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Randall Beach: "South Haven": a fictional town with real issues of race
Hirsh Sawhney admits "South Haven," the title of his new book, is a made-up name for a town but he adds, "It might feel familiar."
That's because Sawhney, now 37, grew up in Orange, the son of immigrants from India. His book is laced with places recognizable to New Haven area readers, including "Paulie's," clearly based on Louis' Lunch.
Sawhney, who teaches English and creative writing at Wesleyan University, seemed a tad nervous as he stepped up to the podium on a recent night at New Haven's Institute Library to read from his book during its official "launch."
Perhaps he was somewhat awed by the introduction moments earlier from acclaimed novelist Amy Bloom, a colleague of his at Wesleyan. She promised, "This is a novelist you will be reading for years to come."
"My best friends from junior high school are here!" Sawhney told us. "My mother (Rama Sawhney) is here. My aunties are here."
After he revealed, "I'm a big Grateful Dead fan" and also loves Bob Dylan, Sawhney acknowledged "South Haven" is based on a suburban town close to New Haven.
"I have a strong connection to New Haven. My father (Shiv Sawhney) migrated here in the 1960s. He's no longer with us. He was such a wonderful reader."
His dad died on New Year's Day of 2009. Two years later, Sawhney began writing "South Haven."
"I was grieving his loss when I wrote it," he said. "It's a meditation on what grief means and what it does to people."
Sawhney did not elaborate but later I asked him to do so. He replied, "Grief, when not properly dealt with, when repressed and not articulated properly, leads people to be angry, frustrated and potentially leads them to be violent."
The main character in his book, Siddharth, is only 10 when his mother is killed after a truck hits her car. Sawhney began his reading by choosing a section near the start of the book, wherein Siddharth's older brother, Arjun, tells him their mother has died.
The book traces how Siddharth and his father, Mohan Lal, try to deal with this loss (Arjun is not on the scene much because he goes off to college in Michigan). Siddharth, craving acceptance by the "cool" kids at his school, gravitates toward bullies. Mohan Lal embraces Hindu extremism, which causes problems at Elm City College (clearly not based on Yale), where he teaches. (Sawhney said those two characters are fictitious, not modeled after himself and his dad.)
During his library talk, Sawhney said, "This novel traces how people learn to hate."
And he noted, "We see this happening" in America today. "We live in an age of fascism taking over our political structure."
In my follow-up conversation with him, I asked Sawhney if he had been referring to comments by the presumptive Republican nominee for president, Donald Trump. He said yes, when he listens to Trump, "the rhetoric is fascistic."
Sawhney believes Trump's success has encouraged some people to talk in the same way. "They feel it's OK giving voice to racial anger. Trump's popularity validates a racism that had been latent. Maybe it's good to get it out in the open."
Sawhney added, "This wasn't the case when I grew up. Maybe I'm being nostalgic, but I think when I was a kid there was a feeling of mutual respect in interactions in Greater New Haven."
"In many ways Orange was hospitable and we did well there. We were friends with our neighbors. In many ways it was harmonious."
But Sawhney added, "As the child of immigrants, there was a feeling of marginalization. Sometimes, there was an unspoken unease we experienced. We weren't part of the mainstream. I think some people did think our customs were strange or weird. I grew up at times ashamed of where I came from. As an adolescent, I think my heritage was a source of embarrassment and shame."
Sawhney noticed a definite change after the 9/11 terrorist attacks. "Because of my appearance, people think I'm an Arab-born Muslim. People can say some hostile, alienating things." (Sawhney was born at Yale-New Haven Hospital.)
After we spoke about this, Sawhney followed up with an email to clarify his thoughts on a very sensitive subject. "Regarding racism in the suburbs: while I was growing up, I definitely think it existed. I heard a lot of racist talk about black people and Hispanic people from my peers and sometimes from their parents."
He added, "The xenophobia toward Asians and Indians was much more subtle, though dangerous in a different way, as it is in my novel -- but I did hear derogatory slurs from time to time. And yes, this xenophobia and racism does make a child feel marginalized or shameful."
Sawhney now lives in the East Rock section of New Haven with his wife, Anjali, and their 11-month-old daughter. "I think the suburbs are becoming increasingly diverse," he said. "But I'm attracted to city living because I find a lot of isolation and detachment and apathy in the suburbs. I like interacting with people, knowing the person who sells me my groceries."
He talked a little more about his father, who taught at the University of New Haven through the early 1980s, then was a teacher at Quinnipiac University until his retirement.
"He cared deeply about books and ideas," Sawhney recalled. "But he never was able to publish the book he wanted to get published."
When I remarked it seems the son fulfilled the father's dream, Sawhney said, "It feels good to finish part of his mission. I think my father would have been proud and happy."
Contact Randall Beach at email@example.com or 203-680-9345.


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WPCNR SOUTH END TIMES. By John F. Bailey. August 4, 2014:
The new site plan of the proposed French American School of New York indicates the school does not have enough financing already in place to build the campus in one continuous sequence.
WPCNR notes the site plan is the first time the school has indicated the project may take 10 years to complete. In Section 10, page 4 of the site plan under the heading "Deferred Phasing of the Elements," the site plan states:
And Phase II is hoped to be completed by 2025, but the start could be delayed until 2025:
Another issue which has not previously been disclosed is that the school does not have capital sources in place to pay for three of the buildings proposed in Phase II of the project, according to this statement in the site plan, it will need to "replenish its capital funds" and appears to hold the city responsible for hurting its fund-raising efforts:

subset: commoncrawl


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The Signature Sleep 13 Inch Independently Encased Coil is a highly recommended product due to the fact that it provides a high comfort and support as well. There is nothing we don't like about this product.
Unfortunately, there are lots of people these days who cannot sleep very well, and the main reason is without a doubt an uncomfortable mattress. Therefore, in case you are in the same situation, you need to purchase a high-quality product just like the Signature Sleep 13 Inch Independently Encased Coil. With this mattress, you will surely improve the quality of your sleep. Signature Sleep is a reliable brand which produces very comfortable and durable items. This model is not extremely expensive, but not cheap either. We can say that it is quite affordable. It is available in three sizes and the price actually ranges from $229 to $339. In this review, you will find all the information you need about this wonderful product.
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This is not everything because with this mattress you will also be provided with a superior edge to edge sleep support thanks to the 4 layers of high-density support foam. Let's not forget about the cover which is made of bamboo and which delivers a breathable and resilient sleep surface, so that you can feel ultra comfortable at all times, especially in the summertime. The Signature Sleep 13 Inch Independently Encased Coil has definitely been built with a high comfort in mind and you will surely not regret buying it. It is ideal for any sleeping position, and it works with most surfaces including box spring beds, bunk beds, sofa beds, platform beds, daybeds, futons, and trundles.
The Signature Sleep 13 Inch Independently Encased Coil mattress has a 1-year limited warranty from the date of purchase against defects in workmanship and/or materials. In case you spot a defect, the manufacturer will repair or replace the product, depending on the size of the issue. In some cases, the manufacturer doesn't have at their disposal the materials the mattress is made of and they reserve the right to replace those materials with similar ones of the same or higher quality. Unfortunately, we didn't find any information whatsoever regarding the trial periods with money back warranty.


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Privacy Policy
This is the main privacy policy for thegreekobserver.com and for certain services provided through the Greek Observer website.
We collect different types of information about our users for four main reasons:
- To provide personalized services unique to individual users.
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There may be other privacy policies that apply to certain services we provide. Please read these when you register or subscribe for these services on these sites.
Our principles
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Some of our webpages use plug-ins from other organizations (such as the 'Facebook Recommend' function). These other organizations may use information about your visit to our websites on their pages. If you browse these pages while still also logged in to your account with us, information they collect may be connected to your account on their site. For more information on how these organizations use information, please read their privacy policies.
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For more information about cookies and managing them, including how to turn them off, please visit our page on Cookies.
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Make a Gift
Our mission to provide highly trained assistance dogs to people with disabilities FREE of charge is possible thanks to the generous gifts of our donors. You can make a monthly or one-time gift.
Support Veterans
Donate now or give monthly to help provide more assistance dogs to veterans with disabilities entirely free of charge. Give the gift of independence to those who have served our country.
Build a Campus
Help make a difference in the lives of people with disabilities by supporting our capital campaign for the new North Central Region campus in New Albany, Ohio.
Honor & Memorial Gifts
Want to donate to Canine Companions on behalf of a loved one? Send an eCard or regular card in honor or memoriam with your donation.
CARES Act
Congress has enacted several tax law changes in response to COVID-19. The Coronavirus Aid, Relief, and Economic Security (CARES) Act was enacted to provide relief to aid America's families and businesses.
Planned Giving
Would you like to include Canine Companions in your estate plans or trust? Find out more about these options and other ways you can support our mission.
Grab a leash and get ready for a tail waggin' good time! Learn how to get involved with our signature national event, DogFest held around the country.
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Support Canine Companions by choosing a fun and meaningful virtual gift for friends and family. Your gift will help provide for Canine Companions puppies, training centers and assistance dogs.
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Find out other ways to support and further the mission of Canine Companions for Independence.


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Pacific Grace 2003 Trip 3
As Requested by bosunsmate.org users!
One night during mug-up John decided to dress up as a girl for a game that we were playing.
Pacific Gracce
I took this picture when we docked at a place called Alert Bay
I took this picture because I thought that the sunset was really pretty that night. I don´t know where it was taken though
One day we saw a couple of orca whales off in the distance and then the whales decided to come closer to us and they swam under out boat.
This is a picture of Jacob(the captians son) posing for a picture.
During mug-up one night John was given a barbie doll from his secret friend. John then decided to duct tape her to his guitar. He then finished the singing with barbie helping him lead it.
Here the Skipper is cutting up one of the fish that we caught on board. We had that fish for lunch the next day.
More of the fish
Another picture of the fish that they caught.
This picture was taken after John had attacked Sara´s dori and then went onto the Swift to get some of their crew wet.
I can´t remember where we were when I took this picture but we had a lot of fun at the waterfall.
Stern Watch
Gryadon Jacob and me on stern watch
Image #369
Emily Morgan Halley Rebecca and me on the last day


text: [DE]Megan 89,348 Posted July 17, 2017 Share Posted July 17, 2017 Chains of Harrow: Hotfix 21.0.9 Changes Operators are now affected by the Smeeta Kavat Mischief/Charm buffs. Improved and widened the Reactant marker visibility range. Improved Kavor Defectors colliding with players and each other. Improved enemies for targeting Atlas' Tectonic Bulwarks so they shouldn't get stuck (at least as often). Opticor Change: Opticor now benefits from Critical Chance / Critical Chance Multiplier Mods (the existing beam always did but the radial AoE damage did not). Panthera Change: Panthera Alt-Fire will now benefit from weapon explosion radius Mods. Fixes Fixes towards Chat sometimes spontaneously not working. Fixed volumetric lighting not working properly when in DX10. Fixed being able to use Atlas' Tectonics Bulwark to prevent Defectors from bulwalking through doorways. The Bulwark wall now detects Defectors and the wall will collapse. Fixed a case where Atlas' Tectonic Bulwark walls can have weird targeting from enemies, causing them to either not see the wall or attack it in incorrect ways (eg. shooting it when they can melee it). Fixed being stuck in a continuous Emote state upon selecting a looping Emote like the Ki'Teer Presence or Meditating Emote. Fixed the Scourge not being affected by Heavy Calibers accuracy reduction. Fixed UI displaying 227 total missions playable when there are actually only 226. Fixed several issues with in-world markers for Hosts and Clients. Fixed certain weapons shrinking when applying skins on them. Fixed seeing duplicate FX for Harrow's Covenant as Client. Fixed a missing blocking volume that was allowing players to go out of bounds in the Earth Forest tileset. Fixed Nyx's Mind Control FX lingering on Ramparts. Fixed the Hyena Sigil FX not fading enough near the edges. Fixed missing muzzle flash on the Tigris Prime. Fixed buff indicator for the Zenith disc lifespan not being removed if you recall the disc manually. Fixed Relic refinement sort by name being inconsistent, and list issue creating a visual copy of a Relic in the grid. Fixed Clients setting Exterminate markers on enemies who don't count towards mission progress. Fixes towards Equinox's cloth getting stuck between legs. Fixed Equinox's mesh being reset to the mixed form when previewing Helmets/Skins/etc in the Arsenal. Fixed Warframes in Landing Craft/Relay getting stuck in a weird animation state after exiting the Arsenal quickly with only a Melee weapon equipped. Fixed hitches when scrolling through Sigils in the Arsenal. Fixes towards the Grax Mirage skin to better match the original Steam Workshop images. Fixed Operator Void Beam not using Energy properly in the Simulacrum. Fixed Clients being able to use Transference while wall clinging in order to float. Fixed using the Arsenal as Client causing permanent invincibility in the Simulacrum. Fixed a crash that could occur when starting a Dojo duel. Fixed the Host experiencing a significant hitch when the Client finishes loading into a Dojo duel. Fixed two Earth Forest tilesets with broken connections to portals which caused issues with objectives and marker pathing. Fixes no enemies sometimes spawning in Earth Forest Exterminate until near the extraction room. Fixed some positioning of weapon trails on sparring weapons (Obex, Kogake, Hirudo, etc). Fixed black and untextured wreckage in Corpus Archwing tilesets. Fixed the Javlok playing a weird animation when quickly cycling through 'Randomized' color options. Fixed the Scourge damaging or killing players when picking it up while paused in Limbo's Rift before it hits the ground. Fixed the Sari Syandana covering the pause menu when playing Solo. The wings will now close a lot faster when pausing. Fixed the Scourge and Cycron Status lasting longer for the Host. Possible fix for Companion Pets being insta-killed in some rare cases (without going into bleedout). Fixed a localized typo of Chroma in his Helmet description text. Conclave Changes & Fixes Increased ammo capacity of Pyrana in Conclave. Fixed Oberon's Reckoning not lifting enemies in Conclave. Fixed Oberon's Reckoning not being terminated if Oberon was killed during the cast in Conclave. Link to post Share on other sites


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International Journal of Integrative Humanism Vol. 10 No. 1, November 2018.
Olayinka Susan Ogundoyin
Communicative interaction in the consulting room is a vital tool that enhances patient positive health outcome. Studies on patient satisfaction in relation to the communication styles employed by doctors are few, since these studies focus more on patient satisfaction as it borders on treatment, services and interventions. This study, therefore, investigates the relationship between communication styles (paternalism, consumerism, mutuality and default) and patient satisfaction and also examines the influence these communication styles have on patient satisfaction at the University College Hospital (UCH) Ibadan. Two research designs were employed for the study, the survey and the interview. Samples were drawn from three out-patient clinics namely: The Surgical, Medical and Obstetrics and gynaecology outpatient clinics. The convenient sampling technique was used to select 420 respondents who responded to a set of questionnaires, while the purposive sampling technique was used to select three doctors who are heads of the three departments and three patients from the three outpatient clinics for the in-depth interviews. The total sample size for the study was 426 respondents. Data were subjected to Pearson Product Moment Correlation and Multiple Linear Regression Analysis at a 0.05 level of significance. Qualitative data were analysed thematically. Findings showed that Mutuality (β = 0.27) and default (β = 0.52) had relative effects on level of satisfaction with communicative interaction with the doctors. The findings from the interview of the doctors revealed that both mutuality and consumerism enhance patient satisfaction. Mutuality and consumerism were found to enhance patient satisfaction. Efforts should therefore be made to use these communication styles more often since it encourages positive health outcomes in patients.
Keywords: Communicative interaction, communication styles, doctors, patients, patient satisfaction.


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This section contains 905 words
(approx. 3 pages at 400 words per page)
"There must be some gene that switches on at the birth of the first-born child, and suddenly stuff like that starts to come out of their mouths. It's like they haven't figured out that the language you're using is English, and they should be able to understand what you're saying. Instead, you pull a string on them, and a bad record plays."
"September", p. 7
"Reading Shakespeare. Of all the strategies Mrs. Baker could come up with, this must be the worst. Teachers bring up Shakespeare only to bore students to death. And I was going to be bored to death for eight months. No human being could stand it."
"October", p. 40
"But that's November. It's the kind of month where you're grateful for every single glimpse of the sun, or any sign of blue sky above the clouds, because you're not sure that they're there anymore. and if...
This section contains 905 words
(approx. 3 pages at 400 words per page)


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Well, the Hillary campaign is most assuredly lying about her primary campaign. She declares victory because she has gone over the require delegate count by the blatant favoritism of her own party, but this is only made possible by the super-delegate practice of the party itself. After all a political party ostensibly named for the practice of democracy has no need for actual democracy.
Anybody who thinks the elites in this country practice what they preach is either a lunatic or in need of serious remedial education at the local school for "special" children.
Yes folks, the Democrats have spoken! They don't want garden-variety Socialism (bad enough on its own). They want Corrupt Socialism run by wealthy elites. And they say Conservatives are the ones who love the rich. At least Bush II didn't run around in $12,500 Armani jackets lecturing people about wealth inequality and white privilege.
Hillary is worse than her husband who, at least, seemed vaguely American even if he was a sleezy, dishonest, scummy, possible-rapist. Hillary is something else. She is post-American, as if such things as borders, peoples, beliefs, and cultures didn't exist at all. As if the hoi polloi were beneath her, merely things there to do her bidding, or be dismissed when no longer needed. American citizens were merely Hillary Rodham Clinton's personal army of servants. Well, hers and those of her immensely wealthy and powerful patrons, anyway.
Only money exists. And her campaign certainly got enough of it. Hillary, naturally, gallivanted around the world, cozying up to dictators and thugs for "speaking engagements" that, at least in some cases, were quite possibly never even delivered (or may have simply said things she doesn't want outed – who knows?).
Whatever. It's like she pretends to be human for awhile:
I wasn't exactly enamored of the raging Communist who opposed her for the Democratic nomination. But one could at least argue that Mr. Sanders may have actually believed in the bullshit he was spewing. Hillary believes in nothing but Hillary. Secret Service agents certainly had some interesting things to say about her stay in the White House during Bill's tenure are farce-in-chief.
She is a tyrant, a self-absorbed narcissist of truly epic proportion. Anyone who votes for her is either a fool, or is corrupt themselves. Without exception.


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Please check back at a later stage.
Symbolism in The Tabernacle
The Tabernacle eBook gives a quick overview of the most important features of the Old Testament teaching on the Tabernacle in the Wilderness of Sinai. This eBook features a Tabernacle cutaway illustration that provides an inside look at more than 15 important features of the Tabernacle, such as the Ark of the Covenant, the veil, the lampstand, the altars, the High Priest, the sacrifices, and more. This handy reference shows how they relate to our relationship with God today through Christ.


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After receiving my double LP of The Empire Strikes Back and corresponding with a friend who is uploading a 96/24 rip of that original configuration, I realized that I had disposed of my original listening copy of that score a while ago with the intention of making a new one, a project that I had never gotten around to doing.
I just spent a bit of time working on The Empire Strikes Back to make a listening version. The issue with this score is that while the complete version is available on the RCA and Sony "Special Edition" two disc sets, the sound is inferior to that of the Arista box set released a few years earlier. Unfortunately, the Arista box set had a rushed post-production schedule, and some of the tracks on The Empire Strikes Back had reversed stereo channels. I therefore set out to build a new complete version of the score, primarily using the Arista box set, but rounded out with additional tracks from the "Special Edition" version, and I tried to make the transition from one source to the other as seamless as possible (which was mostly just adjusting sound levels).
After I finished that project, I did one for Return of the Jedi, although while this also consisted of expanding music from the much better-sounding Arista set and adding a few additional pieces from the "Special Edition" set, I decided against putting together the complete score. In my opinion, while it has its moments, the score for Return of the Jedi isn't as much fun as Star Wars¹, nor has the intensity or harmonic complexity of The Empire Strikes Back, and so while my version runs a little over two hours, it isn't the whole thing.
I've always felt that the film itself was way too overscored, the wall to wall nature of the music robbing the film of some much-needed sonic dynamic. It hurts the score as heard in the film, as one becomes inured to the music even when it should be grand and transcendental. I therefore concentrated on putting together something that was more representative of the score than what appeared in the Arista set (which, among other things, mostly skips over the dark passages at the beginning during the Jabba's palace sequence, and there isn't any trace of Leia's theme in the third film, save for the most fleeting appearance in "Leia is Wounded"), but wasn't as ponderous as the "Special Edition" (which, due to all of the alternate recordings and concert versions, actually runs longer than the film itself). This was actually an easier task than with The Empire Strikes Back, as that album featured some combined tracks ("The Training of a Jedi Knight," "City in the Clouds," etc.), while the only time that is the case with Return of the Jedi is Williams' concert version of "Jabba the Hutt" that concludes "Han Solo Returns (At the Court of Jabba the Hutt);" otherwise with the exception of "Heroic Ewok/The Fleet Goes Into Hyperspace," all of the music is either in the form it is heard in the movie or a completely different recording.
Speaking of sonic improvements, I just received Intrada's remaster of Rambo III yesterday, and I may be redoing my Rambo trilogy compilation shortly. I originally had only planned to update the original assembly with the remastered cues from Rambo III, but I may start the project over from scratch now. I have been considering building suites out of the scores for the latter two films similar to the ones Jerry Goldsmith put together for the album of the first. The new version may also be shorter than the previous one.
I have been on something of a Jerry Goldsmith kick, so this might fit perfectly. I'm also considering a compilation of his music for Franklin J. Schaffner's films, a no-brainer that I somehow never considered before.
¹ — My playing version of Star Wars is the complete "Special Edition," albeit sans bonus tracks and with cues renamed to reflect the original LP track titles; this is the only one of the "Special Edition" releases to sound better than the what appears in the Arista box set.


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Analyze installed programs and complete uninstall even without the help of the provided built-in uninstall program.
It monitors any changes made to your system during the installation of a new program. It allows you to perform a complete uninstall without having to rely on the supplied built-in program which can leave traces behind.
Clean safely the system with a few clicks.
Manage the startup programs, scheduled tasks and services.
Transfer programs to a new PC with backup and restore method.


text: The cold hit us with a quickness in NYC, so in keeping with the holiday spirit and the newfound chill, we thought that the perfect thing to do for the entire family was to create a hot-cocoa bar. Everyone likes to personalize their food, so why not personalize your drinks? ...read more


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Solo electronic musician, David Sharpe made his brand new EP (released Dec. 11) titled, 'Outer Circle' in self-imposed isolation over the course of a couple years. At some points barely speaking to anyone for days or weeks at a time.
David describing his album…
'Outer Circle' is an exploration of the inner self, and what happens when all else is pushed to the outside. tweet
Every aspect of 'Outer Circle' was created from the ground up. Drum machines were run through pitch shifters, analog synths were molded by distortion and his voice which is buried in layers of reverb. tweet
The Toronto-based musician also created the artwork for the EP as well as a video, which you can see below before you stream the five-track album in full:
Audio only:
Don't miss out on listening to our fave songs on the album – 'Imposition', 'Procession', and 'Afterimage'. Stream David Sharpe's full album, 'Outer Circle' below.
Connect with David Sharpe:
Facebook | Instagram | Bandcamp | Soundcloud | YouTube | Spotify
Connect with Indie Underground (indieug):
Facebook | Instagram | Twitter | Snapchat | Spotify | Hype Machine


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When you purchase a digital subscription to Cake Central Magazine, you will get an instant and automatic download of the most recent issue.
Cream cheese covered Tiramisu cake with butter cream piping. Big flower and small flower accents are made of modeling chocolate. Butterfly is made of melted chocolate.
Pink & Brown Wedding Cake Cookies
Pink & Brown Smash Cake
Pink Flower Birthday Cake
(if this is a private computer)
Yes please, register now!


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HBO Chief on Attracting Audiences: Talent + Content = Subscribers
At last week's American Magazine Media Conference, perhaps the best wisdom shared didn't come from the mouth of one of the many magazine publishers that took the stage, but rather HBO chairman and CEO Richard Plepler.
In a session titled Building Addicts: How HBO Hooks Subscribers, Plepler revealed how HBO managed to more than double subscriptions to its standalone digital streaming service HBO Now from 2015 to 2016. In his conversation with Time Inc. content chief Alan Murray, Plepler didn't harp on data or digital marketing strategy. He did speak to the importance of content, but what he really keyed in on is the thing that comes before content: talent.
Below are some highlights from the conversation and Plepler's formula for attracting consumers in the Digital Content Age: talent + content = subscribers.
You Need to Follow the Cord Cutters
There's probably no better example of a legacy content company that has managed to transform its brand for the Digital Age. HBO is dead center in the cultural zeitgeist and has gained this position in part by making its content available to the up-and-coming generation of cord cutters with HBO Now. (HBO Now requires no television subscription like HBO Go.) Launching HBO Now was not an easy decision, says Plepler, because it risked cannibalizing its cable business and alienating partners.
Yet the imperative to adapt to major shifts in media consumption habits was more important. While HBO Now only accounts for a small portion of the company's 49 million US subscribers, reaching those cord cutters now is paramount to its long-term growth. HBO Now is a "millennial missile," says Plepler, and the service's subscribers are disproportionately millennial.
While talent and content reign supreme, not having its content available for on-the-go users would be a nonstarter. "We simply want to make sure that however you want to access HBO, you can do it, wherever, whenever and however you want to watch it," says Plepler,
You're Probably Too Old to Know What Young Audiences Want
The HBO brand, a beacon for quality viewing entertainment, is a "magnet" for attracting subscribers, says Plepler. "Our implicit promise is that there's a lot of terrific content out there -- we're going to curate quality content and we're going to do it across a wide tent."
However, the inciting incident for creating great content is attracting the best talent, says Plepler. "We're as good and only as good as the writers and talent. To me talent is sacred."
And attracting talent requires the kind of culture that encourages the best creative ideas to rise to the top, instead of the word from the top being the final word. Citing the adage that "culture eats strategy for breakfast," Plepler suggested "pushback" is crucial to a creative content business. "A healthy culture where pushback is permitted is a culture that is going to produce better results each and every time."
The idea that a 58-year-old guy from New York City is going to curate all of the programming and his sensibilities will resonate with the culture is absurd, says Plepler. Rather, HBO's success is dependent on Plepler taking others' recommendations over his own.
Plepler cited the HBO series Eastbound and Down as an example of why pushback is important. Plepler says he was initially unimpressed with the series and probably would have passed on it if he had his druthers. However, president of programming Casey Bloys said to him, "You're old and you think Larry David is the epitome of comedy. But here's why it'll land."
Bloys was ahead of what the millennial comedy sensibilities would be, says Plepler, and HBO benefited from Eastbound and Down's offbeat, hip appeal. Without an environment that rewards pushback, HBO would have missed out.
In A Noisy World, Context Is Valuable
Plepler put a button on the conversation by pointing out the role content businesses from NPR to 60 Minutes play today. Simply put, in a noisy world content is valuable, and the world is noisier than ever. "There's a lot of noise out there, and more than ever there's a need for smart, quality journalism and storytelling."
The challenge remains, says Plepler, that publishers need to find ways to monetize digital that don't run against the objectives of creating good content for an audience. HBO has the luxury of focusing entirely on producing the best content. Still, publishers that chase advertising dollars run the risk of miscalculating the digital content formula.
Denis Wilson was previously content director for Target Marketing, Publishing Executive, and Book Business, as well as the FUSE Media and BRAND United summits. In this role, he analyzed and reported on the fundamental changes affecting the media and marketing industries and aimed to serve content-driven businesses with practical and strategic insight. As a writer, Denis' work has been published by Fast Company, Rolling Stone, Fortune, and The New York Times.


text: Email, Messaging, & Video Calls Email Access a Gmail Account in Windows Mail Adding your Gmail also syncs your calendar and contacts by Heinz Tschabitscher Writer A former freelance contributor who has reviewed hundreds of email programs and services since 1997. our editorial process Heinz Tschabitscher Updated on September 11, 2020 Email Gmail Yahoo! Mail Tweet Share Email Microsoft's default light email app for Windows 10, called Mail, offers built-in support for adding accounts for Outlook.com, Microsoft Exchange and Microsoft 365, Google, and Yahoo. The add-account wizard walks you step-by-step through the process of adding a Gmail account to Windows Mail. Open Mail. Click or tap the Settings icon, located in the lower left panel of the window, to access the Settings slide-out menu. Select Manage accounts, and then select Add account. From the pop-up dialog box, select Google. The dialog box shifts to Google's standard Sign-In with Google web form. On the first page of the form, enter your email address. On the second page, enter your password. If you've set two-factor authentication on your Google account, you'll be asked to confirm access on an optional third screen. The fourth screen reviews the permissions that Windows requests; select Allow to proceed. After you authenticate to Google, Mail presents another dialog box asking you to specify the name you wish to use with your Gmail account. This name will appear in the "from" field of your outgoing messages. It doesn't need to match the name you've set up in Gmail. After you've entered your name, press Sign In to continue. Using Gmail with Windows Mail Your Gmail account functions like any other email account within Mail. As an added bonus, Windows automatically applies your Gmail account to the stock Calendar and Contacts apps, too, so your contacts automatically appear in the People app and all the calendars you've associated with your Gmail account appear as sub-calendars under your Gmail address in the Calendar app. However, Windows does not sync other items, like tasks you've set up in Google Keep. If you change your Gmail password or adjust the two-factor authentication you use with your Google Account, you'll need to repeat these steps with either an updated password or with an app password.


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Acoustic Symposium
|Bochum, Germany
|+49 6102 2067 183
|event website
Specialists on acoustic and the best in the industry informs about the latest development in automotive acoustics, especially the new approaches needed for optimizing the acoustics of New Energy Vehicles. The following topics will be the main focus of the conference:
- How to master newly appearing noise sources with a different focus on some parts for acoustic treatment, e.g., accessories, aero noises, tires, beside e-motors.
- How new simulation techniques can contribute to reaching the target quicker and more efficiently, either at early car architecture stage or at later component optimization and open new doors like aeroacoustics.
With the acoustic modeling software VA ONE, You can diagnose potential noise and vibration problems upfront in your development process. Manage risk by identifying possible problem areas that may need more detailed modeling or test-based development.
Looking into the future of vibroacoustic and the wide areas it can cover, ESI introduces the VA One Aero-Vibro-Acoustic module which automatically converts CFD pressure-distribution time histories from a wide range of formats into the appropriate Fluctuating Surface Pressure load or input power in the frequency domain. Both types of dominant excitation components, convective and acoustic, are derived from this CFD pressure data and applied to structures and fluids in the vehicle model to predict interior noise and support wind noise reduction and optimization through virtual design studies. Learn about this solution and more, connect with our colleague on-site.
ESI's vibroacoustic specialist Arnaud Caillet, Team Leader Vibro-Acoustics, will present during the afternoon sessions "Methodologies" on "Analysis of the challenges of sound package definition for electric vehicles using SEA analysis".


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In 1980, Ronald Reagan won in a landslide against Jimmy Carter and did it again in 1984 against Walter Mondale, winning 49 of 50 states. Conservatives thought they had won the political war. Happy days were here again. Not quite.
We had won a few battles. Unfortunately, too many conservatives sat on these victories and let the other side retake hard-won political ground against the Democrats who were less radical than today's Democrats. Bush 41 caved on "no new taxes." Bush 43 plunged us into a multi-trillion-dollar immoral and unconstitutional war.
The special election in Pennsylvania's 18th congressional district shows once again that victories must be maintained. Everyone knew the Democrats would be energized.
Trending: Did Paul Harvey's 1965 Broadcast "If I Were the Devil" Predict America's Downfall?
The continued trashing of Trump has not helped, trashing that's still coming from the Republican Establishment. Trump is by no means the perfect candidate, but he's a great deal better than anyone the Democrats have. Tony Perkins makes an important point about why the trashing of Evangelicals who support Trump is continuing to take place:
take our poll - story continues belowCompleting this poll grants you access to Godfather Politics updates free of charge. You may opt out at anytime. You also agree to this site's Privacy Policy and Terms of Use.
Although the liberal media won't admit it, there's a deliberate effort to try to discourage evangelicals from voting and being involved. That's why we're seeing an almost daily rehashing of Trump's past. Americans can't make it through a half-hour of cable news without hearing about the president's behavior back in 2006. They can't open a newspaper without another columnist shaming Christians for supporting Trump. That's by design. Liberals know that if they can shame evangelicals for supporting this president, they can suppress their enthusiasm. Their aim is to translate that into a decline of our record participation in 2016. If that decline happens — even a little bit — they can retake Congress. And they understand as well as we do that if Republicans lose either chamber, the president's conservative agenda is as good as dead.
By my count, Trump has done more favorable things for Christians than any past Republican President, including Reagan. Again, this does not mean that we should discount his sins and shortcomings regarding proposals we disagree with. At this point in time, the alternative is far worse.
The Democrats put up a candidate in Pennsylvania who sounded like a conservative. Conor Lamb is a 33-year-old Marine vet who trashed Nancy Pelosi and supports the Second Amendment. I'm sure a lot of people voted for him because they thought he was a conservative and he looked good. Salena Zito from the Washington Examiner made these points about Lamb and his campaign strategy before the election:
The young, charming Democratic candidate Conor Lamb is running like a Republican on matters from guns to getting rid of Nancy Pelosi. When your message is simply I am for new leadership and cleaning up Washington, and you look like you just walked out of an Orvis catalog, you are going to connect with voters on both sides of the aisle.
Second, Lamb never slams President Trump; why would he? Trump won this district by double digits…
Third, none of Lamb's campaign signs say he is a Democrat. He is not part of the resistance, he does not call himself progressive, he doesn't try to divide voters into different special interest groups.
And fourth, the establishment Republicans have embarrassed themselves with public hissy fits about Lamb's challenger, Republican state Rep. Rick Saccone — his lack of fundraising polish and his panache. You have to wonder if their bitterness towards this Western Pennsylvania candidate — whose military and diplomatic experience are impressive on paper and manifest in person — is deeply rooted in their persistent resentment of Trumpism.
What do the people who voted for Lamb think he will do when he gets to Washington? Do they believe that any conservative vote Lamb might make will make any difference? The Democrat leadership might even let him vote with the Republicans periodically so he can keep his seat when he runs again in November. (Tuesday's vote was a special election to fill a vacant seat.) Our constitutional system is a numbers game. The Party with the most votes wins. If Republicans lose the majority, the Democrats can stall all legislation.
It didn't help that the Republicans put up a (purposely?) weakened candidate that even the GOP and Trump considered a less than viable. It also didn't help that a third-party candidate siphoned off one percent of the vote.
Trump and the GOP need to get their act together. Trump should spend almost all his time on the road reigniting the base, explaining how crucial the midterm elections are, raising money, and developing a consistent message beginning with "If the Democrats get back in power, they will raise your taxes, wreck the economy, and take away your remaining liberties."
The Democrats will stop every investigation that is going on that is exposing the corruption that was taking place during Obama's eight years in office.
Hillary Clinton, who just denigrated millions of women voters, will get away with serious crimes. Hillary believed that she could get away with her crimes because she believed that there was no way that Donald Trump could win. Surprise! The same is true of Obama's dirty dealings.
We are in a war. Christians and conservatives need to understand this. It's a war that will have consequences far and wide.Don't forget to Like Godfather Politics on Facebook and Twitter, and visit our friends at RepublicanLegion.com.
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Sign up for the free Godfather Politics email newsletter, and we'll make sure to keep you in the loop.


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The Museum of Russian Art Director Vladimir von Tsurikov said it feels like we've returned to Cold War days.
He said constant media coverage that places Russia in a negative light impacts American perceptions of all Russian people and culture.
"It's important to reintroduce something else into this dialogue," he said. "Cultural diplomacy, people-to-people diplomacy."
That's why the museum is planning to facilitate a cultural tour to Moscow and St. Petersburg in 2018. Von Tsurikov said he wants to provide a chance for everyday Americans and Russians to interact.
"It's the perfect time to go to Russia," he said. "It allows us to break barriers and deconstruct myths on both sides."
Despite the negative press, Von Tsurikov said he's not seeing a direct impact on the museum. But he worries it may impact public funding for Russian studies and the arts, at a time when there is a shortage of Russian language speakers and experts in the U.S.
Museum staff are thinking creatively to work around a Russian arts embargo in place for several years. Instead of acquiring pieces directly from Russian institutions, the museum displays work from private collections and other museums and relies on alternatives like multimedia as part of exhibits.
"There are ways to work around this if you're not only looking at showing original artwork," Von Tsurikov said.
One current exhibition is called "Born in the USSR: Paintings of Childhood and Youth," portraying youth in Soviet Pioneer uniforms and later becoming indoctrinated into the Communist party. The joyful piece "Milkmaids, Novella" by Nikolai Nikolaevich was recently installed in the museum's gift shop, a spot that offers complimentary cups of tea.
The museum has tripled its events in recent years. It's hosting family days, vodka and wine tastings, local artists and pop-up exhibitions. After-hours tours are available in English and Russian, and the Belarusian band Stary Olsa will perform the evening of Sept. 7.
"It's a great opportunity to show there is more to Russia than you read on CNN," Von Tsurikov said.


text: Our Services HR Services We offer everything you would expect from a well-rounded HR team, always placing an emphasis on jargon free, straightforward advice and commercial solutions. Read more → Talent Consultancy We partner with our clients to ensure that their business plans and people agenda are aligned, enabling them to achieve their strategic goals. Read more → Training Workshops We have created a practical set of short workshops to help agencies improve their communication and management & leadership skills. Read more → Wellbeing at Work At JourneyHR we believe that both mental and physical wellbeing are issues that employers need to be more aware of. Read more → Employee Engagement Creating brilliant places to work is part of what we do. We believe that there are five elements that drive employee engagement: Read more → Coaching We are often asked by our clients to help them develop and grow as they transition into leadership roles. Read more →


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Chelsea travel to the Britannia Stadium to take on Stoke City - a game which cannot be considered a walk in the park by any stretch of imagination. Especially, when one considers the extent of damage that injuries have already done to the Chelsea first team squad. TheHardTackle previews the first league match of Andre Villas-Boas' Chelsea.
A highly skilled and technical team treating every move like a chess move ; A team that has a very direct approach to goal with an intimidating physical presence. How would they fair against each other? Stoke Vs Barca


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Clean living is the best way to ensure a long and healthy life. Most countries, however, are burdened with pollution due to heavy industrialization to support the countries economic needs. While some countries have found the right balance others have not. If you're looking to move to a cleaner country here is the list of the top 10 countries with the cleanest air.
Countries With The Least Air Pollution And Cleanest Air
1. Iceland
Due to the nature of its landscape, Iceland has had to work within their means and it has worked wonders for them. A country full of glaciers, volcanoes, geysers and hot springs has made the best use of its natural energy sources. The largest part of the population is settled in the capital Rekjyavik, which uses thermal energy for most of its energy needs, cutting down on the need for fossil fuels. [1]
2. Canada
Canada has a ton of green cover which makes up for the industrialization efforts of the nation. The strict conservation laws of the government are also responsible for the lack of pollution in the cities. Even the citizens take pride in being ecologically conscious. [2]
3. Finland
Several European countries including Finland have established laws that give organizations and citizens major tax benefits for using renewable energy sources such as electric cars. Even the government has tried to use renewable energy sources for its public transport. Finland has some of the best air quality even in major cities in the country. [1]
4. Brunei
While it may not be the most well-known nation it should be looked upon as a symbol of success when it comes to merging industrialization and maintaining clean air. Brunei is one of the most developed nations in Asia and it has done so while maintaining their low levels of pollution. [2]
5. Estonia
Although not very large, almost half of Estonia is forests. The green cover releases fresh air to the country and Estonia has some of the best air to breathe in all of Europe. Estonia occupies the 5th spot in the list of countries with the cleanest air. [1]
6. Denmark
Cycling can be said to be one of the main reasons Denmark's air is so clean. It has more than double the cycles than cars. It has half the air pollution of its neighbor Germany and the citizens are more than thankful for it. [2]
7. New Zealand
The New Zealanders love their wildlife and forest. While industrialization is important New Zealand knows the importance of green cover and has very strict laws that govern the setting up of factories and businesses. While it may not be the easiest place to set up a factory, the quality of air sure is amazing. [1]
8. Sweden
Like Finland, the Swedish people enjoy a lot of tax breaks for buying and using electric vehicles. They also use a lot of cycles in Sweden and all citizens are aware of the responsibilities toward the environment. [2]
9. Ireland
Being closer to the coast has helped Ireland lower the levels of pollution in their air to propel it to the 9th spot on the list of 10 countries with the cleanest air. [1]
10. Luxembourg
Part of the credit to Luxembourg's success in keeping the air pollution low can go to the lower population. The country also has very strict environmental laws that prohibit cutting down of trees and pollution from factories, which all companies must comply to. They take their part in protecting the Earth quite seriously. [2]


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|Biomedical model
|History (Observation)
|Examination (Observation)
|Make a provisional diagnosis (Hypothesis)
|Investigations (Hypothesis testing)
|Make a definitive diagnosis (Deduction)
I like this. This is why we went to Med School. This is why we watch House Clancy and St Elsewhere, but it is not the whole picture.
Clearly real life patients particularly in primary care are no so straightforward and often no single disease entity (or entities) is identified. This does not mean attempts to identify and help attenuate their suffering is outside the remit and duties of their physician. Clearly if we restricted ourselves to the purely physical many of us would be out of a job. These models are just frameworks or ways of looking at a problem. But the Medical Model should not be too readily dismissed. A patients Medically Unexplained Symptoms may just be Medically Undiagnosed Symptoms and application of a psychological straight jacket may not always be the best way to go.
Cyriax said "all pain has a cause" treatment should be directed at that cause
Einstein said "you think you are scientists, you call yourselves scientists, you are not scientists"
The point being that Cyriax developed his interest in Orthopaedic Medicine through realising many patients were not getting the proper diagnosis or treatment. His approach is biomedical and echoes Kochs postulates that every illness is caused by a definable agent (Koch's Postulates) and identification of that agent will allow application of approporiate rational treatment.
Lewis Thomas the Youngest Science
Patient Centred Diagnosis Nicholas Summerton Radcliffe 2007
Evidence-Based Diagnosis in Primary Care Andrew Polmear 2008
How Doctors Think Jerome Groupman Houghton Mifflin 2007
Diagnosis Lisa Sanders Icon 2009
|Frasers 7 areas of competence
|1. Interviewing and history-taking
|2. Physical examination
|3. Diagnosis and problem-solving
|4. Patient management
|5. Relating to patients
|6. Anticipatory care
|7 Record-keeping
|Neighbour inner consultation
|5 stage checklist
|1 Connecting – establish and maintain rapport
|2 Summarising – demonstrate to patient you understand why they've come
|3 Handing over – patient accepts agreed management plan
|4 Safety netting – advise expected outcomes and what to do if otherwise
|5 Housekeeping – doctor acknowledges / attends to his own feelings
|Neighbour R (1987) The inner consultation
|Patient centred model
|1. Exploring both the disease and the illness experience
|2. Understanding the whole person
|3. Finding common round regarding management
|4. Incorporating prevention and health promotion
|5. Enhancing the Doctor-Patient relationship
|Patient centred model Stewart and Levenstein 1984
|1. Define reasons for the patient's attendance from their perspective – nature, history, aetiology and effects on their personal and social circumstances; ideas and values about health; their ideas about the problem, its causes and its management; their concerns about the problem and its implications; their expectations for information, involvement and care.
|2. Consider other problems as appropriate – risk factors, other problems
|3. Enable patient to choose an action plan for each problem:
|4. Achieve a shared understanding
|5. Involve patient in management plan
|6. Use time and resources appropriately: both in cosultation & longer term
|7. Establish/maintain a relationship with the patient that helps to achieve the other tasks.
|Pendleton D, Schofield T, Tate P and Havelock P An Approach to Learning and Teaching 1984(2000)The consultation: an approach to learning and teaching. Oxford University Press, Oxford (2003) The new consultation: developing doctor-patient communication. Oxford University Press, Oxford.
See also Pendletons Rules for Giving Feedback
|Stott and Davis
|Areas to be explored during the consultation
|a Identification & management of presenting problem
|b Modification of patient's help-seeking behaviour
|c Management of continuing problems
|d Opportunistic health promotion
Stott NCH and Davis RH (1979) The exceptional potential in each primary care consultation.
Journal of the Royal College of General Praditioners, 29, 201-5.
|Byrne and Long
|6 phases identified from analysis of 2500 audio-taped consultations of 71 GPs
|1. The doctor establishes a relationship with the patient.
|2. The doctor attempts to discover or actually discovers the reasons for the patient's attendance.
|3. The doctor conducts a verbal or physical examination or both.
|4. The doctor, the doctor and the patient, or the patient (in that order of probability) consider the condition.
|5. The doctor and (occasionally) patient agree and detail further treatment or investigation if necessary.
|6. The consultation is terminated (usually by the doctor).
|Byrne and Long Doctors Talking to Patients 1976
Doctor's consultation styles
based on doctor's knowledge, domineering, closed questioning rejecting patients ideas and evading patients questions
incorporating the patient's experience, open questioning, listening challenging and reflecting patients words and behaviour to gain clarity.
Dysfunctional consultations occurred when the doctor failed to discover the reason for the patient's attendance
(2nd phase) or because the doctor did not tailor his explanation to his patient's beliefs (4th phase).
these stereotypes may seem somewhat outdated in our more enlightened and more polite times times but recent developments suggest that
– in austere times patient considerations (eg choice) may need to give way to patient need (as defined by the High Priests)
– knowledge and training in caring, courtesy and human decency can sometimes slip
Balint 1957 the doctor the patient and the illness
1) Psychological difficulties may present as physical problems and physical illness has psychological consequences
2) Doctors have feelings and those feelings have a function in the consultation
3) Doctor's can become more sensitive to the patient through specific training.
1 Doctor a drug – with positive therapeutic effects – and side effects
2 Flash technique the doctor becomes aware of his feelings in the consultation, and when he interprets this back to the patient, the patient gains some insight into his problems.
3 Collusion of anonymity – professionals avoiding taking ultimate responsibility for the patient
4 Child or other as presenting complaint / entry ticket
5 Elimination by examination
6 Mutual Investment Company
Based on work with groups of doctors meeting regularly to discuss their difficult cases.
Balint model emphasises the contribution of psychological factors to the presenting illness, the importance of treating bodies and minds simultaneously, and the importance of recognising
the doctor's own feelings.
Balint M (1957) The doctor, his patient and the illness. Pitman, London.
|Anthropological / folk model
|Patient wants/needs to know
|1 What has happened?
|2 Why has it happened?
|3 Why me?
|4 Why now?
|5 What would happen if nothing were done about it?
|6 What should I do about it and who should I consult for further help?
|Helman Anthropological/Folk Model 1981
|Health belief model ICE
|Rosenstock Becker and Maiman 1975
ubiquitous mnemonic/uber-mantra driven deep into the hearts and minds of trainees and nMRCGP candidates.
visible demonstration of an attempt to explore the patients ICE is a sine qua non of success in assessments and overlooking the same is rightly considered to be a bad thing
there is of course a difference between being a genuinely competent and caring practitioner of the art of clinical medicine (tautology?) and a performing seal.
Any apparent skepicism does not reject the fundamental importance of this stuff, but rather a curiosity as to whether the essential and noble aims of medical education are best achieved by a particular contemporary approach
|ICE version 2 for OSCES and everyday practice (Pastest and others)
|This should also be always at the top of one's mindset, until it becomes and remains reflexive
Berne transactional analysis
Berne Transactional Analysis Games People Play 1964
Human psyche consists of three ego states:
parent — commands and controls nurtures
adult — logical, processing
child — intuitive, creativitve, spontaneous , pleasure-seeking
At any point, each of us is in a state of mind where we think, feel, behave, react and have attitudes as if we were a parent (critical or caring), a logical adult or a child (spontaneous or dependent)
|Heron Six Category Analysis
|Heron Six Category Interventional Analysis 1975
|Calgary Cambridge / Kurtz Silverman
|5 Stages
|A. Initiating the session
|B. Gathering information
|C. Building the relationship
|D. Giving information explaining and planning
|E. Closing the session
Silverman J, Kurtz S and Draper J (1998) Skills for communicating with patients
Cambridge Clinical Skills Unit Communication Skills Website
Calgary Cambridge @ gp-training.net
Consultation models skillscascade.com
McWhinney disease-illness model 1984
Patient presents with problem — Clinician gathers data
Then 2 parallel/simultaneous pathways
Patients Agenda
ICE Feelings Thoughts Affects
Doctors Agenda
Disease Framework Symptoms Signs Investigations Underlying Pathology Differential Diagnosis
To be integrated into Explaination and planning in terms patient can understand
Malcom Thomas effective personal interaction
|RCGP triaxial model (1972)
|Extend thinking beyond organic
Consider Emotional, Family, Social and Environmental factors
Consultation theory gp-training.net
Anthropological model
Developed from studying illness behaviour in different cultures. A healing ritual consists of:
giving the problem a name (diagnosis)
performing a therapeutic ritual (management)
renaming the problem as cured or improved (cure)
Patients believe healers. Society has invested the healers with authority (called Aesculapean authority) which derives from:
the doctors' greater knowledge or expertise sapiential authority
the doctors' desire or motivation to do good moral authority
the doctors' desire to see the practice of medicine as something of a mystery charismatic authority
Cultural Consultation
Communication with patients from other cultures: the place of explanatory models Bhui and Bhugra 2004 rcpsych.org
|Boeckz needs model
Hill model
Consultation Hill Model Ian McKelvey BJGP July 2010
C.O.T and consultation mapping
MRCGP Video Criteria
Doctor encourages patient's contribution.
Dr. responds to cues
Dr. elicits appropriate details to place complaint in social & psycho-logical context
Dr. explores patient's health understanding Merit
Dr. obtains sufficient information for no serious condition to be missed.
Dr. chooses an appropriate examination.
Dr. makes clinically appropriate working diagnosis.
Dr. explains diagnosis.
Dr. uses appropriate language.
Dr. takes account of patient's belief Merit.
Dr. confirms patient's understanding Merit.
Dr. uses appropriate management plan.
Dr. shares management options.
Dr. uses appropriate prescribing behaviour.
Telephone consultations
Scope for telephone consultations
Providing the results of investigations
Repeated prescriptions
Request for sick notes or claim forms
Triage of emergency appointment requests
Triage of home visit requests
Health promotion e.g. promoting immunisation, cervical smear, smoking cessation services etc
Income generation – obtaining QOF data e.g. smoking status
Effective healthcare delivery e.g. follow up of depressed patients, managing diabetes etc
Advantages of telephone consultations
Convenience for patients e.g. no time off work, no transport issues and no child care issues.
Convenience for doctors e.g. tends to be a shorter consultation and so provides better time management.
May reduce practice costs e.g. more doctor time available for other patients or income generating roles.
Can overcome the issue of a lack of consultations rooms
Can improve medical access for the disabled
Disadvantages of telephone consultations
No nonverbal cues – missed hidden agendas or fears
No examination findings
Deafness, accents or language can be a big barrier to communication
Reduced opportunity for health promotion e.g. BP, BMI etc
No opportunity for near patient testing e.g. pregnancy test or urine dip test
Issues of confidentiality – who are you talking to and who may overhear?
Telephone skills:
Introduce yourself.
Speak to the patient if possible not a third party.
Speak slowly and clearly.
Establishing rapport
Demonstrate approachability and helpfulness
Try and maintain a calm and confident manner
Information gathering:
Elucidating the reason for patient contact & their expectations.
Ask clear discriminating questions
Use your active listening skills
Elicit their concerns
Use the verbal cues the patient provides
Assess and respond to emotional issues
Remember the value of reflecting & summarising.
Identifying capable carers
Translating diagnosis into lay terms
Demonstrating how diagnosis links to symptoms
Predicting the course of an illness or the outcome
Checking understanding and agreement
Reaching an agreed plan (including negotiation/assertive skills in arranging appropriate place of assessment)
Educating the patient on use of out of hours services
Putting in place an appropriate safetynet
Ensuring adequate and accurate information is recorded
Avoiding overcommitment of patient's own GP, or lack of appropriate followup
NB Remember to clearly document all your telephone consultations.
Telemedicine & Facetime consultations
Telephone consultations
Get the Story, Get the Picture, and make Shared Decisions.
Caller's have expectations ….. what they want …. generally:
to know who they are speaking to
to get a timely response
empathy and recognition of their anxiety ….. recognition of their concerns
empowerment to deal with …..to know what they can do about, their problem
to know what to do if things change / get worse
Once you have the story ………
obtain enough clinical information to make clinical decisions
be prepared to negotiate your suggestions
collaborate with the caller on the best course(s) of action
Differences between telephone and face-to-face consultations
lack of visual clues / signs need for clear verbal communication
explicit communication rather than relying on implicit visual cues / clues
specific difficulties with deafness, language problems
confidentiality uncertainties at both ends
communication often via third party
improved access for those with mobility difficulties or those who are highly mobile!
improved time efficiency for both parties
Output of triage : "Disposal" or "Call Disposition"
You need to be aware of your options and your resources.
Ambulance (arranged by you for them)
A&E (own transport, if less urgent)
Home Visit (… and specify urgency)
OOH Treatment Centre (own or OOH patient transport if available?)
Various Community based service options (Int.Care, Mental Health Crisis Team etc)
"Referred" to pharmacist … for OTC Rx
Advice (+/ prescription faxed to pharmacy)
& consider your safety net & consider : should they see own GP ?
Pitfalls in telephone consultation; where things go "wrong"
Not reading the Call Handler (CH) script and considering your options
Bad openings, "yawn, hi it's the emergency doctor here"
Interrupting the patients story / narrative
Objecting to the patients statements
Not finding out why they have called (their concerns and/or their beliefs)
Committing too early to your one and only chosen option
Showing clear lack of confidence
Thinking aloud, giving too much away, and lacking focus
Thinking too far ahead … putting their own GP in an awkward situation. When recommending patient sees their own GP, generating specific expectations especially of investigation or referral can cause problems. Could you avoid a clash of expectations by leaving more room for their own GP to assess and manage? Use a generic follow up statement e.g. "I think your own GP would be happy enough to see you, assess you and help you out".
Commenting on other clinicians performance, "bad mouthing" fellow professionals generates complaints. Don't get caught up commenting to patients about other clinicians apparent negative behaviours; it generates and fuels complaints. If another clinician's behaviour gives serious cause for serious concern there are routes for referring that concern.
Making them hang up on you out of frustration.
Retriaging – rarely, if time delay, can be appropriate, otherwise a recipe for confusion and complaint. Speak to the clinician who did the triage.
Telephone Consultation Etiquette : what makes a useful consultation?
Identify yourself CLEARLY by name and the organisation you work for.
Identify who you are talking to: name and one identifier, use a valid excuse if you are not comfortable with this e,g "….. can I just check I have the correct record", "and can I just confirm your date of birth…..?
Apologise if there is delay in response (diffuses the caller)
Early decision dilemma – you may be able to infer from the CHs message that the case appears to be an ALTC. Act on this decisively and swiftly. Only if there is resistance to your recommendation would you need to assess further
Open early with an empathic / empathetic tone "I'm led to believe that your are concerned about your child ……Jade/ Kylie etc
Project your verbal image with a smile (empathetically tuned for the recently bereaved!)
Start with an open question: How can we help you? What's been happening with What's the situation with ….. What can we do for
you….. (addresses the expectation issue without committing yourself)
Use active listening. Make yourself interested. Concentrate on their words not your ideas.
Use grunts, mmm's, ahaa's and empathetic ahhh's as appropriate
Pick up on cues, the use of "strong" words; reflect these back with a question
Use open questions : "How, What, Where, When, Which
Use "Why" carefully or avoid it.
Allow the caller to voice their concerns; & Acknowledge their concerns
Enhance by clarifying and summarising
Do clearly define the patients reason for calling.
Why have they called at this time ? By asking "what's changed"
Assessing children : "please describe to me, what little …… is doing now?"
If it becomes clear that the call will not be ended with advice, and needs face to face assessment whether in hospital of the Primary Care OOH centre, then move on to "floating" (suggesting) appropriate action.
What do they expect? Be careful with the timing of this one. A good open empathetic telephone consultation may modify expectations.
The inappropriate home visit demander may be inspired by your concern and reassurance and be empowered in knowing what to do. Expectations will often be revealed in the narrative. Directly asking about expectations early could lead you off directly into an awkward negotiation before assessment has taken place.
Introduce closed questions with statement of purpose. Focus on relevant clinical specifics, seeking +ve & ve responses to system oriented clinical questions. Remember closed questions don't always get accurate responses.
Do ask about recent contact with their (own) GP, ongoing medical conditions & current medication to get a fuller picture.
Once you have gathered enough information to act, suggest clinically appropriate management.
Get agreement on your recommended outcome
Instructions: K.I.S.S. ….. Keep it short and simple
Check caller knows what's happening!
How are they going to get to A&E / PCC? Directions to PCC (bring their medications!)
Chose a closing safety net statement : 2 messages maximum.
specific reasons to call back, based upon one or two specific additional symptoms, or symptoms changing in severity, or taking longer than an expected timeframe for recovery.
Good safety nets are short and simple BUT specific, AND suggest action to take.
Specific safetynetting gives the patient more control & empowerment to cope with their problem.
Sound empathetic, not overanxious "they" end the call. Use Persuasive style
Collaboration use "We" to mean "you & I" …. & not "our organisation"
Put aside you personal feelings …. Concentrate on the issue to be resolved.
If the other party has a different point of view, do not view this is as a challenge. "We have a problem that we need to talk about to find a solution that is works for both of us".
Recognise and work on the conflict of ideas .. not on the conflict between the two of you.
Be determined to reach an agreement not secure a personal victory.
Look at your objectives from their point of viewpoint. You require their involvement.
Sell your point "sunny side up" (i.e. the positive bits for them)
Listen …. Say the right things in the right way at the right time; know when not to speak ….. listen carefully.
Be wary of compulsive talking, a symptom of lack of confidence – especially interrupting the other person whenever they say something potentially "objectionable" (e.g. scientific fallacy).
Do not give your argument away too quickly – leaves you no space to change the way you put forward your case.
Do allow the other person to complete what they have to say …. You need to know what they are thinking.
"Float" suggestions rather than commit. "there are various thing we could do, suppose I were to suggest …, what do you think? Had you thought…?
Recognising that "demand" usually comes from their anxiety arising out of uncertainty.
Be wary of offering face to face consultation before you "get the story & the picture"
may not be what is needed by either of you
may not be what the caller / parent wants
does not give them more control, it makes them more anxious.
You want to know what can be done to help them best.
What to do about the parents that "inappropriately" demand a home visit?
Performance review of calls suggests that it is commonplace for doctors to "put their foot in it" by not assessing on the phone and then offering face to face consultation as an only solution when one really isn't needed.
What concerns would they have about travel? Dispel myths. The "unreasonable" demand rarely arises if you have been empathetic to their concerns, your advice has been confident, clear and simple to understand. They should now know what to do and
how to cope. More access to the covert, more chance of shared outcome. Assess first ….. do not ask for expectations directly and engage in negotiation without "the facts". Then you can influence and persuade.
Consider slightly manipulative escalations, e.g. "We both want the best for your child. We have better facilities and diagnostic equipment here at the PCC to assess your child".
Consider a "Wince" e.g. "Oh. Oh really. Pause. Most parents do bring their kids down to our PCC. This allows us to prioritise home visits for the infirm elderly and terminally ill; you would be able to be seen more quickly at the PCC".
If you are still stuck, shrug off your emotions, you have not failed, it does happen. Bottom line be wary of choosing your battles.
© Rob Pearson 2007
Prebooked Telephone Consultations
Useful way of providing an alternative point of access for patients – more convenient for both patients and the practice.
1. Trial the system first using just one GP, for a short time period and test the change! What effect did the test have? Did the telephone consultations save time? Were patients satisfied with the service? Think about how telephone consultations could be "rolled out" across the practice.
2. Use a simple protocol for all team members to follow when offering telephone consultations. Some practices have found it useful to provide different "scripts" for reception staff, nurses and GPs to follow when offering telephone consultations to patients. I may be useful to train receptionists to develop their confidence in using the script.
3. Advertise the service. You can inform patients of a "new" telephone service through the Practice Leaflet, Handouts left onReception and given out in consultations, Posters in reception or articles in Newsletters. It may be worth "relaunching" a telephone consultation service as a 'new' and 'tailor made' service for patients.
4. Telephone consultations are not appropriate for all types of consultations. You may wish to start with requests for home visits and same day appointments. Other types of consultations which could be offered include: Condition Reviews, Medication Reviews, Advice, Medical Certificates, Results, Follow Ups or administration.
5. Double check you have the correct telephone number and ring on time. Telephone numbers can be taken at the time the telephone appointment is made so that people can be called on mobile phones or at work when appropriate. Alternatively patients can be asked to call the practice at a set time.
6. Ensure confidentiality; confirm whom you are speaking to, don't leave messages on answer machines.
7. Record the consultation in the clinical records.
8. Both patient and clinician should feel comfortable about the telephone consultation. You may find it useful to monitor the number of telephone appointments that result in a face to face consultation.
Pat Hart, Marple Cottage Surgery, Stockport
Britain lags behind in the telemedicine revolutionindependent.co.uk
The computer in consultations
Home visit requests
Non-consultations – the casual aside
often thrown in at the end of a consultation and not always at a convenient moment
an exhaustive history is not expected but safety-netting is essential and should help to protect the patient and the dr involved
when a patient mentions a medical problem to you you have a duty to deal with it but not necessarily there and then – a short note will obviate the need to rely on ones own recollection which is often hazardous
courts have to resolve a conflict of evidence and may prefer the recollection of a patient for whom this is a unique experience to that of a doctor or whom this was one in a series of consultations
the courts make no allowances for the circumstancs of the consultation eg where the surgery was very busy or if the patient doorstepped you in the car park
MPS Casebook
Complaints and mistakes
When things go wrong: a practical guide to dealing with complaints Hodgson,
Mendis Storey rcpsych.org 2011
Patient Safety Links fammed.buffalo.edu
Medical records
|Clinical Entry Checklist
|DateLocation/type of encounterAuthor/Clinician
Others present
Avoid abbreviations. Legible. Understandable
| PC+ve points-ve points
Risk factors
Patient concerns
Patient expectations
|+ve findings-ve findingsVital signs + other parameters
|ResultsPlanned Ix
| PlanOptions discussedRisk benefits discussed
Advice and info given to patient
Agreed/disagreed actions for patient
Meds prescribed
FU arrangements
|Your practice Vol 6 Issue 1 2012 p11
Current System
GP Gatekeeper controlling access to secondary care
Historical 1800's Apothecaries vs Physicians / Surgeons
Doctor's protecting their own interests
Exceptions A & E perceived emergency
STDs public health
FPCs access
Weaknesses GP monopoly is it fair?
Other countries survive with direct access to secondary care
(But many are trying to develop a GP gatekeeper)
Europe Holland and Norway same as UK
Variation in performance of gatekeeper
Strengths Protect patients from over investigation and over treatment
One person maintains whole picture approach to patient
Gatekeeper rations according to need
GP can target care more specifically
Referral Rates
Variation at least 20 fold 1 to 20 per 100 consultations
Commonest rate is about 7 per 100 consultations (or about 1 in 14 patients)
Strict definition very difficult new or re-referrals
selection bias who does the smear referrals
who has an "old list"
who sees the diabetics etc
Would you like to be a high or low referrer? Which is good, which bad?
No correlation between rate and age / sex of doctor
use of investigations
Increased knowledge in a field often increases referrals knowledge better, internal referrals
Consultants judge fewer than 5% of referrals as unnecessary
Reasons for Referral
Positive Diagnosis access to specialist's experience dermatology
Investigation GP access restricted MRI / CT etc
Treatment especially surgical
Opinion Several treatment options, which is best eg glue ear
Negative Patient pressure
Off-loading patient
Referral Letter
Several people have an interest in a good quality referral letter
GP Good summary point for future reference
Patient Summary of their relevant past and present history
Avoiding repetition of investigations
Consultant Reason for referral
Current position / findings
Previous history
Medication / allergies
Relevant background whole patient approach
Admin. Patient's details including new NHS number!
Layout Headed paper, not illegible scribble on loo paper
Clearly state at beginning reason for referral
Are problems in cancer survival partly rooted in gatekeeper principles? BJGP Aug 2011
NICE referal guidelines
NICE Referral guidelines for suspected cancer
Referral priorities
Referral letters
PILS and patient information
Patient UK Patient Information
Popular DH leaflets, booklets and posters
Health on the net
itunes-u navigating your way to accurate healthcare resources on the internet
Communicating uncertainty and risk
Acknowledging Uncertainty Peter M. Sandman
Communicating risk and uncertainty Madingley lectures ice.cam.ac.uk/m
Risk: what's your perspective? BMA Guide for Health Professionals 2012
Shared decision making
MeReC Rapid Review May 2011 Shared Decision Making
Involving patients in shared decision-making Kings Fund Report Jul 2011 Download
MeReC Using Patient Decision Aids
Risk And Shared Decision Making Internal Link
Community Oriented Primary Care
Patient participation
Getting the most from your GP practice RCGP Aug 2011
belongs more elsewhere – QOF, quality , Uk primary care


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The Return of the 90s Web | Max Böck
Everything old is new again (thank goodness!):
Everything old is new again (thank goodness!):
A nice overview of the Payment Request API, which is getting more and more browser support.
A few straightforward steps for improving the usability of credit card forms. The later steps involve JavaScript but the first step uses nothing more than straight-up HTML.
Andrew picks out his favourite bits from this year's Google I/O, covering web payments, CSS containment, and—of course—Service Workers and progressive web apps, although he does note (and I concur):
I wish Google would focus as much attention on 'normal' sites that perform navigations as they do on so called 'app-shell' (which is just a new name for single-page apps, as far as I can tell), but then many people will be building SPAs and these recipes will make those apps fly. In news publishing we seem to flip flop between traditional page navigations and SPAs, but I've never found a SPA news site (or a native app) that I really like more than a normal website. Maybe a really good progressive web app will change that. But I'm not convinced.
Still, as he says:
All this really just underscores how flexible ServiceWorker is and that with it we can disagree on what the right solution is, but we can all get what we want anyway.
Jason takes good look at the browser support for autocomplete values and then makes a valiant attempt to make up for the complete lack of documentation for Safari's credit card scanning.
A great presentation on contracts and payment by Mike Monteiro …and his lawyer.
PayPal has a new competitor. Amazon is now offering a payment services to developers.
PayPal moves into the territory of merchant accounts. With an API no less!


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Massachusetts Legal Blog
Medical Malpractice
Jury Awards Man $4.2 Million in Medical Malpractice Case
There aren't many people in Massachusetts who want to undergo surgery. Most people do so at the advice of their doctor with the hope that the procedure will improve their lives or, at the very least, prevent additional harm. However, one man now claims in a medical malpractice suit that a doctor performed an unnecessary surgery which resulted in permanent damage to his arm. Read the rest »
Woman Claims Failure to Diagnose Led to Stroke
Most people in Massachusetts have likely seen a public service announcement intended to educate the general public about the symptoms of a stroke. Because of the potential seriousness of a stroke, it is important to receive treatment quickly. However, one out-of-state woman claims that she sought treatment for stroke symptoms, but the doctor's failure to diagnose her blood clot ultimately led to a stroke. Read the rest »
Family Awarded $21 Million in Medical Malpractice Case
Surgeries are performed on patients in Massachusetts every day. In most cases, the surgery goes smoothly, and the patient is usually better off than before the procedure. However, hospital errors could cause serious, long-term issues for patients. In one out-of-state example of medical malpractice, the family of a woman claims that doctors erroneously performed brain surgery on the woman, which ultimately caused her death. Read the rest »
The Failure to Diagnose Heart Disease
Massachusetts residents expect to receive the best possible medical care for any condition they may experience. However, on occasion inattentive health care professionals will misdiagnose or fail to diagnose a potentially life-threatening ailment, resulting in unnecessary treatment, a more serious illness or even death. In the case of heart disease, there is no single catch-all test to diagnose the type or severity of the disease. If diagnostic corners are cut through an error or by design, a relatively benign problem may become much more severe. Read the rest »
Family of Allegedly Brain Dead Teen Sues Hospital
In a case that could be of interest to Massachusetts residents, the family of a 13-year-old girl who was declared brain dead after an allegedly botched tonsil surgery in 2013 filed a lawsuit on March 3 against the California hospital that treated her. The suit seeks unspecified damages. Read the rest »
Got Legal Troubles?
Whether you're having family issues, dealing with the law, or hurt in an accident, the best way to get through it intact is by calling the experienced legal team at DiBella Law Offices, P.C.
The sooner you speak to us, the better, so call (781) 262-3338 for our Burlington office or (978) 327-5140 for our Methuen office for a free consultation.


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Great turnout last Saturday for the ITT.
We had 44 people brave enough to submit results (our suspicion is that there were more than this but a few may be reluctant to share their results :-)
The weather for the event was close to perfect but many found it deceptively warm out on the course.
Not sure of the record over this distance but Iain Veitch's 1:05:48 has to go close.
Full results attached
News >


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Airbnb. Bitcoin. Bicycle sharing services. The ability for people and business to exchange goods and services is changing rapidly.
So how does this effect your business?
Are you losing out by not using them? While only you can answer that by comparing the costs with the way you currently procure these resources, they all have tax implications, and ones you may not be aware of until tax time, and they could hurt!
How popular are these platforms?
Before we worry, let's take a look at how significant these new ways of doing business are:
An article by Danny Eckler in Crain's Chicago said, "During the year ended June 30, there were 4,550 Airbnb hosts in the Chicago market who hosted a total of 165,800 guests."
A typical Chicago Airbnb host-one who has hosted guests consistently for more than a year-took in $8,300 over 77 nights. And this is just Chicago! Airbnb is global.
Forbes Magazine estimates that there is $3.5 billion in Bitcoin in circulation and about 100,000 transactions per day in this virtual currency. This indicates that buying and selling in Bitcoin is not insignificant. However, like all investments, it is subject to the whims of the market. Using bitcoin is like transacting business in a foreign currency with all the uncertainty that goes with exchange rate volatility.
Bike Sharing:
According to a 2014 Census Bureau report, bicycling to work experienced the highest growth since 2000 than any other mode of transportation. It is still a small percentage of the population (the report tagged it as 786,000). The report also reveals that cycling to work is more popular among younger workers and in cities. More exercise for your employees can mean a healthier workforce which can translate to more productivity and fewer sick days (unless they have an accident).
Should You or Shouldn't You?
Could you gain an advantage from swapping abodes with other business owners?
If you do, be prepared to receive a 1099-K from Airbnb showing the value of the rent provided. Remember, no taxes are withheld from these proceeds so you may need to make estimated federal and state payments (April 15, June 15, September 15, and January 15) on these inflows during the year.
What about bike sharing services like Divvy? Do you offer employees reimbursement for this?
Guess what. The value is probably taxable to your employee and needs to be included on their W-2's, with tax withheld from the value. This is according to U.S. Treasury Letter Number: 2013-0032. On the other hand, if you reimburse employees (up to a limit) for using their own bike that they regularly use to commute to work, the reimbursement can be excluded.
Next up – Bitcoin.
Bitcoin is virtual currency because it is not issued by any central authority. The IRS has ruled that virtual currency, such as Bitcoin, is property and not cash. Because of this, when you accept or disburse a virtual currency to obtain or sell services or products, you are subject to the IRS rules for trading property.
This requires a taxpayer to ascertain the fair market value of the virtual currency in US dollars on the date of the transaction. This could lead to capital gains and losses which have limitations on the deductibility of losses (not gains, unfortunately). To me this seems like a lot of work for no discernible benefit.
Just when something seems like a great deal and easy-it isn't! So take advantage of these new markets, but be prepared to deal with a very old problem.