text:
That's oh-be-GUY-n, not oh-be-GIN, as some (primarily people from Texas) would like to refer to my chosen profession. Although, working in this field can sometimes cause one to develop a penchant for gin...hmmm.
Thursday, August 10, 2006
This week has been very busy, but thankfully not terribly exciting. I (just barely) made it to the delivery of one of my patients on Sunday evening. She had been into triage earlier in the day, contracting, but only dilated to 3. She went home and came back dilated to 6 at 11 pm. The nurse called me at 11:15 pm. I got to the hospital at 11:32 pm, and the baby delivered at 11:34 pm! I'll say it again. You have got to love a spontaneous, natural labor! I also delivered 2 breech babies by C-section and a uterus by vaginal hysterectomy yesterday. My hyst patient has an allergy to the type of suture most commonly used in the procedure, Vicryl. No problem, says naive little me, we'll use Monocryl (different type but comparable suture). Unfortunately, no one clued our OR in, because they didn't have the kind of suture that I wanted on the kind of needle that I needed. A compromise was made, and though it did prolong her surgery, I got that uterus and one ovary out from below. I counted that and pulling out a 10 lb breech baby as my workout for yesterday.
I got a *stat* consult from one of the family docs on a patient whom (they were convinced) was bleeding to death. I called the nurses to gather the equipment to facilitate an exam and possible emergent surgery, I rushed through the rest of my office and sprinted to the hospital to find a very stable, not sick, perimenopausal patient. She was indeed bleeding, equivalent to a regular menstrual period. Her vitals were stable. Her blood levels? Normal. Me? Feeling foolish for getting all in an uproar over this "stat" consult. The punchline is that when I called the admitting doc (whom I like very much) and told him my impression and plan for treatment he seemed surprised (and pleased) that I would call him to tell him my thoughts. Isn't this what a *consult* is supposed to be? You ask my (expedited) opinion and I relay it to you immediately? Community medicine confuses me. Good night.
3 comments:
- Guinness_Girl said...
Yay, you posted! :) I've been checking my bloglines like a maniac. Hee!
You'll get your cholesterol and blood pressure down, I know it! - 8/10/2006 10:29 PM
- dr. whoo? said...
Hi GG! My pressure was good today in the office...weight check tomorrow AM, wish me luck!
Hi Mrs. Mom! Great to hear from you! I'm a huge blog voyeur, as well. Congrats on the new little one :) They are the best. Just wait until they can tell you "NO!" and "I DON'T WANT THAT!" Darned kids and their opinions. Thank you for the compliments (head swelling). - 8/11/2006 4:53 PM
- Guinness_Girl said...
GOOD LUCK tomorrow AM. If you are feeling discouraged, check out my latest blog post. :) xoxoxo


text:
Monday, November 28, 2011
♥ Morran ♥
It started slowly in the beginning of the week. She wasn't as happy as usual to go on our walks. Just a small thing but noticable. Then she got fever and for everyday that went she become a little bit more ill. She was tired and was breathing very shallow, but I would say still in a good spirit. Had to bark at the postman and still wanted to play a little. The cancer in her lungs had grown much faster than expected. You know already what the next sentence is going to say so I will not write it...
♥ ♥ ♥
98 comments:
Bye bye sweet little woof woof. X
- November 28, 2011 at 12:49 AM
- ANA said...
¸( - November 28, 2011 at 12:52 AM
- barbara said...
oh f*cking sh*it!!!
I am so sorry for you, Camilla!
she will live forever in our hearts.
love from vienna,
Barbara - November 28, 2011 at 12:56 AM
- Ellen Vesters said...
oh no, camilla. so sorry for you and sweet morran...
- November 28, 2011 at 12:58 AM
Någon sa att sorgen är kärlekens pris... det är väl det bitterljuva i livet.
- November 28, 2011 at 12:58 AM
- Machteld Hardick said...
Dear Camilla, what a terribly sad message this is. I am so sorry for you. Wish you would have had more time with your sweet little Morran. A big warm hug for you,
Maggy - November 28, 2011 at 1:01 AM
- Vesle Serena said...
SO sorry. I had to share a tear.. She will be missed!
Hugs from Norway. - November 28, 2011 at 1:06 AM
- Mélanie said...
There's no word when you lose your dear friend. I know this feeling too well. You and Morran have been bless to meet each other.
- November 28, 2011 at 1:08 AM
- Marloes de Vries said...
Dear Camilla, that's so terribly sad to hear. :( I wish you had more time to spend with eachother. Poor, poor Morran, sweet little dog... :(
Please know that there are so many people, who haven't even met her, love Morran so much. She will be in our memories.
All the best and I wish you much strength. - November 28, 2011 at 1:08 AM
- kristi said...
there are tears falling for morran in zürich today...
dear, sweet camilla there will be a candle for you on our table tonight.
take your time to grieve and heal.
i know how long it can take...
our pets know us inside and out and losing them is like losing a piece of ourselves.
much love to you. - November 28, 2011 at 1:29 AM
- Cynthia said...
I'm verry sorry for you but at least we know that all dogs go to paradise ♥
- November 28, 2011 at 1:30 AM
- Wilma said...
I want to say a lot of things but my poor English can't help me, I will do in Spanish: Camilla, lo siento mucho, es un momento difícil y por desgracia lo conozco bien, Morran es la perra más querida del mundo seguro que la perra a la que más lloraran, ha tenido la vida más feliz que podía tener y es gracias a ti, puede irse tranquila y serena de sentirse tan arropanda y querida. A big hug for your family
- November 28, 2011 at 1:31 AM
- Julia said...
I'm so sorry to hear this Camilla. I feel like crying... Adiós, Morran ♥
- November 28, 2011 at 1:34 AM
- WSAKE said...
i´m so sorry, camilla!
we all share your grief.
hugs, anna - November 28, 2011 at 1:36 AM
- Natascha Rosenberg said...
Dear Camilla, I'm very sorry for your lost. Morran will never be forgotten. A big hug.
- November 28, 2011 at 1:52 AM
- Cristina Storti Gajani said...
I'm really sorry, Cammilla.
A big hug to you.
Bye Morran, do a good trip. - November 28, 2011 at 2:06 AM
- marga.marina said...
Oh Camilla, I´m so very sorry for you!
I know the feeling and in this moment many tears falling in germany!
Morran remains in our hearts! - November 28, 2011 at 2:15 AM
- Esti said...
From the bottom of my heart, with teary eyes, I feel your loss Camilla. So so sorry. Sending you hugs.
- November 28, 2011 at 2:34 AM
- Hussam Elsherif said...
I know that there's no word in the world that would comfort you, to you I send my strength, I'm honored to have had the chance captured her essence in my works, and I'm so sad to say good bye so soon and can't help my tears... she'll always be remembered.
- November 28, 2011 at 2:36 AM
- annton said...
goodbye, little morran!
- November 28, 2011 at 2:38 AM
- [sen.siˈʝes] said...
so sorry to hear. makes me wanna cry...
- November 28, 2011 at 2:38 AM
- lamina @ do a bit said...
Oh no... so so sorry... so sad...
...hope you have sweet sweet dreams moran... <3 - November 28, 2011 at 2:44 AM
- FHNavarro said...
i´m so sorry, camilla!
Enjoy the ride, morran!
http://youtu.be/1mqEoNhsJT8 - November 28, 2011 at 3:15 AM
I'm so sorry :( x
- November 28, 2011 at 3:20 AM
So sorry to hear...
Morran brought people around the world closer together.
The book is a beautiful tribute to her. Lots of strength, Camilla. - November 28, 2011 at 3:27 AM
- Julia Fontes said...
- November 28, 2011 at 4:06 AM
- renilde said...
Dear Camilla, Morran will be missed, she was an inspiration to many of us.
Sending you a big hug, x - November 28, 2011 at 4:09 AM
- Alicja Jagoda Paluch said...
Dear Camilla and Morran,
this step is just a sad part of your journey together. All you have built together over those years is eternal, because it is anything material, but is something much more deep and spiritual, as all true friendships are. Use all that love and strength that you have accumulated thanks to each other to overcome this difficult time.
If this can be helpful to know that somewhere in Italy in the middle of the distant mountains is someone who thinks and has a wonderful memories of you.
I wait your book Morran, to keep your happy face for ever.
Alicja - November 28, 2011 at 4:16 AM
- Kristen Donegan said...
Big Hug Camilla and a box of tissues too...
- November 28, 2011 at 4:25 AM
- Isabella Fabris said...
I'm sorry. She will be missed... Goodbye little Morran!
- November 28, 2011 at 4:31 AM
- eni mai said...
♥ ♥ ♥...bye morran...you cute, little, amazing dog!!!!
- November 28, 2011 at 4:42 AM
- Stella said...
I'm quite sure that you and Morran had a great time together. Shall every Morran's memory be a celebration of her life. Love, Cristela
- November 28, 2011 at 5:09 AM
- Amy said...
Oh Camilla! I'm so very sorry for your loss. Sweet Morran, may you dance with joy forevermore. Much love from me & my dog, Jack
- November 28, 2011 at 5:10 AM
- teconlene said...
I'm really sorry, Camilla, we have all lost our little Morran. I will miss her.
Warm hug,
sara - November 28, 2011 at 5:18 AM
- my hyggelig said...
i am choked up. my heart aches for you because I know how it feels. Morran you were loved by people who never even met you. Please say hello to my little guy as you run on the forever beaches together. big hugs to all of you.
- November 28, 2011 at 5:25 AM
- Ulicam said...
This made me cry. I've been following Morran for such a long time that it doesn't feel real that she's gone.
- November 28, 2011 at 5:27 AM
- molly said...
oh gosh, i'm so sorry. morran was the best. poor sweet girl. hugs to you and yours.
- November 28, 2011 at 5:41 AM
- Cat said...
Dear Camilla, I'm so sorry for your loss. I have never met Morran and yet I loved her very much, she was a very popular girl. She will live forever in our hearts and I agree with kirsten, Morran's book is a beautiful tribute from all of us.
Big hug - November 28, 2011 at 5:52 AM
- Jo said...
Oh Camilla. I lost my sweet, darling soul dog on Friday. She was 15 and a half. She had kidney failure and many other things to deal with.
The pain of this is extreme and it comes in crashing waves.
My heart, broken as it is, goes out to you. Morran was a wonderful dog and will be loved and remembered by many who never were lucky enough to meet her.
x - November 28, 2011 at 6:20 AM
- alessandra said...
:( so sorry Camilla.
- November 28, 2011 at 6:26 AM
- Suana said...
Dear Camilla,
I am so sorry to hear this! I'll miss that beautiful sweetheart of yours. I send you strength to get through this sad time.
I agree with Kirsten and Cat, Morran's book is a wonderful tribute from all of us.
A big hug from me too,
Suana - November 28, 2011 at 6:27 AM
- Rebecca said...
I know this feeling oh so well. May that emptiness be filled with the knowledge her pain is gone. My heart goes out to you and all of those who loved her. Thank you do much for letting us be a part of her wonderful journey here on earth!
- November 28, 2011 at 6:34 AM
- Rendell said...
Camilla please find comfort in this quote that has helped me when I've said goodbye to my trusty and loved canine companions..."Dogs are not our whole life, but they make our lives whole." I know you will miss her.
- November 28, 2011 at 6:38 AM
- ElleSee said...
I met Morran only this year, but I fell in love instantly. My thoughts are with you. Goodbye, sweet Morran.
- November 28, 2011 at 7:37 AM
- nelleke said...
aaaaah, so sad to hear this, poor Morran, poor Camilla! When I look at these pictures I get tears in my eyes, those eyes..., such a lovely dog!
I wish you all the best Camilla!! - November 28, 2011 at 7:40 AM
- blue china studio happy said...
Oh I am so so sorry. Losing a dog is so hard. Take care, my thoughts are with you.
- November 28, 2011 at 7:43 AM
- lori said...
so sorry camilla, hope you are doing alright. my heart goes out to you...
- November 28, 2011 at 8:18 AM
- November 28, 2011 at 8:31 AM
- serra said...
I am really sorry. I lost my buddy two years ago. I know how hard it is. Finally I realised how lucky I was to meet him, and all the great moments we spent together. So i am grateful.
You and Morran must be happy too, you shared your happiness with lots of people.
A big hug Camilla. - November 28, 2011 at 8:41 AM
- Elizabeth said...
I am so so sorry! Morran, thank you for sharing your amazing adventures with us. You will be incredibly missed by all.
- November 28, 2011 at 8:47 AM
- Hayley said...
Sending love from California.
- November 28, 2011 at 9:06 AM
- Jane Cabrera said...
Dear Camilla, Just saw the sad news. Had a little weep...but my goodness what that little dog brought to you and to all of us around the glob... She will live on forever in many other ways! Sending much love. xxxx
- November 28, 2011 at 9:13 AM
- Jane Cabrera said...
That should say globe above.. not sure what a glob is!??
- November 28, 2011 at 9:23 AM
- Maite Oz said...
I am so so sorry. A big hug to you.
- November 28, 2011 at 9:40 AM
- gregemar said...
Tears from my eyes! Taka care!
- November 28, 2011 at 9:55 AM
- ellereveille said...
I am so sorry. Take care, a big hug.
- November 28, 2011 at 11:38 AM
- serena said...
so sorry..so sad!
bye morran,
big hug to you, camilla. - November 28, 2011 at 11:56 AM
- Mlle Miracle said...
Morran, dulce, preciosa y única Morran.
A big big hug to you Camilla from this tiny part of the world. - November 28, 2011 at 12:11 PM
- Susan Magnolia said...
Been a fan of Morran since favoriting the "welcome party" photo on flickr in 2007. ^_^ What a wonderful adventurous life he had! Can't wait for another book.
- November 28, 2011 at 12:31 PM
- Ameesha Lee said...
"...he will be our friend for always and always and always." ~ Rudyard Kipling
Hugs from Toronto, Ameesha - November 28, 2011 at 1:28 PM
WE L♥VE MORRAN…! I´m so sorry, a big kiss for you. mariana.
- November 28, 2011 at 1:38 PM
- pilar said...
im so sorry
- November 28, 2011 at 2:02 PM
- Karen said...
I am so so sorry for your loss.
- November 28, 2011 at 2:33 PM
- Ez said...
Oh noooo Camilla! I am so so terribly sorry for the tragic loss of your friend and furry family member. Morran's beautiful spirit and the love you had for her touched so many hearts around the world. May memories of the incredible times you shared together bring you comfort and peace during this difficult time. Sending hugs across the miles. xox Ez
- November 28, 2011 at 3:00 PM
- Jude said...
I'm so sorry.
- November 28, 2011 at 4:11 PM
I am so sorry!!!!!!!!!!!!
Morran will be deeply missed
All my love from Argentina - November 28, 2011 at 4:48 PM
Oh no!!!
Dear Camilla
I am so sorry for your loss. It was always so nice to follow Morran even though I did not know her or you in person.
She will be missed.
Lots of thoughts
Karina, Denmark - November 29, 2011 at 1:53 AM
- Reda said...
I'm so sorry for your loss , Camilla. I hope you're OK. Hang in there!
Morran is in my thoughts... - November 29, 2011 at 2:19 AM
- BY ANJA DENZ said...
I am so sorry Camilla! I didn't get to know her, but I liked her so much on the pictures you posted. She seams to me as the dog everyboday always wants to have!
Lots of Love from Zurich
Anja - November 29, 2011 at 4:42 AM
- SIMONETTA said...
I'm so sorry. sending you a big hug from Italy. - November 29, 2011 at 6:15 AM
- marion said...
Camilla, there will always be an empty space inside your heart but little Morran's spirit lives on.
- November 29, 2011 at 8:56 AM
- Stefanie said...
On, no! I'm so sorry for your loss! What will the internet be without Morran?
Tears and hugs from Switzerland. - November 29, 2011 at 9:33 AM
I cannot stop crying... This is so sad... It's so hard to lose a best friend..
- November 30, 2011 at 1:38 AM
- Cally said...
This is such sad news. We have all loved Morran, but no-one could love her more than you. You must feel heart broken, yet so happy to have had her in your life.
Thank you for sharing her loveliness with the world. She made me smile and laugh more times than I can count. The book will be a wonderful reminder of how she inspired. And knowing it will help other dogs makes it all the more wonderful. I can't wait to buy a copy.
Sleep well sweet Morran, you continue to be loved and remember. - November 30, 2011 at 7:39 AM
- sandgirl said...
oh sweet morran you will be missed. my heart goes out to you, camilla, and i hope all these morran-images will bring comfort.
- November 30, 2011 at 7:59 AM
dear camilla,
Much love to you. Morran brought so much joy to you and I know that you and your family and friends were a joy to her. She will always be with you. - November 30, 2011 at 8:01 AM
- Susan said...
There are some griefs so loud
They could bring down the sky,
And there are griefs so still
None knows how deep they lie ...
of Grief
May Sarton
oh my dear Camilla we are so sorry & our hearts are with you. Much love xoxo Winnie Dixon & Susan - November 30, 2011 at 10:54 AM
- sparringK9 said...
crushed and saddened. what a loved dog and her spirit will live on. I cant wait to buy her book. I am so sorry. sending you love
- November 30, 2011 at 11:09 AM
So terribly sorry for you. First, I saw his sweet face and I went 'Awww', but then I read the terrible news. So awful losing your darling, wishing you strength...
- November 30, 2011 at 11:19 AM
- Rumisu said...
there goes another sweet sweet soul... hopefully going running on the other side with our beloved (and so missed "tofi" and other new friends) ... she will be in our hearts... thank you for introducing her to us... and bes wishes to you dear Camilla...
- November 30, 2011 at 12:36 PM
- Elin Karlsson said...
- December 1, 2011 at 7:06 AM
Good bye sweet girl! You will be missed!
- December 1, 2011 at 10:58 PM
- k said...
Oh how we love our sweet little canine friends, but never as well as they love us. I hope you are comforted by the love so many have for your beloved Morran. She will be remembered as a fine dog-and really there is no finer being than that.
- December 2, 2011 at 1:12 AM
- Lisa said...
Oh Camilla, so sorry she was a beautiful girl! Thinking of you xx
- December 2, 2011 at 9:40 PM
- Cat said...
These last two pictures have me undone--what a beautiful girl she was. I have had to put too many beloved dogs to sleep not to understand how you must be feeling. (we had 6 dogs living with us at one time!) Thank God you have that book coming with all those wonderful pictures of Morran. My heart is broken for you and the two of you are in my prayers. By sharing Morran with the world, you started something very special and I know that mine is not the only broken heart.
- December 3, 2011 at 7:32 AM
- Sheena said...
I'm so sorry to hear this news. It is heart-breaking to lose such a good friend. RIP Morran, you gave her a great life x
- December 3, 2011 at 2:52 PM
- Dawn said...
Though we didn't know her, Morran has been beloved for some time in our blog-reading house. What a sweet soul. Wishing you peace.
- December 4, 2011 at 6:54 AM
- AnnStudio said...
I read your post with tears in my eyes. Morran touched so many hearts. You gave her a wonderful life.
I am so very sorry for your loss. I lost my wonderful lab to cancer earlier this year. Dogs truly are members of our family. - December 4, 2011 at 8:00 AM
so said
all my love from Italy - December 4, 2011 at 12:55 PM
- ekkoart said...
So sad.
All my love from Japan... - December 6, 2011 at 12:26 AM
- Georgette said...
Oh Camilla,
The news broke my heart and brought tears to my eyes.
Morran softened and inspired a sense of magic in our hearts.
Thank you for sharing with us the beauty between you two.
Morran was perfectly yours, and alongside you, she inspired the world.
Much love and strength to you from New York.
xoxo - December 6, 2011 at 8:03 AM
- Anna said...
Kisses for you, Morran. And love always!
- December 7, 2011 at 6:57 AM
- Katarina w said...
I've only just found out...that is so sad...my heart's with you, Camilla <3
- December 7, 2011 at 7:27 AM
So sorry.
- December 9, 2011 at 11:43 AM
- B.Tech MCA training in Chandigarh said...
its so sad to know about this sweet dog
- December 21, 2011 at 3:24 AM
- sMacThoughts said...
OH no. Camilla, I am so sorry for your loss. This is your little girl, and you gave her such a happy home. I loved seeing her in your blog, and always thought what a wonderful little dog she was. Now she is an angel dog. She will be there to greet you when it is your time. Until then, she will watch over you. My greatest condolences for the sadness you must feel!
- December 22, 2011 at 5:28 PM
- sukey said...
i just found you and now you are gone. bye sweetness.
- January 2, 2012 at 9:11 AM
- Emma Collins Ba (Hons) said...
I only just realised the sad news.
My eyes are teary and i'm sad for your loss. It's amazing how much happiness a dog can bring. - April 11, 2012 at 4:07 PM

subset: commoncrawl


text:
Translation affects every aspect of your life - and we're not just talking about the obvious things, like world politics and global business.
Translation affects you personally, too. The books you read. The movies you watch. The food you eat. Your favorite sports team. The opinions you hold dear. The religion you practice. Even your looks and, yes, your love life. Right this very minute, translation is saving lives, perhaps even yours.
Translation influences everything from holy books to hurricane warnings, poetry to Pap smears. It's needed by both the masses and the millionaires. Translation converts the words of dictators and diplomats, princes and pop stars, bus drivers and baseball players. Translation fuels the global economy, prevents wars, and stops the outbreak of disease. From tummy tucks to terrorist threats, it's everywhere.
This book will help you see how the products you use, the freedoms you enjoy, and the pleasures in which you partake are made possible by translation.
- Paperback: 288 pages
- Publisher: TarcherPerigee (October 2, 2012)


text:
Thanks to Tyler Moore's pinch-hit 2-run single late in the game, the Nationals took a 1-0 series advantage over the St. Louis Cardinals. I spent a good part of the evening last night reading Jerry Crasnick's long story about Harper's journey through his first big league season. It's a great read.
"I sit on the aisle and he sits on the aisle on the plane, so I talk to him all the time," Nationals broadcaster F.P. Santangelo says. "I'm probably as close to him as anybody on the team. The first thing he says on the plane after the game is, 'I passed the Mick tonight.' How often do you hear that? I get goosebumps now just saying it. It's something I'll remember for the rest of my life: 'I passed the Mick tonight.' He said it with respect and reverence and maybe a little bit of astonishment, all wrapped up in one."


text:
Events Film: MARY QUEEN OF SCOTS at Pentangle Arts
Mary Queen of Scots is a retelling of the turbulent life of Mary Stuart (Saoirse Ronan), based on the book "Queen of Scots: The True Life of Mary Stuart" by Dr. John Guy. Queen of France at 16, at 18 Mary is widowed, defies pressure to remarry and instead returns to her native Scotland to reclaim her rightful throne. By birth, Mary has a rival claim to the throne of Elizabeth I (Margot Robbie), who rules as England's Queen. Contrary to earlier accounts, and based on Dr. John Guy's research, we see Mary as a capable politician and leader who wanted an alliance with her cousin Elizabeth. Mary fights to govern her unruly kingdom at a time when female monarchs are reviled as monstrous. To secure their thrones, the two Queens make very different choices about marriage and children. Mary's reputation is under continual attack from her enemies, who construct lies about her sexual conduct. Betrayal, rebellion and conspiracies within each court imperil both Queens–driving them apart, as each woman experiences the bitter cost of power. Directed by Josie Rourke.
Dates & Times
Friday, Jan. 25 at 7:30 pm
Saturday, Jan. 26 at 7:30 pm
Sunday, Jan. 27 at 3:00 pm
Monday, Jan. 28 at 7:30 pm
Woodstock Town Hall Theatre
31 The Green
Woodstock, VT 05091
United States


text:
My friend Chris is a fantastic drummer. When we first met, some 20-odd years ago, I knew he had the goods - an assured right foot on the bass pedal and a Ringo-like sensibility on the toms. Plus, he possessed an exuberant range and an ear for detail that rivaled the pros.
Name a style of music and Chris could make it sing, effortlessly. Rock 'n' roll? He rocks, he rolls. R&B? Groove for days. Jazz? Cool or otherwise, we're talkin' chops up the butt. But heavy metal, particularly the NWOBHM popularized by groups like Judas Priest and Def Leppard, was his specialty, and Chris brought a good-natured swing to his speed that never failed to impress. Why he never made it was something I could never quite figure out.
Actually, that's not really true. As towering a musician as Chris could be, he never mastered the art of people. That self-edit function that most people have tucked in their brains, Chris doesn't have that. You know what I mean: You meet somebody for the first time and you tell yourself not to mention the enormous pimple on the guy's nose? Chris would always say something like "Wow, man, that pimple must hurt like a bitch." Not making friends and alienating people were Chris's side businesses, and business was always brisk. Meanwhile, his full-time gig, that one that paid the bills, was working at a CPA firm. Chris didn't have a head for people, but he knew his numbers. It's no wonder he could switch time signatures as quick as others could underwear.
Like all of us, Chris is getting up there. He turned 38 a few months ago, a milestone that precipitated a phone call in which he informed me that he was thinking of hanging up his sticks for good. "Why should I keep hoping I can make money as a musician?" Chris asked. "I'm too old for this. Everybody I know has either made it or moved on. I go on auditions and there's dudes in their 20s. If I was going to make it, I would have made it by now." After a pep-talk from me, Chris reversed his position and vowed to keep on pounding the skins.
All Chris had ever wanted was to play the drums for money. Fame and real fortune are nice ideas, and Chris fantasized about them long and hard for many years. But making a steady income from his obvious skills should have been within Chris's grasp. Unfortunately, things don't always work out that way.
A week ago, Chris responded to an ad to play drums in a cover band that was going to enjoy a summer residency at the Jersey shore. It seemed like a sweet deal: four nights a week, performing classic rock tunes and a smattering of current hits. The pay was $1,200 a week. "I can do this gig," Chris said, to which I agreed enthusiastically.
I accompanied Chris to the audition. The band members were all in their late 20s and early 30s, and it seemed as though the drummers auditioning were all of equal age. Chris sat down at his drums and breezed through some tunes with his normal accomplished ease. He's got this in the bag, I thought. After the audition was over, the band members asked Chris about his availability. But instead of saying something like "I'm ready when you are," Chris started to list the dates and conditions that he could play. Then he rattled off his ideas for cover tunes and proceeded to trash some of the newer songs the band was intent on performing. Oh, no, I thought. He's doing it again. Driving home, I went off on Chris, telling him in no uncertain terms that he had the job in his hands and blew it, the same way he harpooned every other situation he could have had. "Why don't you tell me the truth?" Chris said. "That I'm too old." All I could do was shake my head.
Last night, Chris called me to tell me the expected news that the band had decided to go with another drummer. "I can't believe they picked somebody over me," Chris fumed. "The guy's 46. He can't possibly rock as good as me!"
Maybe not, Chris. But he knows when to keep his mouth shut and drum. And he'll be doing so for $1,200 a week this summer while you're sitting at your desk. Getting older. Not drumming.
By Joe Bosso


text:
Praise For "DECIDE - The Ultimate Success Trigger"
21 Comments
If you think this is another feel-good, touchy-feely, self-growth guide – you're mistaken! When I first picked up this book I thought it will be a re-hash of what I already know and I'll quickly put it down. I was wrong! Jim's transparent personal stories, real-life examples, step-by-step advice, and bold calls to action turns "DECIDE: The Ultimate Success Trigger" into the every entrepreneur's ultimate success guide. Frankly, I think you'll be making a mistake if you don't buy it and don't read it as quickly as you can!
Without a doubt, the root cause of what prevents far too many entrepreneurs from achieving their dreams and reaching their fullest potential, is indecision. When opportunities arise or when challenges present themselves, which they always do, the ability to make fast, sound decisions moves businesses forward and helps you grow. I've been studying and teaching on the power of mindset for many years and I must say that Jim Palmer has nailed it with his latest book, DECIDE: The Ultimate Success Trigger. I especially appreciate how much Jim shared his own personal demons and struggles and how he overcame them. You will be inspired by Jim's story and moved into action from his strategies.
When someone finds out I'm a #1 best-selling author, they say, "I've thought about writing a book." When someone discovers I own three businesses, they say, "I've thought about starting a business." When someone figures out I have online coaching programs, they say, "I've thought about…"
These people live at 1313 I'veThoughtAboutIt Lane, Squishyville, USA.
To all of these people still thinking about it, my friend and hero Jim Palmer says, "DECIDE!" I only wish he had written this book 15 years ago when I was starting out. I would have more hair on my head and money in my accounts.
Read this book as if your business and life depend on it…because they do.
Your ability to make decisions will directly affect your ability to be successful. Should you take retirement funds and start a new company? Should you hire someone to do a task for you or do it yourself? Should you wait or move ahead? Every decision has some knowledge built within it, but in the final analysis, every decision requires a step (or leap) of faith. Jim's new book, DECIDE: The Ultimate Success Trigger, is a roadmap to help you learn how to make decisions more efficiently and more timely. I hope you will take time to study each section of this book and then assimilate them into your own life. After all, "you get to choose."
I've had the privilege of knowing Jim Palmer for many years, and he is an extraordinary coach, entrepreneur and friend. I've read his other books, but DECIDE is my favorite by far. I felt like I was sitting side-by-side with Jim in a coaching session as he candidly shares what it takes to be truly successful.
What I like most about this book is Jim's authenticity, transparency and true love for those he currently coaches and those who will be coached by reading this book. If there is anyone that can help you build your dream life, Jim Palmer is the right guy to do it!
After reading DECIDE, I have DECIDED that this is one of the best tools an entrepreneur can own. I felt that Jim really understood the mental struggles EVERY entrepreneur goes through and gave sound credible advice on the head trash we all deal with. He is right on target with his wisdom and observations. This is definitely a book you should start your entrepreneurial life with and live by it. Thanks Jim for not being afraid to stand tall and tell it all.
Jim Palmer's book, DECIDE, is amazing! The valuable nuggets of information on clearing head trash, acting and moving forward are a must for every entrepreneur.
As a founder of several multi-million dollar businesses, I've had my share of successes over the past 14 years. They've afforded my family and me the opportunity to live a life I never could have imagined. None of these successes would have been possible had I not decided to take action, even in the face of fear, uncertainty and doubt. When I'm asked the question, "What's your secret to success?" I usually reply by saying "There is no secret." However, after reading this book, I've found I owe much of my success to the very same principles that Jim shares within these pages. Read this book and apply its concepts. I can think of no better manual for the entrepreneurial mind.
Not only did I have the privilege of being featured in Jim's book DECIDE, I have the benefit of having Jim as my business coach and reading DECIDE was like being in a massive coaching session with him. In DECIDE, Jim offers tough love and actionable steps, coupled with a willingness to share the nitty-gritty of what it takes to truly succeed. He articulates not only the barriers, but the essential need for us to DECIDE in the midst of fear and uncertainty. Jim's conversational guidance and authenticity makes you feel like he is coming along side you, and rooting for your success. Jim's knows our struggles, he is in the trenches and DECIDE is a handbook of wisdom every entrepreneur needs.
Being an entrepreneur is not an easy road and very few books tell it like it is. Jim Palmer's DECIDE: The Ultimate Success Trigger is a warrior's journey at its very best! Arm yourself with real entrepreneurs baring it all about overcoming and beating the odds; turning failure into strength, and mistakes into lessons. Get a highlighter. DECIDE is THE guidebook for the journey ahead.
I read every word. Good information, only wish I had read this book 30+ years ago when I began my selling career. Your personal life struggles are a testimony to the successes that have brought you through to make DECIDE a must-read book for anyone asking the hard questions. For those who've ever found themselves face to face, having that 3:00 a.m. moment of self discovery, your book's words help to understand what life is about and how to overcome the many obstacles we ALL face. Thank you for sharing.
It's so easy, as an entrepreneur, to get caught up in the head trash that attacks all of us. We think too small and convince ourselves that working harder will result in success. In reality that just isn't true – you end up working harder, don't have time for your family, and are tired all the time. (I know because I've been there!) When you couple that with a fear of success, you have a recipe for getting mired in "Squishyville." This is not a good place to spend your time!
Jim Palmer's book, DECIDE, quickly dispels the myths we carry around in our heads and helps us to see beyond whatever ideas that come from our childhood. I can truly say that Jim's books, coaching program, and mastermind group have made a significant difference in myself and my business. I am now empowered to become the successful entrepreneur that I was created to be!
I have read each of Jim Palmer's books, but DECIDE is in a class all but itself. This is the best down to earth, real and solid business advice book you must read. Starting in the foreword with the statement "The quality of your choices shapes the quality of your results" to the final question on the very last page of the book "If not now, when?" Each page contains at least one golden nugget, and Jim's advice is always on target and exactly what I need to hear to achieve better results. Get this book now and watch the results you will get if you just follow Jim's advice. The book is the best investment that you can make in yourself and your business right now.
Jim's book, DECIDE: The Ultimate Success Trigger, is by far one of the best books for both new and well-seasoned entrepreneurs. There are many reasons to read this book, but the biggest reason is this: it is not simply a book of suggestions, tips and strategies. Jim opens up and shares details of his personal journey and the many struggles he faced, and how he overcame them to grow his Dream Business. After reading DECIDE, you will feel motivated and inspired into action.
Jim Palmer is the go-to coach for entrepreneurs who are ready to get down to business, toss the excuses and get it done! Give him 30 minutes and he will give you gold (as long as you are willing to put it into action). I highly recommend partnering with Jim to take your business to the next level-fast!
The Ultimate Success Trigger indeed! In his new book, Jim has really hit the nail on the head with what it takes to succeed as an entrepreneur! Many would-be entrepreneurs fail to realize how vitally important your mindset is to succeeding at ANY endeavor. What you tell yourself, your self-talk will ultimately make or break you. Your success is not determined just by the mechanics of whatever business you are in, but how you make decisions and take action. In DECIDE, Jim did not just create another mindset book, but Jim brings key success concepts into clarity by really opening up and sharing his personal experiences; his own journey from struggle to abounding success. Jim shares his success not only in his own business, but also by helping others to achieve abundant success in their own right through his various publications, coaching programs, and events.
Jim is the real deal! DECIDE to not just read, but absorb the lessons Jim shares in his book. When you embrace the lessons of DECIDE, you will be uncomfortable for a time, but you will not regret it!
During these times, who wouldn't want to "build a more profitable business faster"? Jim's thought-provoking, stimulating and practical book walks you through the exact steps you can take to move you into decision-making mode! I promise you, if you decide to read this book, it might rattle you, get you going, make you really think, but in the end you won't regret taking the time to DECIDE! Great read Jim, thanks for helping to equip entrepreneurs!
Just about every entrepreneur will experience a "crisis point" during their journey toward ultimate success. This can be so debilitating, you find yourself a spectator to your own business's impending doom. When this happens, read Chapter 8, "Decide to Use GPS" – and allow Jim Palmer's new success map to guide you toward a more profound success, profitability, and prosperity.
Wow! Absolutely love Jim Palmers most recent book DECIDE. It's packed full of honest, relevant, and cutting edge tips, tools and strategies for not only overcoming the mental blocks we have as entrepreneurs, but also provides proven techniques for gaining clarity and confidence in making powerful decisions. If you are an entrepreneur who is serious about success and making a difference in the lives of those you touch, this book is for you.
Working alongside Jim Palmer for over five years I've been privileged to witness a ton of great things from the man himself. As a member of his "Dream Team," I see firsthand exactly what it takes to be successful as an entrepreneur. I've also watched him help many, many people move past their own self-imposed road blocks, quite often in an amazingly short amount of time. In his book, DECIDE: The Ultimate Success Trigger, Jim pulls back the veil on the sometimes ugly bits that a lot of entrepreneurs face at some point. This book helps you look in the mirror, face your fears and finally do what you know you need to do, what you've been fighting against all along. Reading this book, and reflecting, I'm very familiar with "Squishyville," I lived there a long, long time – I suppose we all have at some point. Thank you Jim for writing it all down and help to make sense of it all!
There are a ton of business books available for entrepreneurs to read and use as they work on growing their businesses. DECIDE stands apart from the rest because of Jim's authenticity and straightforward style of coaching. The whole book is fantastic, but for me, just one chapter gave me the motivation to decide to raise my prices and by doing that, my revenue grew immediately. I can only imagine how much my business will grow as I continue to implement the advice written throughout DECIDE!
I thought the Stop Waiting For It to Get Easier book was the blueprint for my business, but after reading DECIDE, all I can say is WOW!!! This is truly a life changer and contains some of the juiciest insights into what really makes the difference between a successful and unsuccessful entrepreneur. High-level business lessons cloaked in colorful, entertaining and insightful story telling. This is a must read for anyone looking to take their business to the next level.
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Inderal® (propranolol hydrochloride) is a synthetic beta-adrenergic receptor-blocking agent chemically described as 2-Propanol, 1-[(1-methylethyl)amino]-3-(1-naphthalenyloxy)-, hydrochloride,(±)-. Its molecular and structural formulae are:
C16H21NO2 · HCl
Propranolol hydrochloride is a stable, white, crystalline solid which is readily soluble in water and ethanol. Its molecular weight is 295.80.
Inderal LA is formulated to provide a sustained release of propranolol hydrochloride. Inderal LA is available as 60 mg, 80 mg, 120 mg, and 160 mg capsules for oral administration.
The inactive ingredients contained in Inderal LA capsules are: cellulose, ethylcellulose, gelatin capsules, hypromellose, and titanium dioxide. In addition, Inderal LA 60 mg, 80 mg, and 120 mg capsules contain D&C Red No. 28 and FD&C Blue No. 1; Inderal LA 160 mg capsules contain FD&C Blue No. 1.
These capsules comply with USP Dissolution Test 1.
Propranolol is a nonselective, beta-adrenergic receptor-blocking agent possessing no other autonomic nervous system activity. It specifically competes with beta-adrenergic receptor-stimulating agents for available receptor sites. When access to beta-receptor sites is blocked by propranolol, the chronotropic, inotropic, and vasodilator responses to beta-adrenergic stimulation are decreased proportionately. At dosages greater than required for beta blockade, propranolol also exerts a quinidine-like or anesthetic-like membrane action, which affects the cardiac action potential. The significance of the membrane action in the treatment of arrhythmias is uncertain.
Inderal LA should not be considered a simple mg-for-mg substitute for conventional propranolol and the blood levels achieved do not match (are lower than) those of two to four times daily dosing with the same dose (see DOSAGE AND ADMINISTRATION). When changing to Inderal LA from conventional propranolol, a possible need for retitration upwards should be considered, especially to maintain effectiveness at the end of the dosing interval. In most clinical settings, however, such as hypertension or angina where there is little correlation between plasma levels and clinical effect, Inderal LA has been therapeutically equivalent to the same mg dose of conventional Inderal as assessed by 24-hour effects on blood pressure and on 24-hour exercise responses of heart rate, systolic pressure, and rate pressure product.
The mechanism of the antihypertensive effect of propranolol has not been established. Among the factors that may be involved in contributing to the antihypertensive action include: (1) decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral resistance may increase initially, it readjusts to or below the pretreatment level with chronic use of propranolol. Effects of propranolol on plasma volume appear to be minor and somewhat variable.
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at any given level of effort by blocking the catecholamine-induced increases in the heart rate, systolic blood pressure, and the velocity and extent of myocardial contraction. Propranolol may increase oxygen requirements by increasing left ventricular fiber length, end diastolic pressure, and systolic ejection period. The net physiologic effect of beta-adrenergic blockade is usually advantageous and is manifested during exercise by delayed onset of pain and increased work capacity.
Propranolol exerts its antiarrhythmic effects in concentrations associated with beta-adrenergic blockade, and this appears to be its principal antiarrhythmic mechanism of action. In dosages greater than required for beta blockade, propranolol also exerts a quinidine-like or anesthetic-like membrane action which affects the cardiac action potential. The significance of the membrane action in the treatment of arrhythmias is uncertain.
The mechanism of the anti-migraine effect of propranolol has not been established. Beta‑adrenergic receptors have been demonstrated in the pial vessels of the brain.
Propranolol is highly lipophilic and almost completely absorbed after oral administration. However, it undergoes high first pass metabolism by the liver and on average, only about 25% of propranolol reaches the systemic circulation. Inderal LA Capsules (60, 80, 120, and 160 mg) release propranolol HCl at a controlled and predictable rate. Peak blood levels following dosing with Inderal LA occur at about 6 hours.
The effect of food on Inderal LA bioavailability has not been investigated.
Approximately 90% of circulating propranolol is bound to plasma proteins (albumin and alpha‑1-acid glycoprotein). The binding is enantiomer-selective. The S(–)-enantiomer is preferentially bound to alpha-1-glycoprotein and the R(+)-enantiomer preferentially bound to albumin. The volume of distribution of propranolol is approximately 4 liters/kg.
Propranolol crosses the blood-brain barrier and the placenta, and is distributed into breast milk.
Propranolol is extensively metabolized with most metabolites appearing in the urine. Propranolol is metabolized through three primary routes: aromatic hydroxylation (mainly 4-hydroxylation), N‑dealkylation followed by further side-chain oxidation, and direct glucuronidation. It has been estimated that the percentage contributions of these routes to total metabolism are 42%, 41% and 17%, respectively, but with considerable variability between individuals. The four major metabolites are propranolol glucuronide, naphthyloxylactic acid and glucuronic acid, and sulfate conjugates of 4-hydroxy propranolol.
In-vitro studies have indicated that the aromatic hydroxylation of propranolol is catalyzed mainly by polymorphic CYP2D6. Side-chain oxidation is mediated mainly by CYP1A2 and to some extent by CYP2D6. 4-hydroxy propranolol is a weak inhibitor of CYP2D6.
Propranolol is also a substrate of CYP2C19 and a substrate for the intestinal efflux transporter, p‑glycoprotein (p-gp). Studies suggest however that p-gp is not dose-limiting for intestinal absorption of propranolol in the usual therapeutic dose range.
In healthy subjects, no difference was observed between CYP2D6 extensive metabolizers (EMs) and poor metabolizers (PMs) with respect to oral clearance or elimination half-life. Partial clearance of 4-hydroxy propranolol was significantly higher and naphthyloxyactic acid was significantly lower in EMs than PMs.
When measured at steady state over a 24-hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the Inderal LA capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of Inderal Tablets. The lower AUCs for the Inderal LA capsules are due to greater hepatic metabolism of propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24) hour period, blood levels are fairly constant for about twelve (12) hours, then decline exponentially. The apparent plasma half-life is about 10 hours.
Propranolol is a racemic mixture of two enantiomers, R(+) and S(–). The S(–)-enantiomer is approximately 100 times as potent as the R(+)-enantiomer in blocking beta adrenergic receptors. In normal subjects receiving oral doses of racemic propranolol, S(–)-enantiomer concentrations exceeded those of the R(+)-enantiomer by 40-90% as a result of stereoselective hepatic metabolism. Clearance of the pharmacologically active S(–)-propranolol is lower than R(+)-propranolol after intravenous and oral doses.
The pharmacokinetics of Inderal LA have not been investigated in patients over 65 years of age.
In a study of 12 elderly (62-79 years old) and 12 young (25-33 years old) healthy subjects, the clearance of S-enantiomer of propranolol was decreased in the elderly. Additionally, the half-life of both the R- and S-propranolol were prolonged in the elderly compared with the young (11 hours vs. 5 hours).
Clearance of propranolol is reduced with aging due to decline in oxidation capacity (ring oxidation and side chain oxidation). Conjugation capacity remains unchanged. In a study of 32 patients age 30 to 84 years given a single 20-mg dose of propranolol, an inverse correlation was found between age and the partial metabolic clearances to 4-hydroxypropranolol (40HP ring oxidation) and to naphthoxylactic acid (NLA-side chain oxidation). No correlation was found between age and the partial metabolic clearance to propranolol glucuronide (PPLG conjugation).
In a study of 9 healthy women and 12 healthy men, neither the administration of testosterone nor the regular course of the menstrual cycle affected the plasma binding of the propranolol enantiomers. In contrast, there was a significant, although non-enantioselective diminution of the binding of propranolol after treatment with ethinyl estradiol. These findings are inconsistent with another study, in which administration of testosterone cypionate confirmed the stimulatory role of this hormone on propranolol metabolism and concluded that the clearance of propranolol in men is dependent on circulating concentrations of testosterone. In women, none of the metabolic clearances for propranolol showed any significant association with either estradiol or testosterone.
A study conducted in 12 Caucasian and 13 African-American male subjects taking propranolol, showed that at steady state, the clearance of R(+)- and S(–)-propranolol were about 76% and 53% higher in African-Americans than in Caucasians, respectively.
Chinese subjects had a greater proportion (18% to 45% higher) of unbound propranolol in plasma compared to Caucasians, which was associated with a lower plasma concentration of alpha-1-acid glycoprotein.
The pharmacokinetics of Inderal LA have not been investigated in patients with renal insufficiency.
In a study conducted in 5 patients with chronic renal failure, 6 patients on regular dialysis, and 5 healthy subjects, who received a single oral dose of 40 mg of propranolol, the peak plasma concentrations (Cmax) of propranolol in the chronic renal failure group were 2 to 3-fold higher (161±41 ng/mL) than those observed in the dialysis patients (47±9 ng/mL) and in the healthy subjects (26±1 ng/mL). Propranolol plasma clearance was also reduced in the patients with chronic renal failure.
Studies have reported a delayed absorption rate and a reduced half-life of propranolol in patients with renal failure of varying severity. Despite this shorter plasma half-life, propranolol peak plasma levels were 3-4 times higher and total plasma levels of metabolites were up to 3 times higher in these patients than in subjects with normal renal function.
Chronic renal failure has been associated with a decrease in drug metabolism via down regulation of hepatic cytochrome P450 activity resulting in a lower "first-pass" clearance.
Propranolol is not significantly dialyzable.
The pharmacokinetics of Inderal LA have not been investigated in patients with hepatic insufficiency.
Propranolol is extensively metabolized by the liver. In a study conducted in 6 patients with cirrhosis and 7 healthy subjects receiving 160 mg of a long-acting preparation of propranolol once a day for 7 days, the steady-state propranolol concentration in patients with cirrhosis was increased 2.5-fold in comparison to controls. In the patients with cirrhosis, the half-life obtained after a single intravenous dose of 10 mg propranolol increased to 7.2 hours compared to 2.9 hours in control (see PRECAUTIONS).
All drug interaction studies were conducted with propranolol. There are no data on drug interactions with Inderal LA capsules.
Because propranolol's metabolism involves multiple pathways in the Cytochrome P-450 system (CYP2D6, 1A2, 2C19), co-administration with drugs that are metabolized by, or affect the activity (induction or inhibition) of one or more of these pathways may lead to clinically relevant drug interactions (see Drug Interactions under PRECAUTIONS).
Blood levels and/or toxicity of propranolol may be increased by co-administration with substrates or inhibitors of CYP2D6, such as amiodarone, cimetidine, delavudin, fluoxetine, paroxetine, quinidine, and ritonavir. No interactions were observed with either ranitidine or lansoprazole.
Blood levels and/or toxicity of propranolol may be increased by co-administration with substrates or inhibitors of CYP1A2, such as imipramine, cimetidine, ciprofloxacin, fluvoxamine, isoniazid, ritonavir, theophylline, zileuton, zolmitriptan, and rizatriptan.
Blood levels and/or toxicity of propranolol may be increased by co-administration with substrates or inhibitors of CYP2C19, such as fluconazole, cimetidine, fluoxetine, fluvoxamine, tenioposide, and tolbutamide. No interaction was observed with omeprazole.
Blood levels of propranolol may be decreased by co-administration with inducers such as rifampin, ethanol, phenytoin, and phenobarbital. Cigarette smoking also induces hepatic metabolism and has been shown to increase up to 77% the clearance of propranolol, resulting in decreased plasma concentrations.
The AUC of propafenone is increased by more than 200% by co-administration of propranolol.
The metabolism of propranolol is reduced by co-administration of quinidine, leading to a two to three fold increased blood concentration and greater degrees of clinical beta-blockade.
The metabolism of lidocaine is inhibited by co-administration of propranolol, resulting in a 25% increase in lidocaine concentrations.
The mean Cmax and AUC of propranolol are increased respectively, by 50% and 30% by co‑administration of nisoldipine and by 80% and 47%, by co-administration of nicardipine.
The mean Cmax and AUC of nifedipine are increased by 64% and 79%, respectively, by co‑administration of propranolol.
Propranolol does not affect the pharmacokinetics of verapamil and norverapamil. Verapamil does not affect the pharmacokinetics of propranolol.
Administration of zolmitriptan or rizatriptan with propranolol resulted in increased concentrations of zolmitriptan (AUC increased by 56% and Cmax by 37%) or rizatriptan (the AUC and Cmax were increased by 67% and 75%, respectively).
Co-administration of theophylline with propranolol decreases theophylline oral clearance by 30% to 52%.
Propranolol can inhibit the metabolism of diazepam, resulting in increased concentrations of diazepam and its metabolites. Diazepam does not alter the pharmacokinetics of propranolol.
The pharmacokinetics of oxazepam, triazolam, lorazepam, and alprazolam are not affected by co‑administration of propranolol.
Co-administration of long-acting propranolol at doses greater than or equal to 160 mg/day resulted in increased thioridazine plasma concentrations ranging from 55% to 369% and increased thioridazine metabolite (mesoridazine) concentrations ranging from 33% to 209%.
Co-administration of chlorpromazine with propranolol resulted in a 70% increase in propranolol plasma level.
Co-administration of propranolol with cimetidine, a non-specific CYP450 inhibitor, increased propranolol AUC and Cmax by 46% and 35%, respectively. Co-administration with aluminum hydroxide gel (1200 mg) may result in a decrease in propranolol concentrations.
Co-administration of metoclopramide with the long-acting propranolol did not have a significant effect on propranolol's pharmacokinetics.
Co-administration of cholestyramine or colestipol with propranolol resulted in up to 50% decrease in propranolol concentrations.
Co-administration of propranolol with lovastatin or pravastatin, decreased 18% to 23% the AUC of both, but did not alter their pharmacodynamics. Propranolol did not have an effect on the pharmacokinetics of fluvastatin.
Concomitant administration of propranolol and warfarin has been shown to increase warfarin bioavailability and increase prothrombin time.
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This article is more than 1 year old
Sonim nudges NFC into hard-as-nails handset
Communication that doesn't break down?
Mobile manufacturer Sonim has extended its range of hardened handsets with what it claims is the world's most rugged NFC phone: the XP1301 Core NFC
The XP1301 Core NFC rocks Sonim's familiar form-factor, sharing the fortified body of its other products, such as the XP3300, a long-life battery beast revealed at the Mobile World Congress show in February.
As with all the company's wares, the handset is said to be "beyond military specification" and can withstand harsh abuse. Whether you drop it, freeze it, heat it or swim with it, the XP1301 should keep ringing away, with its 2in, 240 x 320 pixel display, protected by a puncture proof Corning Gorilla Glass screen.
Battery life is impressive too, boasting 20-24 hours talk time and 800 hours standby. There's also active noise cancellation, a multimedia player, an FM radio, a torch and a MicroSD slot expandable to 16GB.
Should you have the use for such a device, an unlocked Sonim XP1301 Core NFC can be grabbed with a three-year warranty for £289. ®


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The Ridley Island bulk commodity terminal at Prince Rupert will be expanded with a $90 million road and rail project, Premier Christy Clark announced Monday.
The B.C. government is pitching in $15 million, with another $30 million each from CN Rail and the Prince Rupert Port Authority.
The project includes three inbound and two outbound tracks for coal, potash and other bulk terminal developments at Ridley Island, plus electrical and water connections for new facilities.
Billed as "Canada Starts Here: The B.C. Jobs Plan," the tour continued Monday with a stop near Kitimat, at the site of a proposed liquefied natural gas (LNG) terminal for shipping to Asia and other international customers.
Clark promised to support LNG exports by speeding up the permit process for large industrial developments, increasing skills training and promoting B.C. gas exports internationally.
The Kitimat LNG project is proposed by Encana Corp., Apache Canada Ltd. and EOG Resources Inc., investors in the Horn River shale gas region and other gas resources in northeastern B.C. Others have been proposed, and Clark said her goal is to have up to three LNG export terminals developed by 2020.
"We want to create a new industry with the capacity to export B.C.'s liquid natural gas to markets overseas," Clark said at her Prince Rupert stop. "And if we don't fight for this opportunity now, we could lose it."
Australia already has LNG facilities exporting gas to Japan, which needs alternatives to its troubled nuclear power system. Australia has two LNG export facilities in operation and six more in development.
NDP MLA Carole James said Clark's Prince Rupert announcement is a belated commitment of money to a Pacific gateway export program announced in 2006 by former premier Gordon Campbell.
The Prince Rupert and Kitimat announcements are the first stage of a week-long economic development tour being led by Clark and Jobs, Tourism and Innovation Minister Pat Bell.
Announcements are scheduled Tuesday at Thompson Rivers University in Kamloops, Wednesday in Clark's speech to the Surrey Board of Trade, and a full description of the plan on Thursday in a speech to the Vancouver Board of Trade.


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Space Weather Mysteries & Unanswered Questions
The study of space weather is a relatively young science. As such it has many unanswered questions and unsolved mysteries. Although some of our data relevant to space weather, such as sunspot counts, go back many years, most of knowledge of the field stems from recent times. Supercomputers, satellite-borne instruments, and telescopes capable of imaging the Sun in many different parts of the electromagnetic spectrum are recent developments, and each plays a large role in our developing understanding of solar science and space weather.
Here are a few of the unsolved mysteries related to space weather:
- Is there a connection between space weather and Earth weather?
- What causes the 11-year sunspot cycle?
- What caused the Maunder Minimum?
- Where does the heliosphere end? Is Voyager there yet?
- Why do Earth's magnetic poles move around?
- Why does the polarity of Earth's magnetic field flip, and why on such an irregular basis?
- Is the strength of Earth's magnetic field reduced when the poles flip, and, if so, does this expose life to higher doses of radiation? If so, why don't we see indications of this in the fossil record?


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Please contact: Sonia Singh, Public Health: 602-679-3098
PHOENIX (Aug. 23, 2019) – Today, Maricopa County Department of Public Health and Arizona Department of Health Services learned that a teenage international traveler competing in the World Hip Hop Dance Championship at the Arizona Grand Resort in August has tested positive for measles and may have exposed others to the disease.
"Public Health is continuing to gather information on locations where this person may have visited during her time in Maricopa County. Measles is highly contagious and can expose individuals up to 2 hours after an infected individual has left the room," said Dr. Rebecca Sunenshine, medical director for disease control at Maricopa County Public Health. "Because of this, it is important that anyone who was in the same place as this person, monitor for measles for 21 days after the exposure."
Sunenshine added, "If you haven't developed symptoms by Sept. 2, you are in the clear."
As of today, Public Health has confirmed that this individual was infectious with measles at the following locations, dates and times:
This is an ongoing investigation. Please Visit WeArePublicHealth.org for an updated list of locations WHERE EXPOSURES OCCURRED.
Anyone who develops symptoms, such as fever or an unexplained rash, is urged to stay home and contact a health care provider over the phone. Please let the healthcare provider know that you may have been exposed to measles.
Measles is a highly-contagious, vaccine-preventable viral illness spread through coughing, sneezing, and contact with secretions from the nose, mouth, and throat of an infected individual. Measles virus can survive in the air for hours and may be transmitted to susceptible individuals even after an infected individual is no longer in the room/area. You may be protected from measles if you were immunized with 2 doses of MMR (Measles, Mumps and Rubella) vaccine or if you have previously had the disease. Healthcare providers are required to report suspect cases of measles to Maricopa County Department of Public Health.
People who have depressed immune systems may have a rash that does not fit the description above.
What to do if you think you have measles:
If you have a healthcare provider, contact him/her by phone and let them know that you may have been exposed to measles. They will let you know when to visit their office so as not to expose others in the waiting area.
If you do not have a health care provider, you may need to be seen at your local hospital emergency room/urgent care center. Please call before going to let them know you may have measles.
For more information on measles' signs and symptoms or where you may find vaccine, please visit www.WeArePublicHealth.org.


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- March 1, 2024
Eric Collins first came to Sarasota when local director Bill Castellino called him down for an audition four years ago. Manhattan, N.Y.,-based Collins had worked with Castellino many times before.
Collins made his Sarasota debut in January 2008, at Florida Studio Theatre's "Hula Hoop Sha-Boop," a show celebrating sock hops and doo-wop. He's been gracing FST's stage every season since and has become a seasoned Sarasotan — he spends about four months a year here. Collins is a snowbird or, rather, a "showbird."
You might have seen him in the productions of "That's Life," in 2009, "The Wanderers," in 2010 and "That's Life, Again," in 2011.
"Everyone here at FST is really great," Collins says. "It's kind of like a second, winter family."
This year, Collins is back for FST's "Let's Twist Again: with the Wanderers," a show full of the 1950s and 1960s music that brought him here in the first place. Richard Hopkins and Jim Prosser developed the show, with assistance from Rebecca Hopkins.
By now, Collins is well-versed in this era, but not because he experienced it personally — he's only 36 years old.
"Actually, FST was the first time I'd gotten into this pop '50s and '60s era of music," he says. "Well, aside from a couple of productions of 'Grease' here and there, but that's common with any musical-theater performer."
He's found his niche, at least in Sarasota.
"I really enjoy it," he says of the style of music. "And the patrons down here, it's their music and it's something they really love. It's always great when your audience loves what you've done."
Collins is the only "wanderer" returning from the past company of "The Wanderers." This time, fellow New Yorkers José Restrepo, Brett Rigby and Teddy Tenson will join him. But, there might be a few surprise reprises from the past "Wanderers," says Collins.
"Each time you come in contact with new people, you have to find your own sound, (your) own blend," Collins says about performing with a new group. "But I don't think they'll be disappointed with this product."
And with eight-hour daily rehearsals, the cast is certainly putting in the work required.
"The first week is pretty intense," Collins says of his arrival. "You have to build up some stamina … it can be vocally taxing until you get that rhythm going."
He hasn't even had a chance to go to some of his favorite places, such as Ceviche, Selva Grill and Café Amici, let alone the beach. Collins' performance and rehearsal schedule doesn't allow him to experience Sarasota's entire arts-and-entertainment scene. But a few years ago, Sarasota Opera's Artistic Director, Victor DeRenzi, invited him to the opera, and he found it to be a great experience.
"The art scene here can't be beat — it's definitely the cultural hub of Florida," he says.
He calls the people here "culturally savvy," and even though it's slower-paced than New York, the city projects a big-city mentality.
This year, those culturally savvy patrons will have an extra month to see his show. His production has been extended because of the new Gompertz Theatre.
He's amazed with how quickly the theater has gone up; when he left for New York in January, there was nothing done yet.
"The fact that a community can support a theater of this size and have it be as successful as it is — you can't find many places like that," he says.
Collins has nothing but nice things to say about the patrons and FST: "I've always been happy here," he says.
"They always ask you back," he says of Richard Hopkins' loyalty to performers, " … And I think the public kind of likes that. In a way, they start feeling like they really know someone."
No matter how much "wandering" Collins does, this "showbird" will always fly back.
'Let's Twist Again: with the Wanderers'
When: Opens Oct. 17; runs through Jan. 13.
Where: Goldstein Cabaret
Cost: $19 to $36.
Info: Call 366-9000 or visit floridastudiotheatre.org.
Collins' Rundown
First performance: Age 7, as an orphan in "Scrooge"
First Broadway show he saw: "Cats"
Favorite performance he's been in: As Tommy in "The Who's Tommy"
Best production he's seen: "Metamorphosis"
Role he's always wanted to play: Tobias in "Sweeney Todd"
Favorite production: "Sweeney Todd"


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Consultants have seized upon their Next Big Idea: You. Having seen clients pull back on discretionary spending, consulting firms now regard the finance department as a still-warm, if not hot, target for their services, thanks to the slimming down most departments have endured. IBM, for example, plans to approach CFOs "with some pretty bold claims" about how much and how fast its new business-analytics unit can cut costs in areas like financial reporting, says Fred Balboni, head of the unit. Tata Consultancy Services is offering finance chiefs a two- to three-week "diagnosis period" to help assess where the quick fixes lie, and says many projects can pay for themselves within two quarters. Still others are benefiting from clients' fear, offering reassurance to CFOs who must supervise activities outside their expertise, such as international expansion.
Services specific to CFOs are "the bright spots" for firms like Accenture, Ernst & Young, and many smaller ones, says Derek Smith, director of research for Kennedy Consulting and Advisory, a market-research provider. That's relative, to be sure: Kennedy projects just 2% growth in finance-management consulting in 2009, down from 16% in 2008. Still, in some areas, the growth can be called dramatic. For example, some 42% of executives who began an outsourcing relationship this year report using an adviser to help structure it, according to a recent Black Book of Outsourcing report, up from just 16% last year.
Even in high-demand areas, however, consulting is still a buyer's market. In IT consulting, for example, bill rates are down anywhere from 5% to 15%, says James Friedman, an analyst with Susquehanna International Group who follows Accenture and other IT consulting firms. CFOs also have "a fair amount of leverage" in negotiating with firms that work on a contingency-fee basis, notes Steve Crane, CFO of ModusLink Global Solutions. In general, clients are pressing for "the ROI to be a lot more visible and a lot shorter," says Mark Goodburn, vice chair for KPMG's advisory services.
Finance chiefs thus have an opportunity to get more bang than usual for the consulting buck, but only if they structure projects to make consultants' time as efficient as possible. If an engagement drags on without a clear sense of direction or tangible achievements, lower hourly rates can still add up — and perhaps culminate in a potentially far greater cost: outright failure. CFOs, in short, need to select the best consultant for the job, crisply define the tasks to be accomplished, break them into independent phases so that spending can be turned off at any point, and lean on internal staff to both monitor and streamline the process.
To Buy or Not to Buy
Buying smart begins with deciding whether you truly need to hire a consultant. CFO Holly Koeppel, for one, has progressively challenged her staff at American Electric Power (AEP) to take on roles she once used consultants for, such as leading strategic-planning exercises and managing budget overhauls. That has saved untold millions of dollars, she says, and such processes "have actually gone more smoothly, because people are more engaged" with an internal expert at the helm rather than an outside consultant.
But when a project is too risky, or too important to be handled by nonexperts, many finance chiefs say they won't hesitate to buy what they need. Jack Judd, CFO of data storage provider Compellent, says he never considered using internal staff to organize tax records and plot tax strategy as the New York Stock Exchange–traded company approaches profitability. That approach would have been "very impractical" given that his small staff lacks a tax expert, and could have resulted in lost tax savings if the job wasn't done right, he says.
Likewise, Sentinel Group CFO Ryan Ziemann hired IBM (and its software) to help amplify the company's ability to detect fraud in medical claims, its main business line. "We theoretically could have developed this in-house, but it would have taken years of commitment and resources. The value lies in getting deep knowledge and expertise, plus avoiding pitfalls" that can be costly in themselves, says Ziemann.
Finding the right consultant is decision number two, and arguably the most difficult one. Many CFOs say they rely primarily on references from their colleagues to identify, and then interview, three or four firms. Then they contact more-formal references as they narrow down the process. Doing this well takes no little effort, however. ModusLink Global Solutions CFO Steve Crane says he always does reference checks to make sure that a consultant has some experience, but he also always worries about getting overly optimistic reports from company-provided sources. To help cut to the chase and uncover any glitches that may have occurred, Crane likes to ask: "What did you learn from the project that you'd want to do differently next time?"
A Piece at a Time
Happily, the consequences of hiring the wrong consultant are smaller than ever, as most projects these days are structured into discrete phases so that each part is, in a sense, a trial run. "Put off that long-term commitment as long as possible, and at least until you've seen the results of the upfront work," advises Ziemann. He says it is particularly important to push back when firms ask for upfront fees or the promise of more work if initial milestones are met, since you may decide along the way that "even if they met their milestones, it was more pain than it was worth."
Structuring a consulting project into phases is the approach CFO Karen Cambray is taking at Zeemote, a small private company that manufactures and distributes gaming controllers for cell phones. Zeemote was in the process of readying products for sale in Europe when Cambray joined in September 2008, and she wanted to make sure the legal aspects were addressed properly. While she "could have spent a lot of time researching and networking" to get the answers, she decided she was safer using outside help and hired High Street Partners. While there was not, in fact, much wiggle room on the rate, Cambray kept a lid on costs by initially hiring the consultancy only to write a white paper on the pros and cons of setting up an office in various countries. Then, satisfied with that, she hired High Street to help with the administrative work of registering in the United Kingdom, the country she chose.
Cambray is now considering using the firm's outsourcing capacity for administrative tasks like processing European payrolls. Throughout the process, she says she and her controller look at monthly consulting charges and compare them with their estimate of the time it would take to do something internally, "and we reassess with every new project we add."
Consulting firms say this type of thinking is now par for the course. "Less today is better than more tomorrow; clients are aiming to do smaller projects rather than big bang," says David Michelson, head of Tata's business-process and change-management consulting practice in North America. Projects involving outsourcing (and often a new source of cash) are illustrative, with the time-consuming strategy piece getting short shrift.
"A year and a half ago, clients would have had big internal debates about whether to do an internal captive or go offshore, or to just improve existing processes," says Bob Cecil, global executive director for Equaterra's business and financial processes group. "Now executives aren't tolerating a lot of back-and-forth to get everyone on board; they want to move faster to a solution."
Staff Time Counts
Finally, a key ingredient of a successful consulting engagement is taking a realistic view of how much staff time it will take to manage the consultants. Compellent's Judd just hired Grant Thornton to do a "382 study" (as in Section 382 of the Internal Revenue Code) to maximize net operating loss carryovers, an R&D tax credit study, and some sales tax work. "Just on the R&D piece, the credit from the federal government could be 10 to 20 times what we'll pay the consultant, so it's a real no-brainer to do it," he says. But with the work slated to span six to nine months, Judd is keeping an eagle eye on how many hours he's being billed for. Without formal milestones in the contract, "the number-one thing" is to dedicate a staff person to make sure consultants "aren't wasting time when they're on site," says Judd. To that end, he waited until year-end reporting was over so that one of his directors of finance who "is not a tax expert but knows everything Grant Thornton needs to provide" could take on the job of monitoring the consultants.
The cost of staff time is important to bear in mind even when the consulting work is done on a contingency basis, or ostensibly for free. Crane of ModusLink Global Solutions is currently interviewing various firms to comb his accounts-payable records for errors and assess his real-estate portfolio for additional savings. With data housed all around the world, though, the company will incur the upfront cost of having a staff person assemble the necessary information, with the risk that no savings emerge. Not to mention that the work is "quite boring — there's no way around it," adds Crane.
But the result of a consulting engagement ought to be exciting, in terms of better growth, profitability, or efficiency. Make sure that the consultant takes your company where you want it to go — and that when it gets there, you aren't shocked by the size of the fare.
Alix Stuart is a senior writer at CFO.
The Big and Small of It
When Compellent CFO Jack Judd was looking for tax help for his small, publicly traded technology company last spring, he auditioned several accounting firms, including one of the Big Four, but ultimately chose a (relatively) smaller firm. "The Big Four are easy choices when you need lots of infrastructure and someone to come in quickly," he says, but since they were the most expensive and the project wasn't particularly time-sensitive, Judd went with the smaller firm. It wasn't just cost that drove his decision; the fact that the people who met him from that smaller firm were also the ones who would actually do the work mattered as well. "An awful lot of my choice was about who I trusted [the most]," says Judd.
Indeed, many CFOs at small firms worry that they will get lost in the shuffle if they go with a big brand name for consulting services. That hasn't stopped Sentinel Group CFO Ryan Ziemann from hiring global information-technology vendors to help his 30-person health-care-fraud-prevention firm, though. To help ensure good service, he says that he avoids upfront and flat fees and pushes for full contingency pricing whenever possible, so vendors are "strongly incented to perform well."
So far, it has worked out well, says Ziemann. Not only has one vendor's software tool helped identify more than $50 million worth of health-care fraud in the past five years, but the vendor's support team is always available by phone to Ziemann's staff, and recently helped them develop a special report based on the software's capabilities at no additional cost.
In general, choosing between a large and a small firm may depend on the project. Big firms are typically good at enterprisewide, global projects and carry much less risk, notes Dan Morris, co-founder of Verasage, a think tank focused on trends in professional services, "but if you want true innovation, you're much better off with a boutique or even a solo practitioner." — A.S.


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Most guys love beer. With that in mind, any gift involving beer will make most guys happy, and if you're looking for a cool stocking stuffer then you have to check out the Shakoolie – the original shower beer holder. Yes, many of us like to drink an ice cold beer in the shower, so the Shakoolie provides a handy tool to hold your beer in the shower and also keep it cool. It even comes in pink as you can see above for the ladies on your list!
Everyone loves fun gifts on the holidays, so keep this one in mind. The Shakoolie is also a perfect accessory for your bachelor pad, your boat or for the bathroom in your man cave.
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Insurance Coverage & Costs Access to Care Uninsured and Low-Income Racial/Ethnic Disparities Safety Net Providers Community Health Centers Hospitals Physicians Insured People Quality & Care Delivery Health Care Markets Issue Briefs Data Bulletins Research Briefs Policy Analyses Community Reports Journal Articles Other Publications Surveys Site Visits Design and Methods Data Files |
A Growing Hole in the Safety Net: Physician Charity Care Declines AgainTracking Report No. 13 Continuing a decade-long trend, the proportion of U.S. physicians providing charity care dropped to 68 percent in 2004-05 from 76 percent in 1996-97, according to a national study from the Center for Studying Health System Change (HSC). The ongoing decline in physician charity care is alarming given the increase in the number of uninsured people, particularly during the first half of the decade. Declines in charity care were observed across most major specialties, practice types, practice income levels and geographic regions. Increasing financial pressures and changes in practice arrangements may account in part for the continuing decrease in physician charity care.
Physician Charity Care Continues to Declinehysicians have long played a key role in the nations health care safety net, providing free or reduced cost care to uninsured patients in their own practice or as volunteers at free clinics. However, financial and time pressures, as well as ongoing changes in the medical marketplace, may be contributing to decreases in the proportion of physicians providing charity care. The percentage of physicians providing any free or reduced cost care decreased to 68.2 percent in 2004-05 from 71.5 percent in 2000-01, according to HSCs nationally representative Community Tracking Study Physician Survey (see Data Source). This trend dates back to at least 1996-97, when more than three-fourths (76.3%) of physicians provided some charity care (see Figure 1 and Table 1). Despite a decrease in the proportion of physicians providing charity care, the actual number of physicians providing charity care has remained relatively stable because the overall number of practicing U.S. physicians increased from approximately 347,000 in 1996-97 to 397,000 in 2004-05. Additionally, among physicians who provide charity care, there was little change in the amount of charity care provided during this period. From 1996-97 to 2004-05, the average number of hours spent providing charity care and the percentage of practice time spent on charity care both declined slightly, but these changes were not statistically significant. Nevertheless, there has been a decline in the amount of physician charity care relative to the number of uninsured Americans. The overall number of charity care hours per 100 uninsured people declined from 7.7 hours in 1996-97 to 6.3 in 2004-05, an 18 percent decline.1 Most of this decrease has occurred since 2000-01, primarily because of large increases in the number of uninsured, from 39.6 million in 2000 to 45.5 million in 2004. Back to Top
Physician Specialtyhe proportion of physicians providing charity care declined across all major specialty groups (see Table 2), as well as across all geographic regions and in both urban and rural areas (latter findings not shown). Surgical specialists are the most likely among specialty physicians to provide charity care, probably because many are required to be on call at hospitals and therefore have less choice about whether to treat uninsured patients. Pediatricians are the least likely to provide charity care, which perhaps reflects the fact that fewer children are uninsured because of more generous public coverage eligibility compared with adults. Back to Top
Physician Practice Characteristicsharity care is declining across most types of physician practices, and physicians are increasingly moving to practice settings where there is less provision of charity care. Levels of charity care are highest among physicians in solo or small group practices and those that are full or part owners of their own practice, perhaps because they have greater control over the types of patients they see and there are fewer organizational barriers for uninsured persons to see these physicians. About 80 percent of physicians in solo practice or small groups (10 physicians or fewer) provided charity care in 2004-05, and this has not changed significantly since 1996-97. By comparison, physicians in larger groups and institutional-based practices (i.e. medical schools or hospitals) are much less likely to provide charity care, and charity care among these physicians declined sharply between 1996-97 and 2004-05. Furthermore, a decreasing number of physicians are in solo practice, and an increasing number of physicians are practicing in the practice settings that are less likely to provide charity care. Between 1996-97 and 2004-05, the percentage of physicians in solo or two-physician practices declined from 40 percent to 31 percent, while the percentage in large groups, hospitals, and medical schools increased from 21 percent to 26 percent (findings not shown). Similarly, physicians who own their practice are more likely to provide charity care than nonowners (who are more likely to be in large practices and institutional settings). While charity care decreased between 1996-97 and 2004-05 for both owners and nonowners, the percentage of physicians who are full or part owners has been steadily decreasing, from about 62 percent in 1996-97 to 54 percent in 2004-05. Back to TopPhysician Incomerovision of charity care has declined for physicians at all levels of income. Physicians at the highest income levels continue to report the greatest provision of charity care, with 75.6 percent of physicians with practice incomes greater than $250,000 providing charity care in 2004-05, compared with 66.4 percent of physicians earning less than $120,000. However, physician income has declined in real terms in recent years, both for primary care physicians and specialists, likely because of constraints on public and private reimbursement levels.2 Declining practice incomes likely make it more difficult for physicians to subsidize charity care. Back to TopLocation of Charity Carehe majority of physicians who provided charity care (more than 70%) reported that they typically did so in their own practice (see Table 3). About 14 percent of physicians reported providing charity care primarily while on call in a hospital emergency department, about 6 percent in another practice or clinic (e.g. as volunteers at a free care clinic), and 8.4 percent at another unspecified location. Pediatricians and family practice physicians are the most likely among major specialty groups to provide charity care at their main practice. Medical and surgical specialists are the most likely to provide charity care as a result of their on-call responsibilities at hospitals, although most specialists report that their own practice is the place where they typically provide charity care. Back to Top
Declines in Access to Medical Carehe long-term decline in charity care provided by physicians may have contributed to reductions in uninsured peoples access to medical care. In 2003, 63.1 percent of the uninsured had a regular source of medical care, down from 68.6 percent in 1996-97 (see Table 4). Additionally, the percentage of the uninsured with a physician visit in the past year fell from 51.6 percent to 46.1 percent during this period. Emergency department visits as a proportion of all ambulatory visits increased for the uninsured between 1996-97 and 2000-01, as did the proportion of uninsured people with unmet medical needs. However, the downward trend in access leveled off between 2000-01 and 2003, and even improved in terms of unmet medical needs. Continued declines in physician charity care during the early 2000s may have been offset to some extent by the strengthening of the safety net in some communities, especially the expansion of federally supported community health centers.3 Back to Top
Implicationshysicians and hospitals historically have provided charity care to the uninsured in part by charging higher fees to other patients, particularly those with private insurance coverage. But both public and private payers have held the line on reimbursements to medical providers, creating financial pressures that may be limiting physicians ability to provide charity care. Hospital uncompensated care levels have held steady in recent years, aided by hospitals private insurance payments rising somewhat faster than costs.4 However, declining practice incomes among physicians suggest that they have been less successful than hospitals in negotiating fees with private payers, and they also have experienced continued constraints from public payers. Time pressures for physicians also have increased, in part because of a strong surge in demand for physician services during the late-1990s.5 As a result, the decline in charity care between 1996-97 and 2004-05 may reflect physicians who believe they can no longer afford or have time to provide charity care. The movement toward larger practice arrangements and less ownership is also contributing to a decrease in charity care, although this shift may be a response in part to financial and time pressures that physicians are experiencing. Larger practices in which physicians are employees can help shield them from these pressures, provide more leverage in negotiating fees with private payers, and relieve them from some of the burden of on-call responsibilities. However, larger practices also may present greater organizational barriers to uninsured patients, and employed physicians have less discretion over the types of patients they see. The result is that the uninsured likely must rely even more on formal safety net providers, such as community health centers, other free clinics and public hospitals; or they are getting less medical care. This also implies a shift in the financial burden of providing care to the uninsured from physicians to taxpayers in the form of direct and indirect subsidies to major safety net providers. The expansion of federally supported community health centers in recent years may have helped to stem the decline in access to care among the uninsured that was observed during the late-1990s, although overall federal spending on the safety netwhile increasinghas not kept pace with the growing number of uninsured.6 Unless there are steps taken to halt and even reverse increases in the number of uninsured, it is likely that safety net resources will become even more constrained as a result of increased demand. Back to TopNotesBack to TopData SourceThis Tracking Report presents findings primarily from the HSC Community Tracking Study Physician Survey, a nationally representative telephone survey of physicians involved in direct patient care in the continental United States conducted in 1996-97, 1998-99 (results not shown for ease of presentation), 2000-01 and 2004-05. The sample of physicians was drawn from the American Medical Association and the American Osteopathic Association master files and included active, nonfederal, office- and hospital-based physicians who spent at least 20 hours a week in direct patient care. Residents and fellows were excluded. The 1996-97, 1998-99 and 2000-01 surveys each contain information on about 12,000 physicians, while the 2004-05 survey includes responses from more than 6,600 physicians. The response rates ranged from 52 percent to 65 percent. In addition, this Tracking Report presents findings from the HSC Community
Tracking Study Household Survey, a nationally representative telephone survey
of the civilian, noninstitutionalized population. Data were supplemented by
in-person interviews of households without telephones to ensure proper representation.
The 1996-97 and 2000-01 surveys each contain information on about 60,000 persons,
while the 2003 survey includes responses from about 46,600 persons. The response
rates ranged from 57 percent to 60 percent. More detailed information on survey
methodology can be found at www.hschange.org. Back to TopISSUE BRIEFS are published by the
Center for Studying Health System Change. Vice President: Jon Gabel |


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Tweed can be tricky. It can be hard to pull off, and at times (like early fall), it can feel a bit too much like outerwear when sported inside. Which is why a tweed waistcoat offers an easy solution. It's a way to bring a bit of rustic, autumnal charm and add a nice layer of texture to a regular shirt and tie, without taking over the whole look. And as the temperature dips, they look great under outerwear—from a blazer or top coat to a leather or denim jacket. And thankfully, there are plenty of options this season. L.L. Bean has an impressively priced shetland wool vest in a handsome herringbone and Rugby offers a smart looking style with dual chest pockets in an English windowpane plaid.
What should I pack for my first business trip?
- Matt, OH
With nearly every airline imposing a baggage fee nowadays, if you can get away with flying with just a carry-on, do it.
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Welcome to Whaley Hall
We're delighted you've found your way to our website and encourage you to have a look around and discover what we have to offer. We offer high class facilities and exciting activities for groups and individuals. We're also located in a beautiful part of the country, ideal for walking, sailing, climbing and much more. If you have any questions, contact us and we will be happy to help.


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Applications: burglar alarm, public address systems, intercoms, telephone stations, speakers, instrumentation, control and other low voltage circuits that are power limited.
Manufacturer: Southwire
Plenum Rated? Yes
Jacket Color: White
Number of Conductors: 3
Conductor Gauge: 18 AWG stranded copper
Shielding: Foil shielded
Manufacturer's Part#: P40032-1B
Full Part#: 1880AB3M/CMP/CL3P
Specification Sheet: View
Orders with in-stock items received by 4pm CST will ship out same day from our warehouse in St. Louis Missouri. Orders placed on the weekend will be processed on the next business day. Once your order has been processed you will receive tracking information via email. For non-stock items, tell us when you need them and we will arrange the shipments to meet your requirements with the most economical shipping method.
If you have any questions or comments for us, always feel free to call us at 1-866-958-4499. We are available to take your call between 7:30am to 5pm CST Monday to Friday.
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