefits of to local people. Julian Le Grand Something we have not mentioned so far is the incentives in the system. GPs have an incentive to economise on prescribing because they have got to think about all the possible demands on their prescribing budget. Pharmacists cannot over-sell prescription medicine but they can sell over-the-counter medicines and their incentive might be to sell a little more than might be wholly appropriate. These incentives work in opposite directions. We must have a system that operates with checks and balances. David Pruce In Canada, they have looked at that by having a "non-dispensed fee". When a pharmacist actually says, "No, you really do not need this," the pharmacist gets a fee from the equivalent of the PCT for stopping the medicine, which I think is a very interesting model. It incentivises pharmacists to look at what the GP has prescribed and say, "Actually, you know, you can rationalise this". We currently have a system of medicines use reviews being started up within the NHS in England and Wales that asks patients: "Are you actually taking these medicines?" "Are you having problems taking them?" We know from research that patients do not take about 50 per cent of statins prescribed. We spend a lot of money getting the prescription right but much less getting the patient right. Sue Sharpe On pharmacists' incentive to sell medicines patients do not need, I think it is important to get that in perspective. Ninety per cent of a pharmacist's income comes from the NHS. Only 5 per cent of total income comes from selling medicines and that has been reducing year on year as supermarkets have taken up much more of that sort of need. So I think it is important to look at pharmacy as an NHS business now, not a private-sector business with a very healthy front-of-shop turnover. That changes the way you think about how you use that resource. David Stout As the conversation has gone on, I have been thinking that there are two effects going on here. One is around use of medicines, minor ailments and so on, where we clearly want pharmacists and general practice to work together as a team, and then there are other services where pharmacists are actually competing with general practice. Vascular screening might be an example; the practice might want to offer the same service that a pharmacist might and they will be competing for business. One of the conundrums we need to manage is that relationship between competition and collaboration. If you are competing with each other, you might not be collaborating when you should and if you are only collaborating you might not be getting the competition you need. So how do we manage those two pressures simultaneously? Branwen Jeffreys Steve Field, how do you see that referral working from one to another? Steve Field We have a pharmacist in the surgery for quite a bit of the week. We also work with our local pharmacy "shop", if you like. We do joint advice across the divide. One of the ways of incentivising this is to prioritise joint bids for work between pharmacists and GPs. If you had a joined-up system and you encourage that through the commissioning cycle, just as you would do through a pathway of care, diabetes or whatever, I think the world would be a better place and would also allow for some choice. We are at our best when the pharmacists are working in the surgery looking at the complexity of medicines and trying to reduce the number of medications people are taking or stop them. However, we know that a lot of our city patients want to go to their local pharmacy because it is open at different hours and it is not as far for some of them to walk. That is their choice and that is fine while you have got that referral backwards and forwards between the two. I think joint commissioning is the way forward. Branwen Jeffreys So, in the same way that GPs group together to bid as consortia, do you think that is how it might work with GPs and local pharmacists getting together to make a joined-up offer to provide a package of services? David Colin-Thomé I hope so because that is the thrust of our core policy in the Primary and Community Care Strategy from the Darzi Review. One of the problems with that, maybe, is our immaturity around some of the market issues. We either kick hell out of each other or we collaborate too cosily. The issue is how do you work together as a coherent whole but allow some choice within that? How do you keep that choice element so that people can go to the doctor; they can choose between different GP practices within this integrated-care approach? It will be a test of our mettle as to whether we can do both. Steve Field That is why we are promoting the federated model between pharmacists. Actually, the future will be aggregations of practices and pharmacists and other healthcare professions working together. At the moment, we do not trust all our PCTs to make appropriate commissioning decisions. We have a lot of mistrust in the system down at ground level, partly because of the new centres that have been put in and the way a lot of the discussions and consultations have not worked. Integrated care is something we support very strongly but we need PCTs to commission appropriately. Ben Bradshaw In terms of their relatively enthusiastic advocacy of the state of the NHS, GPs have never been quite in the forefront! [Laughter] Perhaps that is the most diplomatic way I can put it. Second, their morale is considerably better than it was before the new contract was introduced. Steve Field That is true. I think my point is not about the fact of these centres, because we welcome the investment but, when you start to look at commissioning, it is the local trust that is important. I think what your "NHS Devon" needs to do is work with its GPs and pharmacists to develop use of language locally, and demonstrate that they are working with pharmacists and GPs and nurses and others. Unfortunately, I think what happens is that that is quite patchy at PCT level. Branwen Jeffreys What needs to happen to make sure that there is not a huge difference between richer and poorer areas and also urban and rural areas in terms of providing a good variety of choice and making sure that everyone is equipped to use it? Julian Le Grand There is a problem with engaging in competition (if you believe competition is a good idea) within rural areas because rural areas do not have enough services, effectively. So you have to think of some way of making sure that those services meet the needs and wants of patients. Actually, 90 per cent of the British population live in urban areas, so, in terms of population, rural areas are extremely small. In trying to think of system change and reform, we really ought to concentrate on problems in urban areas and try not to worry too much about the rural situation. David Haslam In many of the urban areas, there are significant numbers of transient or immigrant populations who simply do not understand the way we work. Their default position is to go to hospital because, in many of the cultures that they come from, that is what they have done. Also, because of the complexity of our model, their ability to know about the alternatives is limited. The Healthcare Commission has been pretty keen on developing a single-access phone number for non-urgent care as a means of getting around this. There are all sorts of arguments for and against but it looks as if that is one way of bringing clarity into the system. Over the past couple of years, we have been talking a great deal to the Academy of Royal Colleges, the BMA, the Royal College of Nursing and others about what high-quality care looks like? Clinicians really want to buy into this and the vast majority are signed up to delivering improved care. So, engagement with them is the key, rather than a position on them. Ben Bradshaw I think I am right in saying that your report last week showed that patient satisfaction, as well as your grossly misrepresented findings on GP access, were generally better in rural areas than they are in urban areas. The trajectory of improvement in London is significantly slower than the rest of the country and a lot of that is about primary care and GP access. Second, we have to be cognisant of the debate there has been about dispensing GPs and the particular role that they play in rural areas, while addressing some of the problems there have been with market entry. Although there are serious problems with the system at the moment, we would not want to do anything that had a disproportionately negative impact on rural areas. Inevitably, if you live in an isolated rural area, how real will your choice of GP ever be? At least the GP-led centres will give people a choice. For example, people who commute from rural Devon into Exeter, whose own GP in their village does not have extended opening, for whatever reason, will still be able to access a GP in the evenings or at weekends in the place where they work. David Colin-Thomé NHS Direct is another option too, rather than always going to the clinician. David Furness I think what we have are policy trends going in the right direction. If you offer diversity, then perhaps that makes it easier for people to access services most appropriate for them, which makes them more likely to do so. If people get on particularly well with their pharmacist, why not go and see them rather than their GP as the first port of call? There are issues around supporting people's choices and PCTs have a big role to play in that. There is a challenge to overcome in terms of variation. It might also be about on-site support. Perhaps there are things we can do to make consultations with pharmacists and GPs more effective. A company in the US has people sitting in GP waiting rooms waiting for the pharmacist to help them work out what questions they want to ask, rather than receiving the information dump that can be a feature of GP consultations. So there are options. There is not really any evidence of frivolous demands on the health service, so we probably need to focus on the small percentage of people who do not access the NHS at all and who should be accessing it. Branwen Jeffreys But how do you get to the people who are not using the health service enough? Steve Field It might not be the normal suspects. Men commuting into cities do not access health systems particularly and that is partly because of the timing of accessing the surgery. I would agree with Ben when he says somebody having to take a day off work to see the GP is a problem. However, you have to balance access with maintaining continuity of care. If you have a patient with a long-term condition or multiple conditions, they need someone to help them navigate their way through all of that. Ben Bradshaw The other thing the government announced last year, along with the new health centres, was an investment in extra practices in the 50 or so least well-provided areas. Also, we are changing the Quality and Outcomes Framework (QOF) in a way that will help incentivise GPs to look for and find those people that are currently hard to reach. Martin Roland I think there is some agreement about choice. Choice has a tendency to increase inequality simply because the articulate are more able to navigate the system and they happen, also, to be the sicker people. The London Patient Choice pilots provided patients with advisers to help them make those choices and also provide some financial support for transport if they were going to go to a different hospital. It is important to recognise that choice does increase inequalities and we do not have to accept that. We can actually do something about it. On the QOF, my hobbyhorse here is around continuity of care. We have never had a means of looking at the extent to which practices are providing continuity of care, allowing patients to see the GP they want to see, but we will have that from the new year because it is going to be in a new questionnaire that Richard has commissioned. That will go out to millions of patients in the new year. I think that is an important aspect to bring into the discussion. Branwen Jeffreys Sue, how do you ensure that someone does not have that terrible experience of going to the GP surgery, perhaps going to a walk-in centre, perhaps going to a pharmacy and constantly retelling their story? Sue Sharpe It is a problem in secondary care as well as in primary care. Easy access to shared records among all the clinicians who are participating in care is the only sensible way that we can get the infrastructure to support that. I wanted to make a point about people, and particularly men, who are more reluctant because of work pressures or whatever to access care. There was a very interesting NHS-funded pilot in the centre of Birmingham where Lloyds Pharmacy undertook some heart checks. Seventy per cent of people who walked into pharmacies to go for a heart check were men and that compares with about 20 to 30 per cent of normal users of pharmacies who are men. Branwen Jeffreys Is it that they simply felt that they could not or should not be bothering their doctor or that it was just opportunistic and offered to them on the spot, so it was convenient? Sue Sharpe We do not know why, but we need to find out. My guess is it is both of those. David Colin-Thomé Fewer men go to pharmacies than to GPs. That is why this pilot was so different, because it was counterintuitive. David Pruce Continuity of care is right for some conditions but not for everything. We know that from work we have done in pharmacies. Patients with long-term conditions will often use the same pharmacy. But patients seeking advice on minor conditions or seeking anonymous advice will go anywhere. We have seen that with pilots around chlamydia screening where anonymity is important to people. Not everybody actually wants continuity of care. David Stout PCTs are not just working on developing new health centres. They are focusing efforts on tackling health and equalities as well - targeted intervention. We often describe patient choice as wrong, in a way. If it is a relatively minor condition we say going to A&E is wrong. I think we need to change our mindset around that. If that is an individual's choice and that is where they have gone for healthcare then let us make sure that we have the services that can deliver, if that is the pattern of care in the locality. Smart commissioning will be designing services to meet local needs, not a national template. Branwen Jeffreys David Haslam, could I ask you to talk a little bit about this idea of investing more in guiding people through the system? David Haslam You just have to deal with the person presenting where they are with the right sort of service. If people present at A&E with a problem that is not an A&E problem, you need to have worked out a way to get a good generalist there, ideally a GP, who is much less likely to admit or investigate or whatever than a junior hospital doctor. There is plenty of research showing that that is what is required. As I said, the Healthcare Commission is enthused about the concept of clearly signposted navigation, mainly through single phone numbers. We need to consider the genuine meaning of "patient-centred" rather than it just being a mantra. It is looking at what the patient really needs and wants and that may be different on different occasions. If I get crushing chest pain I really do not care who treats me as long as they are qualified. But if I get a long-term condition flaring up again, I do not care if I wait a fortnight to see my GP because that matters to me. We need to build that flexibility into the system. Branwen Jeffreys How much are patients already exercising the choices that they have? David Furness The evidence is slightly mixed. It has always been accepted that you need relatively few people exercising choice to have a big impact on providers but I think we need to recognise that this is a different sort of choice. We are not talking about, "Where would you like to have your hip done?", after you have been admitted into the system and had those diagnostics. We are talking about what, for most patients, will be a more important sort of choice, which is a range of services that you can pick from on everyday healthcare stuff. Ben Bradshaw We have only had free choice for six months, have we not? There has been a manifold increase over those few months of people exercising choice for secondary care. We do not have true choice in primary care everywhere yet because, as we know, some people find it difficult to change their GP. Some people are not aware that they can. Awareness of choice is still too low, partly because patients are not being told loudly enough or regularly enough by GPs and PCTs and others that they have a choice that they can exercise. I would just like to challenge Martin on something. It is logical that the more informed you are and the bigger elbows you have, the more you are going to exercise your choice but I think the evidence also suggests that choice does help drive up standards across the piece. The anecdotal evidence from some of these new health centres that are opening with extended hours is that it is blue-collar workers using the services because they are paid by the hour and otherwise they would lose pay. The potential for choice to drive up standards across the piece should not be overlooked. Alan Johnson made the point about health inequalities recently that, yes, the gap has widened over the past ten years, but the lowest two deciles are now at the level that the upper two were ten years ago. So would we have achieved that massive increase across the board if we had not introduced some incentives, including choice? Julian Le Grand The crucial point is that non-choice systems also favour the better off, possibly even more. They are much better able to manipulate and manoeuvre our systems. There is some very preliminary research out that is not yet published, so early days, but it is beginning to look as though in 1997 the poor tended to wait longer than the better off for certain elective procedures. It now appears as though they are waiting less time than the better off. I would like to think it is because of the introduction of choice. There are probably a number of reasons. Branwen Jeffreys Is there any reason we can draw on to tell us anything about primary care and whether or not poor people will benefit from the introduction of more choice in terms of their everyday health services? Julian Le Grand We do have this problem at primary care level, that many of the poor areas are not well served by GPs. Certainly increasing the sheer availability of GPs and GP services in those areas will be desirable, quite apart from anything we think about the incentive effects of choice. Richard Armstrong There is quite good evidence that the more primary care clinicians - not just GPs - you put into an area, the more you drive up the standards of health. Partly that must be because of choice in that there is choice to have those clinicians, but, generally, it is because investing in more primary care clinicians is a much more cost-effective way of improving health and healthcare. Steve Field That is why we welcome the investment in inner cities. We would have done it in a slightly different way but, in some areas, you do need new centres. In other areas you need to build on what you have. Across all of it you need to get clinicians working together. Pharmacies and GPs working in a federated way would be better than simply putting in small practices. One of the problems we have is a lot of smaller practices. They need to work together more efficiently. David Colin-Thomé There is some evidence in the US that the threat of choice gets providers to sharpen up. However, the other aspect of choice that we have not been good at in the health service is patients might like their provider but it is a choice of what happens to them that we are maybe not so good at. The Commonwealth Fund suggests that British doctors, not necessarily primary care, were less participatory in their consultation style than doctors in other countries. For chronic disease/long-term conditions, that shift in culture is fundamental and might even help some of that drug uptake if people felt it was shared decision-making. We hear many stories where patients were just told, "This is good for you". Sue Sharpe Around choice, there is an interesting example in Hackney, which is a very under-doctored area. Pharmacies in Hackney started to undertake regular flu jabs for patients and City and Hackney PCT moved from near the bottom of the league table for targeted flu jabs to right towards the top, just in the year that they introduced pharmacy-based flu jabs. So, there is an indicator that extending access might help in those sorts of areas. David Pruce On patient participation, we know from patients coming to us as pharmacists that they often do not understand what their tablet is, what it is for and so on. We also know that the more information we give people about their medication, what is it for, what the side effects are and how long is it going to take to work, the more it encourages people to stick with that medication. This is particularly true for things such as antidepressants, where it takes four to six weeks before you see any effect, and most of the side effects occur in those first four to six weeks. So, providing the patient with that information is likely to improve uptake, compliance and so on. Patients only take away a fraction of what you actually tell them. That may be as low as 30 per cent, particularly if the GP has just given the diagnosis. That clouds everything. Steve Field It needs rephrasing and reinforcing. I agree completely. The problem we have is that some practice is poor. Branwen Jeffreys I would like to go round the table again and this time ask you where you think we will be in five years' time. Do you think that patients will be exercising their choices and options and that this will benefit them? Julian Le Grand Yes, I think we will be in a situation of more choice and I think it will benefit patients too. I am not that worried about the massive range of opportunities open to people. I think having a range of options is a good thing. I think there are loads of under-utilised skills that we could make more use of. So, yes, I think there will be more choice available and I think it will indeed benefit patients. David Pruce It depends what we do over the next five years. It depends whether the professions put effort into working together, whether government puts incentives into people working together and whether the PCTs or "NHS Devons" facilitate it. If it is left to happen on its own then probably it will not happen. Steve Poulton In terms of point of entry to the system then, inevitably, we will have more choice and people will be exercising more choice. I hope that, once people are in the system, we will have a more holistic view of the whole pathway, that is: awareness, presentation, diagnosis, treatment, prescription and advice. Primary care is focused on the bit between presentation and prescription but there is also the upstream bit around awareness and presentation and the downstream bit around compliance. I think that is where pharmacy can really add value. Ben Bradshaw Commissioning will clearly be key. We have not talked about the economic context and the importance of delivering all of this and, at the same time, delivering value for money, which is where commissioning will have to come into its own. How far the public are encouraged to and actually do exercise their choice will be important if it is to work. Branwen Jeffreys Do you think there may be more services but also more demand? Ben Bradshaw We may already be seeing this with a somewhat mysterious rise in GP referrals in some PCTs. It would seem that part of it is that GPs are actually referring, whereas before they would not have bothered because the person would have had to wait too long. Martin Roland I am fairly pessimistic. Unless the professions put effort into working together, and unless there are incentives for them to do so, I do not think a lot will change. If we want things to change in the way that people clearly have a vision that they could, we need to do more than we are doing at the moment. Sue Sharpe It is a big challenge. The NHS must play its part in promoting pharmacy as an NHS resource, and inter-professional working. Shared records are absolutely key. We must have a degree of commonality or consistency of what is on offer around the country in order to support patients having the understanding of the range of options as they go and access care. David Stout I am optimistic that the effort we are putting into commissioning is driving this system in the right direction but it is dependent on multiple perspectives working together. It is about the professions, commissioners, the public and regulators dealing with poor performance. The media have a role in telling the story of how this operates. Push the policies in the right direction and I am optimistic that, if all those groups work together effectively we will see better services, better access and better outcomes. David Haslam One area we have not talked about at all is the really important concept of encouraging self-care, which I know the Department of Health (DoH) is very enthused about. I have been doing some work for the Academy of Royal Colleges with the DoH on an educational curriculum on this. The trouble is that the more you open up access to expertise such as doctors, nurses and pharmacists, the more self-care seems to move back. Not to knock it, but it actually does something to the building up of expertise and it will require doctors and pharmacists to do an awful lot more education as opposed to prescription. The boundaries between primary and secondary, NHS and the independent sector, health and social care are falling away. They have become less and less relevant and important and the role of a regulator like the Care Quality Commission (CQC), which will be across all these sectors, has real potential. If we focus around good, safe quality and get rid of some of these boundaries and recognise that the strength of primary care is generalism and the strength of secondary care is specialism, and bring those together, I think we have a different model. Steve Field I am an optimist, but I think the key is this integration, horizontally and vertically. The professions need to understand that they are not under threat. Once you feel under threat, it is difficult to move but there are massive opportunities for pharmacists and for GPs. I think one of the issues in the past nine months has been GPs feeling threatened. Yes, integrated care, with care moving towards the patient and out of hospital buildings into closer areas. My only concern is that the future will actually be smaller units, not at PCT level but conglomerations, aggregations, practices, pharmacies, dentists and physiotherapists. I think PCTs are too distant from that, so forming clusters around health economies is going to be key. Inevitably, unfortunately, there will need to be a restructuring to support that because some PCTs are too distant from where the patients are. David Colin-Thomé Five years is quite a short time. Yes, there will be more choice. I think also, in certain areas in particular, we want more demand. One of the issues, especially in working-class areas, is that we need to be more proactive about looking for problems. Sometimes the professions are in such a dependency culture that they want the incentives to hit them between the eyes. That is why I am quite keen on pilots. Historically, we have tended to concentrate very much on the underperformers and our national trades unions, rather than saying, "Give some of the guys who want to do stuff their head." I think the integrated care worker will say, "Here are the keen guys. Let them fly," rather than constraining them. If that splits the profession, all well and good. The hope for fast tracking some of this stuff is in the use of incentives, because we can use that best, rather than saying, "The government should do this and the government should do that". A number of people are hoping to get involved in these integrated approaches. David Furness I think, echoing David's last point, it is spot on to be focusing on where we can get pockets of good practice and the challenge will be to roll those out across the whole system. That is why I think there are two key challenges here. One is commissioning and the organisational capacity of PCTs in different parts of the country to deliver this as well as what the top guys will be doing. The second is a regulatory issue. We know there will be a lot of change and disruption over the next months and years. The introduction of CQC and its role in spreading good practice could be crucial but may be difficult to deliver, given that it will be dealing with a whole new set of challenges. So many different positive things. I think we have got the policy-keepers all facing the right way but there are lots of different stakeholders that need to get together and deliver it. Obviously we hope that, in the end, the winner will be the patient. Branwen Jeffreys We hope indeed. Thank you very much for taking part in this round table. This round table report is one of a series of reports based on the New Statesman & Pfizer Policy Forum, a programme of events and publications. Launched in April 2005, the programme aims to explore, through dialogue and debate, a range of issues that concern policy-makers and the electorate alike. Previous reports can be found on our website. Subscribe from just £1 per issue This article first appeared in the 03 November 2008 issue of the New Statesman, Israel v Hamas More


text:
Charles Paint 1G Clear Paso Liquid Sander Deglosser
- Removes wax, grease, polish, etc. from surface without sanding or stripping.
- Cleans the surface and dulls most glossy finishes.
- Helps provide an excellent bond between the finish coat and the existing finish.
- Can eliminate 99% of the sanding, just scratch the surface with steel wool or sandpaper.
Cleans the surface to provide better adhesion. If you don't like to sand, try Paso


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'Kitty McScratch' Dances Into Guinness World Records 2012 Gamer's Edition With More Than 85 High Scores
Suggested Photo Caption: Iowa's Elizabeth Bolinger, AKA Kitty McScratch, dances her way into history
where she earned the title for'Most Prolific Dancing Game High Scorer' with top scores in over 85 songs spanning across the Dance Central and Just Dance franchises. She's featured in the Guinness World Records 2012 Gamer's Edition out now. (Photo Credit Ryan Shude/Guinness World Records)
NEW YORK (January 12, 2012)– A new dancing queen has boogied her way into the latest edition of the Guinness World Records 2012 Gamer's Edition. The global authority on all things record-breaking is recognizing Elizabeth'Kitty McScratch' Bolinger as the 'Most Prolific Dancing Game High Scorer' with more than 85 number one high scores on the Just Dance and Dance Central franchises.
Elizabeth's love of gaming stems from using videogames as a way to challenge herself to new heights of achievement. The 24-year-old was first introduced to video games in the early 90's by her father, who was immersed in the world of casual PC gaming.
Having first earned a place in the 2011 Gamer's Edition with the high score for'Dare' on Just Dance (11,661 points on Aug 8, 2010), Liz caught the record bug and has since racked up more than 85 high scores on the Twin Galaxies leaderboard. Her highest score is for the Dance Central track"C'mon Ride It (The Train)", with a staggering 432,793 points!
A true dancing game enthusiast, Liz pushes the limits of her ability by achieving top scores blindfolded and sometimes backwards! Her favorite songs to dance to include"Hot and Cold" by Katy Perry where she's scored over 16,000 points blindfolded and"Bullet Proof" by La Roux.
A long-time fan of the Guinness World Records books as a kid, Liz says: "You really can make dreams happen, it's just a matter of putting in the hard work and dedication."
She is an active member of the International Video Game Hall of Fame and Museum in her hometown Ottumwa, IA and is dedicated to preserving the history of videogames.
Guinness World Records 2012 Gamer's Edition is available now in the US for a suggested retail price of $14.99 and available in the UK on January 19 th.
For more information on gaming record breaking, please visit www.guinnessworldrecords.com/gamers
About Guinness World Records
Guinness World Records is the universally recognized authority on record-breaking achievement.� First published in 1955, the annual Guinness World Records book is published in more than 100 countries and 25 languages and is one of the highest-selling books under copyright of all time with more than 3 million copies sold annually across the globe. Guinness World Records celebrated its 50th anniversary edition in 2004, a year after the sale of its 100 millionth copy.� Guinness World Records also annually publishes the Gamer's Edition; a records book devoted solely to the world of computer gaming and high score record achievements.�


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Another case...?
Wootalyzer's Pricing Post! - The price of today's woot item is saved here for future reference------------------------------------------------------------MEElectronics Leather Case for iPad$5.99 + $5 Standard OR $10 Two-Day OR $20 One-Day ShippingCondition: New*DISCLAIMER* Wootalyzer! is in no way affiliated with Woot!, and this post may not always be here!
So, NOT Surface compatible?
dabrain13 wrote:Another case...?
They're "costumes" for your electronics, get it?
For the ipad 1 or the "new" ipad?
Wow... woot-off theme; Cheaply made cases for tablets and point&shoot cameras.
Leather? I thought all iPad owners were vegans.
bob671 wrote:They're "costumes" for your electronics, get it?
Then why don't they look like spongebob?
You could totally spray paint that thing yellow.
anago wrote:Then why don't they look like spongebob?
Um, sorry to be picky, but on the write up...
Put you iPad in and say...
I'm really not planning on being an iPad for 9Hallo/Kludg)oween, but...
Maybe this one is into leather...
Ailetoile wrote:You could totally spray paint that thing yellow.
Good point!
same as amazon
Which iPad? I have the "new" soon to be old iPad 3rd gen). Will this fit mine?
ipodguy wrote:same as amazon
Actually cheaper at Amazon due to shipping!
There's been a whole lot of iStuff in this Woot-Off!
View All →


text: I am closing the discussion thread about naturalism with this post.Some have objected that my arguments against naturalism are rooted in fundamentalism. Nothing could be more wrong. 20th century social philosopher Max Horkheimer was not noted for being particularly religious. However, he saw the same flaw in naturalism (which he termed "positivism") as I see. And as Catholic theologian (whatever the Vatican may call him) Hans Kueng sees. Here is Hans Kueng quoting Max Horkheimer. The … [Read more...]


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very good day :P
This is a discussion on Bought Two New Toys Today... within the Defensive Carry Guns forums, part of the Defensive Carry Discussions category; hmm i keep getting those pre apporved notes from credit card companies. Thumper, knock it off! You're gonna get me in trouble! -mac...
hmm i keep getting those pre apporved notes from credit card companies. Thumper, knock it off! You're gonna get me in trouble!
"In those days, there was a lot more respect for other people and it showed in peoples values.... Today the word value means nothing more than something you get on the $1 menu at McDonald's." -BARK'N
very good day :P
War is not the ugliest of things. Worse is the decayed state of moral feeling which thinks nothing is worth a war. A man who has nothing for which he is willing to fight, nothing which he cares for more than his personal safety, is a miserable creature who has no chance of being free. -J.S. Mill
I have definite P-envy!!
"When they come kick at your door, how you gonna come, with your hands on your head or on the trigger of your gun" The Clash©
XD40 Service
Panther AR-15
Between You and my brother (he got a new Walther ppk yesterday) Your KILLING me....
Colt Officers ACP
Smith & Wesson 649-5
Smith & Wesson 637-2
As a SIG'o'phile I can understand but - still - say after me three times ..
"Yes - I know - I was so wicked"
Just hope you have some pennies left to buy 'fuel'
Chris - P95
NRA Certified Instructor & NRA Life Member.
"To own a gun and assume that you are armed
is like owning a piano and assuming that you are a musician!."
http://www.rkba-2a.com/ - a portal for 2A links, articles and some videos.
I am glad to see somebody else with "SIGitis". On Wednesday I ordered a P226R .357 TDA Combo Pack with the free .40 barrel and blue Siglites for, like, $730 from Buds Gun Shop here: http://www.budsgunshop.com/catalog/index.php. They might even have a couple left. This pistol will join my 229 .40 TDA, 229 .40 DAK, 239 .40 TDA, 239 .40 DAK and, as of last Saturday, a DPMS LR308 AP4 which is a .308/7.62 NATO AR. The Finance Committee is fit to be tied, so this will be it for a while, I bet.Next year, maybe, I will get a..wait for it...226R .40 DAK and a .357 barrel! Oh, the agony..
Those are nice, I don't have a Sig yet.


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DRONAcharya Bharadwaja
|Died in Kurukshetra, Kurukshetra, Haryana, India
|Cause of death:
|Immediate Family:
Son of Saptarishi BHARADWAJA Brihaspathi and Apsara GHRITACHI
|Managed by:
|Private User
|Last Updated:
Immediate Family
<private> Bharadwajastep-parent
<private> Bharadwajahalf sibling
half sister
mother's partner
half brother
About DRONAcharya Bharadwaja
Drona was born a Bharadwaja brahmin, in 9000BC Dehradun. Drona implies that he was not gestated in a womb, but outside the human body in a droon (vessel or a basket). The story of Drona's birth is recounted dramatically in Mahābhārata, Book I: Adi Parva, Sambhava Parva, Section CXXXI.[2] Bharadwaja went with his companions to the Ganges to perform his ablutions. There he beheld a beautiful apsara named Ghritachi who had come to bathe. The sage was overcome by desire, causing him to produce a reproductive fluid. Bharadwaja captured the fluid in a vessel called a drona, and Drona/Dronacharya himself sprang from the fluid thus preserved. Drona would later boast that he had sprung from Bharadwaja without ever having been in a womb.
Drona was often without doubt, partial towards Arjuna. Any great teacher would feel enthralled if his protege so excels as Arjuna did, thus, so was Drona. Drona was somewhat parallel to Bhishma both in martial prowess, and in his unwavering commitment to fighting for the kingdom of Hastinapura irrespective of who the ruler was and whether or not the cause was just. Lord Krishna was critical of Drona for remaining a mute spectator and not having protested the humiliation of Draupadi by Dushasana and Duryodhana following the fateful game of dice. He is also criticized for his pride and conceit, siding with evil despite knowing of and acknowledging the righteousness of the Pandava cause. However, he was compelled to side with the Kauravas because he was indebted to their royal household, which had provided him and his family with shelter, wealth and an occupation. It may also be concluded that he was responsible for the devious murder of Abhimanyu, as it was he who had suggested simultaneously attacking and disabling the tired, outnumbered and trapped warrior. He also acted unfairly, when he demands as Guru Dakshina, payment to the master, the right thumb of Ekalavya who taught himself with Drona as his "Manasika Guru"(Guru in mind). This point is debated as Ekalavya learnt by secretly watching the instruction of the princes. This was tantamount to stealing, and Drona contends that his Guru dakshina was not merely Ekalavya's thumb, but the knowledge that he had stolen. However, he remains a revered figure in Hindu history, and a pillar of the Indian tradition of respecting one's teacher as an equal not only of parents, but even of God. The Government of India annually awards the Dronacharya Award for excellence in sports tutelage to the best sports teachers and coaches in India.[11] It is believed that the city of Gurgaon (literally - "Village of the Guru") was founded as "Guru Gram" by Drona on land given to him by Dhritarashtra, the king of Hastinapur in recognition of his teachings of martial arts to the princes, and the 'Dronacharya Tank', still exists within the Gurgaon city, along with a village called Gurgaon.


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Rush: "We Don't Need RINOs Cutting Deals With Imam Obama"
Research ››› ››› MEDIA MATTERS STAFF
By Adam Shah
Rush spent most of his opening monologue complaining about Stephen Colbert's testimony before Congress. Moving on to more serious matters, he attacked conservatives and Republicans who were not enthusiastically supporting GOP Senate candidates Joe Miller from Alaska and Christine O'Donnell from Deleware. Rush stated that we don't need any more RINOs cutting deals with "Imam Obama." He also said that he'd vote for Mickey Mouse or a rat if it would vote against Obama. Rush closed out the first hour by singling out Charles Krauthammer and Jonah Goldberg as people who need to call for Sen. Lisa Murkowski to get out of the Alaska senate race.
Rush later moved on to attacking President Obama for his United Nations speech. Rush claimed that Obama was bashing Israel by talking about the Israeli-Palestinian conflict. Israeli Prime Minister Benjamin Netanyahu, however, praised Obama's speech. Rush also discussed Obama's statement in his UN speech that Wall Street caused the financial crisis. Limbaugh said that in some parts of the world, " 'Wall Street' is shorthand for the Jews," and let his listeners draw their own conclusions about what Obama was doing. Turning to Iranian President Mahmoud Ahmadinejad's 9/11 truther comments before the UN, Rush claimed that some of Ahmadinejad's speech sounded a lot like Democrats' "talking points."
It was open-line Friday, and because of a question from a caller, Rush spent a large part of the third hour talking about what type of private jet he liked best. But he did have one new political thing to say: Rush speculated that the stock markets were doing well, in part, because the Federal Reserve is trying to help Obama. Rush said that they did the same thing in causing the financial crisis in 2008 and passing the TARP.
Here are some highlights from today's show:
Limbaugh: "We don't need RINOs cutting deals with Imam Obama"
Limbaugh: "I should have won" Nobel Peace Prize "given that a hoax and a hoax master won the thing"
Limbaugh: Democrats' "talking points" are "similar" to those of Mahmoud Ahmadinejad
Limbaugh: Obama blamed Wall Street for global recession; "in some parts of the world ... Wall Street is shorthand for the Jews"
Limbaugh repeats false claims about FDA's reason to revisit Avastin approval, invokes "death panels"
Limbaugh: "If Mickey Mouse could get on the ballot and would vote against the Obama agenda, I would support" him
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The Minnesota Sports Facilities Authority (MSFA) was established by the legislature in 2012 and charged with the design, construction and operation of U.S. Bank Stadium. The MSFA consists of five members and is chaired by Michele Kelm-Helgen. The other members are John D. Griffith, Tony Sertich, Bill McCarthy and Barbara Butts Williams.
Minnesota Sports Facilities Authority Votes on New CEO
University of Minnesota Baseball Coming to U.S. Bank Stadium
In May 2012, the Minnesota Legislature and the Minneapolis City Council approved funding for a new $975 million multi-purpose stadium to replace the Metrodome. U.S. Bank Stadium is scheduled to open in time for the 2016 NFL season. Click to view legislation.
email contact-MSFA- 1005 4th Street S., Minneapolis, MN 55415-1752TTY: 612.335.3357