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Improving Interpersonal Communication Between Health Care Providers and Clients
- Roberta Bruce
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1 Quality Assurance Methodology Refinement Series Improving Interpersonal Communication Between Health Care Providers and Clients By Bérengère de Negri Lori DiPrete Brown Orlando Hernández Julia Rosenbaum Debra Roter Quality Assurance Project 7200 Wisconsin Avenue, Suite 600 Bethesda, MD USA 301/ , FAX 301/
2 Contents Part 1 A Conceptual Framework for Interpersonal Communication I. Introduction... 7 II. Background... 9 III. Why Is Interpersonal Communication (IPC) Important? IV. What Are the Characteristics of Effective IPC? V. Guidelines and Norms for Effective IPC VI. Planning and Implementing Training Activities VII. Case Studies Part 2 Case Studies A. Honduras B. Trinidad and Tobago C. Egypt Appendices A. Job Aid B. Training Manual for IPC (Egypt) C. Training Manual for IPC (Trinidad and Tobago) D. Training Manual for IPC (Honduras) E. Data Collection Tools Instrument 1: The Roter Interaction Analysis System (RIAS) Instrument 2: Health Provider s Observation Check List Instrument 3: Physician Questionnaire Instrument 4: Patient Exit Interview (English) Instrument 5: Patient Exit Interview (Spanish) F. Annotated Bibliography
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4 Part 1 A Conceptual Framework for Interpersonal Communication 5
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6 Improving Interpersonal Communication Between Health Care Providers and Clients I. Introduction Effective interpersonal communication (IPC) between health care provider and client is one of the most important elements for improving client satisfaction, compliance and health outcomes. Patients who understand the nature of their illness and its treatment, and who believe the provider is concerned about their well-being, show greater satisfaction with the care received and are more likely to comply with treatment regimes. Despite widespread acknowledgement of the importance of interpersonal communication, the subject is not always emphasized in medical training. Over the past 30 years substantial investments have been made to enhance access to basic health services in developing countries. However, there have been relatively few studies that investigate the quality of the services delivered, and fewer still that study the quality of interpersonal communication. 1 The quality of care research that has been done shows that health counseling and provider-client communication are consistently weak across countries, regions and health services. 2 Even when providers know what messages to communicate, they do not have the interpersonal skills to communicate them most effectively. They often do not know how to communicate with their patients. Despite widespread acknowledgement of the critical importance of face-to-face communication between client and provider, there are few rigorous studies of health communication in developing countries. 3 Evidence of positive health outcomes associated with effective communication from developed countries is strong. Patient satisfaction, recall of information, compliance with therapeutic regimens and appointment keeping, as well as improvements in physiological markers such as blood pressure and blood glucose levels and functional status measures have all been linked to provider-client communication. 4 Thus, experience in the developed world has shown that providers can improve their interpersonal skills, leading to better health outcomes. The research described here explores whether these findings are valid and replicable in the developing countries. 1 Roemer MI, Montoya-Aguilar C. Quality assessment and assurance in primary health care. Geneva: WHO Offset Publication, Nicholas DD, Heiby JR, Hatzell TA. The Quality Assurance Project: introducing quality improvement to primary health care in less developed countries. Quality Assurance in Health Care 1991, 3(3): Loevinsohn BP. Health Education Interventions in Developing Countries: A Methodological Review of Published Articles. International Journal of Epidemiology 1990 Dec:19(4): Hall J, Roter D, and Katz N. Correlates of provider behavior: a meta-analysis. Medical Care :
7 Unfortunately, effective communication does not always occur naturally, nor it is easily acquired. Even when client and provider come from the same geographic area and speak the same language, they often have different educational, socio-economic and cultural backgrounds. Moreover, their expectations about the health encounter may be different, or they may be faced with other problems, such as lack of privacy during the encounter, or time constraints due to heavy patient loads. Better communication leads to extended dialogue which enables patients to disclose critical information about their health problems and providers to make more accurate diagnoses. Good communication enhances health care education and counseling, resulting in more appropriate treatment regimes and better patient compliance. Effective interpersonal communication also benefits the health system as a whole by making it more efficient and cost effective. Thus, clients, providers, administrators and policy makers all have a stake in improved provider-client interactions. This monograph discusses the importance of IPC as a tool for improving health care outcomes in developing countries and describes techniques for enhancing provider communication skills. It also provides a job aid and several data collection instruments that can be used in various settings. Our field experiences in Honduras, Egypt and Trinidad, described later in the text, suggest that test results in developed countries are valid and replicable in developing countries. Therefore, we hope that our findings will serve as useful models for implementing future interpersonal communication programs, and that the monograph will help interested health care policy makers and practitioners improve the quality of health care in their facilities through improved interpersonal communication. The monograph can serve as: an introductory overview on provider-client communication skills a framework for assessing IPC skills a guide for developing IPC training activities a resource describing important IPC experiences in selected developing countries. Because each health care setting requires locally-appropriate strategies, the guide provides only a general framework for action, leaving health care policy makers, managers and providers to develop their own analyses and interventions. Therefore, we encourage readers to modify the content of the monograph as needed and to develop locally-appropriate examples for training and other IPC interventions. 8
8 II. Background The research and training activities reported here were carried out by an inter-disciplinary team of experts in health service delivery, counseling, health communication and training. Our effort began with a literature review 5 to assess current knowledge on client-provider communications in both developed and developing countries, and to identify the critical issues that needed to be addressed in developing countries. Following the literature review, we developed a set of IPC guidelines for health care providers. 6 The guidelines drew on counseling and IPC themes found in the professional literature and on insights gained from the cross-cultural field experiences of our team. After preparing a preliminary set of guidelines, we developed the format and materials for provider training workshops based on cross-cultural insights into IPC. We found that provider-client communication problems exist worldwide, and that several principles about good communication can be generalized. We expect that IPC improvement initiatives could build on universal principles to develop effective solutions that take into account local socio-cultural factors and resources at hand. Accordingly, we field-tested our materials in three different developing country settings and collaborated with local health care providers to tailor the IPC guidelines and training course to local socio-cultural environments. Collaboration in Honduras, Trinidad and Egypt enabled us to refine the guidelines and test our methods for training providers on how to apply the guidelines. Following each workshop, we conducted evaluation and observation surveys among trainees to gauge training effectiveness. We found that providers could improve IPC practices with patients in small but important ways, to the greater satisfaction of all parties. 7 For the most part, physicians were willing to apply IPC skills once they were convinced that use of the techniques would not necessarily lengthen medical visits and that concrete skills could be mastered through short training programs that emphasized practical approaches. A detailed description and analysis of the three country programs is presented later. 5 Quality Assurance Project Working Group on Counseling and Health Communication Annotated Bibliography April 1992, Bethesda, MD. (See Appendix F) 6 It is important to acknowledge that both clients and providers contribute to successful communication in medical encounters. While it would be possible to intervene on either side of this relationship, we have chosen to focus on health care providers, since most providers do not currently have, or practice, many of the basic communications skills that would enable them to carry out their responsibilities efficiently and cost-effectively. We recognize that it would also be important to work with health care clients, to help them become aware of their rights, to encourage them to ask questions, and to familiarize them with basic information that allows them to take full advantage of the health care system. Such interventions are outside the scope of this monograph, but are considered by the researchers to be v ital topics for future research. 7 DiPrete Brown, Lori, et al. Training in Interpersonal Communication: An Evaluation of Provider Perspectives and Impact on Performance in Honduras ; March 1995; Quality Assurance Project, Bethesda, MD. (Included here as Case Study A) 9
9 III. Why Is Interpersonal Communication Important? IPC is important because it leads directly to better health outcomes. A pathway is clearly established which links processes, such as the way health care providers communicate, to proximate outcomes, such as patient satisfaction and recall, to final outcomes, such as client compliance with treatment regimes and improved health results. Hence, our emphasis on the importance of improving provider communication skills. Figure 1 illustrates a system linking communication processes with short-term, intermediate and long-term outcomes. As can be seen in Figure 1, the communication context is shaped by the socio-demographic characteristics of the patient and provider, as well as by the environment in which the communication takes place. The age, sex, ethnicity, and educational background of providers and clients affect how they communicate with each other. Other factors such as degree of privacy, time allotted for encounters, comfort and cleanliness of the clinic, and treatment of clients from the time they enter the clinic until they are seen by a provider, can also inhibit or enhance client-provider interaction. While many of these socio-demographic and environmental factors are beyond their control, providers can improve IPC practices in their own clinics by adopting specific behaviors and techniques which lead to distinct positive outcomes. In the short-term, improved communication leads to more effective diagnosis and treatment of health problems; in the mediumterm, to greater compliance with treatment programs, better utilization of services, and enhanced feelings of awareness and confidence for both client and provider; in the longterm, to greater relief of symptoms, enhanced prevention and reductions in morbidity and mortality. In some cases, overall health care costs are also reduced. IV. What Are the Characteristics of Effective IPC? IPC is effective when it leads to the following five outcomes: 1) the patient discloses enough information about the illness to lead to an accurate diagnosis; 2) the provider, in consultation with the client, selects a medically appropriate treatment acceptable to the client; 3) the client understands his or her condition and the prescribed treatment regimen; 4) the provider and the client establish a positive rapport; 5) the client and the provider are both committed to fulfilling their responsibilities during treatment and follow-up care. The above outcomes, however, do not describe the steps in the process of effective communication. These steps generally include encouraging a two-way dialogue, establishing a partnership between patient and provider, creating an atmosphere of caring, bridging any social gaps between provider and client, accounting for social influences, effectively using verbal and non-verbal communication, and allowing patients ample time to tell their story. 10
10 Figure 1: Organizing Framework for Studying the Effects of Provider Communication Socio-demographic Factors Age Sex Ethnicity/Class/Caste Education/Literacy Social Factors Community Integration Kinship and Familial Patterns Cultural Supports/Barriers Process Behaviors Immediate Outcomes Intermediate Long-Term Communication Behaviors information-giving closed and open questions persuasive counseling emotion-handling/ empathy facilitating patient input soliciting patient s concerns and agenda Patients satisfaction recall/comprehension agreement on problems and recommendations anxiety reduction Providers satisfaction Compliance Utilization Competence Confidence Symptom resolution Physiologic status Functional status Quality of life Costs of care Societal costs/ economic burden lost productivity Morbidity Mortality Proficiency Behaviors meeting clinical criteria providing appropriate DX and RX 11
11 Two-way Dialogue Good interpersonal interaction between client and provider is, by definition, a two-way street where both speak and are listened to without interruption, both ask questions, express opinions and exchange information and both are able to fully understand what the other is trying to say. Partnership Between Provider and Client Providers and clients should view health care as a partnership in which each party contributes to maximize end results. Mutual respect and trust and joint decision-making will result in a greater likelihood of a positive outcome. Both provider and client must realize that, even though the provider is the medical expert, both are responsible for the outcome of their interaction. The patient must disclose all relevant information in order for the provider to determine a proper diagnosis and treatment; the provider must interpret and analyze the information received and effectively explain the condition and treatment options to the patient. Both should make decisions about treatment regimes, with the client making every effort to comply with the prescribed treatment and any necessary lifestyle changes the treatment implies. Providers should foster an active role for patients in their care and treatment. Providers should encourage active questioning and interaction during office visits and should involve patients in their own health care regimes. Atmosphere of Caring Patients need to believe that their provider cares about them and is committed to their welfare. Both verbal and non-verbal communication help the provider convey interest and concern to patients. Being attentive, making eye contact, listening and questioning thoughtfully, and demonstrating understanding and empathy make patients feel important and worthy. On the other hand, being brusk or appearing busy or distracted makes patients feel insecure, anxious or fearful of their relationship with the provider. Effective Bridging of Social Distance Social distance refers to the socio-cultural-economic factors that make people feel they belong to different class tiers. Education, economic status, class, race or ethnicity, gender and age may all contribute to how close or distant two individuals feel about each other. For example, an illiterate peasant woman and a young, highly trained, city-dwelling male physician who share the same language and were raised within miles of each other are still worlds apart socially. Clients bring to medical visits a whole range of emotional, socio-cultural, economic, educational and psychological traits that affect communication. Social distance should not impede good communication, and providers must realize that many people, even those in their own circles, may not be conversant with their language. Therefore, they should strive to bridge any social gap that might exist between them and their clients and establish an open dialogue, a partnership and an atmosphere of caring. Clients must also do their part to bridge the social distance by being candid and communicative. 12
12 Social Networks Social networks refer to those interpersonal relationships that bind people together. Typically consisting of family, friends, acquaintances, neighbors and colleagues, social networks influence differently depending on the individual and his or her environment a person s desire and ability to understand and comply with professional advice. For example, in some societies the mother or mother-in-law is key decision-maker in the extended family. Therefore, teaching the young woman about the benefits and methods of birth spacing may be ineffective if her mother or mother-in-law is uninformed or opposed to this practice. Similarly, in a home where a woman cooks for the whole family, dietary recommendations that could enhance her health may not be put into effect if they interfere with the family s culinary customs and tastes. Effective Use of Verbal Communication Verbal communication consists of spoken and written words people use to convey ideas. In a health care encounter, the choice of words clients and providers use greatly influences how well they understand each other. The medical jargon physicians use to describe symptoms and treatments allows them to communicate clearly and precisely with other clinicians. However, because the scientific and clinical terms may be confusing to patients, the use of such terms with patients is inappropriate. Patients communicate during medical visits in their particular dialects, accents, cadences and slang, often making comprehension difficult for providers from other parts or regions of the country. Patients also describe health problems in peculiar ways, often reflecting their unique Use Simple Language Medical jargon Simple explanation The clinical spectrum of cholera is broad, ranging from inapparent infection to severe cholera gravis, which may be fatal in a short time period. After an incubation period of 6 to 48 hours, there is an abrupt onset of watery diarrhea. Vomiting often follows in the early stages of the illness. Signs of severity include cyanosis, tachycardia, hypotension, and tachypnea. The symptoms and signs of cholera are entirely due to the loss of large volumes of isotonic fluid and resultant depletion of intravascular and extracellular fluid, metabolic acidosis, and hypokalemia. Not all persons that get cholera look equally sick. Some cholera patients seem to have a minor illness, while others look very sick. Some others can even die after hours of getting cholera. Because cholera germs spread within 6 to 48 hours of entering the body, the person may suddenly have a lot of watery diarrhea. Many patients also begin to vomit. When the sick person is getting worse, his skin can become blue (especially at the lips, nose, and fingertips), he may begin to breathe quickly, his heart works very rapidly, and blood pressure drops. All this happens because the body has lost a lot of liquids and minerals through diarrhea and vomiting. The body cannot survive when it loses too much liquid and minerals. 13
13 perspective on the illness origin or severity. Sometimes local perceptions can influence the way a patient describes the illness onset and symptoms. For example, if diarrheal diseases are common in their area, patients may not report symptoms of the disease unless they are quite severe. Because they view the symptoms as routine, patients simply neglect to mention them. For the provider, however, detection of early symptoms, even mild ones, is important in making proper diagnoses and developing appropriate treatment regimes. Effective Use of Non-verbal Communication Words express only part of a message being conveyed; tone, attitude and gestures convey the rest. Avoiding distractions, such as answering the telephone during a patient s visit or scribbling notes on other cases, and appearing fully attentive communicate positive messages to clients. Smiling, listening thoughtfully, sitting on the same level as the patient also enhance interaction. Much non-verbal communication is specific to cultural customs. For example, while in some cultures direct eye contact is a sign of positive regard and respect, in others it is deemed improper or aggressive, particularly with members of the opposite sex. Also, while in some cultures physical contact during a conversation is considered a sign of affection, in others it might be construed as highly improper. What is important to remember is that all forms of non-verbal communication convey a message. Often, simple gestures by the provider, such as a warm greeting or a thoughtful question, can help put the client at ease and enhance communication. Such actions do not require great effort but can have significant results. Following is an example of non-verbal communication conveying a positive message. Non-verbal Communication Dr. Green is seated behind a desk when Mrs. Sierra enters the examining room. He stands, greets her warmly by saying Good morning, Mrs. Sierra and walks to the other side of his desk, where there are two chairs. He offers one chair to Mrs. Sierra and sits in the other. He leans forward and, with his full attention on his new patient, he thoughtfully asks, How can I help you today? Non-verbal communication can have as great an impact as verbal communication but can be more easily misinterpreted. Thus, it is important for health care providers to be aware of the non-verbal messages they convey to their patients and of those their patients convey to them. Opportunity for Patients to Speak About Their Illness The medical visit should provide ample opportunity for a patient to describe his or her illness. Storytelling has its own healing value in that it provides patients with a release and opportunity for insight and perspective. It may also afford the health provider the insights needed to understand, interpret and explore the significance of the symptoms and clues the 14
14 patient provides. A patient s comprehension and feelings about a medical problem may be extremely important in prescribing appropriate treatment. A great deal of distress, for example, may stem from a patient s perception about the seriousness of his or her illness, not from its actual seriousness. Providers should not minimize a patient s anxieties, but strive to alleviate them. All of the factors described above have been shown to enhance communication between patient and provider. However, the fact that providers follow individual approaches increases the complexity of formulating a communication skill program. To change provider behavior in concrete ways, the above factors must first be broken down into concrete skills and behaviors as illustrated in the following guidelines. V. Guidelines and Norms for Effective IPC Our research and analysis of effective IPC has led us to develop a set of guidelines and norms for health care providers. While these norms should be further tested, refined, and validated, we are confident that the issues and skills presented here are both useful and valid in improving IPC. We define three types of IPC. Caring/socio-emotional communication: The objective of caring or socioemotional communication is to establish and maintain a positive rapport with the patient throughout the encounter. This is an integral part of all IPC and enhances patient disclosure and compliance. Diagnostic communication/problem solving: The objective of diagnostic communication is for the patient and provider to share all the information needed for accurate diagnoses and appropriate treatment prescriptions. Counseling: The objective of counseling is to ensure that clients understand their condition and treatment options. Counseling helps them to follow treatment regimes and behavioral change recommendations, by ensuring that these are comprehensible, acceptable, and feasible. Counseling emphasizes making decisions together with the client and helping solve actual or anticipated problems. A provider should convey expressions of caring at the outset of the encounter when rapport with the client is being established; rely on diagnostic or problem solving techniques during the history taking portion of the encounter; and use counseling skills at the end of the encounter to explain treatment and provide health education. However, all three approaches may be applicable throughout the encounter. Within the broad category of each approach, specific communication techniques or behaviors can be identified which can improve IPC. These and related examples are presented in the following section. 15
15 Caring A caring behavior emphasizes respect for patients and recognition that their concerns are important. Health care providers should display caring throughout the medical encounter in order to establish a trusting relationship and good rapport with the patient. Frame the encounter Set the tone for the interaction by greeting clients in culturally appropriate ways that communicate openness and concern. For example, the provider might frame an encounter by saying Good morning Mrs. N., my name is Dr. N.. I d like you to feel free to tell me about any health concerns you have. Use appropriate non-verbal communication Be sure your posture, eye contact, gestures, tone of voice, manner and attitude are appropriate and conducive to dialogue with the client. For example, a provider who is scribbling notes on a chart when a patient enters, might put down the pen, close the chart, and stand up or lean forward as he greets the patient. This shows the patient that he or she has the provider s full attention. Solicit feelings Invite patients to talk about how they feel, both physically and emotionally. A provider might ask a patient who is describing symptoms of her headaches, How do the headaches make you feel? How do they affect your other activities? Show positive regard Show clients, explicitly and implicitly, that they are respected and valued. For example, a provider might show positive regard for a patient by being courteous, smiling, asking the patient whether he or she is satisfied with the care received so far, or complimenting the patient s efforts in seeking medical assistance or following treatment recommendations. Positive regard is especially important when dealing with conditions that may have a social stigma attached to them, such as tuberculosis and AIDS. It is also helpful to bridge any social distance between provider and client that might be based on age, sex, social and educational status, race, religion, or ethnicity. Validate the patient s experience and efforts Recognize the patient s experience and efforts in an honest and straightforward manner. This may be done through statements of concern, empathy or legitimizing that show the provider cares about the patient and his or her problem. For example, when dealing with a hypertensive patient who does not take his or her medicine regularly, a provider might say, I m concerned that you re not taking care of yourself. This is likely to be more effective than scolding. Statements of empathy show that the provider understands and shares the patient s feelings. Legitimizing statements validate the patient s feelings. For example, a provider might tell a patient who is nervous about surgery, I understand that you are worried about this operation, or when counseling a cancer patient, a provider might say, It s easy to understand why you feel afraid and angry. Most people in your situation feel the same way at first. 16
16 Echo patients emotions Help patients express their feelings by echoing them. For example, when a patient says I ve been feeling very depressed lately, the provider might respond with It sounds like something is really getting you down. This technique provides the patient with an invitation to elaborate further on the topic. Express support and partnership Let clients know you will work with them to help them get better. A provider might say, I m going to use all my skills and expertise to help you get better, and I m counting on you to do your part to take care of yourself. Give reassurance Encourage and reassure clients about the outcome of their condition. For example, a midwife might say to a patient, I know you re feeling a lot of pain and anxiety right now, but tomorrow you ll feel much better, and you ll have a new baby to take home with you. In reassuring patients, it is important to be honest and realistic about the medical prognosis and to avoid premature or unjustified reassurance. Diagnosis and Problem Solving These skills help health care providers gather critical information for diagnoses. Use of data-gathering skills enables them to improve their accuracy and effectiveness in performing this function. The skills involve a variety of questioning techniques designed to encourage the patient to talk about all aspects relevant to the problem. Listen attentively and actively Use gestures to show patients they have your full attention and ask relevant questions to indicate your understanding of what they say. You may want to face patients and nod or comment occasionally as they describe their medical condition. Encourage dialogue In addition to yes/no questions, ask patients open-ended questions that encourage them to provide details about their problem. Often, one open-ended question will elicit a response that covers several yes/no questions. For example, instead of asking a patient Do you have a fever? Do you get headaches? Are you nauseated? You may simply say Tell me about any pain and discomfort you ve been feeling. Once the patient describes the condition, you might need to ask one or two yes/no questions to supplement the information. Avoid interruptions Do not interrupt patients when they are speaking. Wait until they have finished their thought before asking a new question. Also, avoid being interrupted by the telephone or other distractions during a patient s visit. Avoid premature diagnosis and resist immediate follow-up Wait until you have listened to the patient s full story and have asked all the relevant questions before determining a diagnosis and treatment. The patient s first complaints are not always the most important ones. Hasty conclusions can lead to diagnostic 17
17 error. For example, when a patient reports headache pain, resist the urge to immediately assume the ailment is minor and to prescribe pain relief drugs. Instead you might say Tell me more about how you re feeling. Often, a simple cure for headaches is all that is needed, but at other times the client might respond, I m so worried and upset, there are times when I don t feel like getting out of bed and feel like I could die. Such a case warrants further inquiry into the psychological and physical causes of the condition. Probe Encourage patients to provide more information by asking questions or inviting them to continue speaking. For example, the provider might use phrases like Tell me more or Please go on to help patients delve deeper into the nature of their problem and their reaction to it. Ask about causes Help patients share more information about their condition by asking their opinion on the causes of the ailment and what they think might help them. This technique will provide information needed to make a diagnosis and help providers evaluate the patient s understanding of the illness. Counseling and Education These skills enhance providers ability to explain to patients their conditions, the circumstances of their illness, diagnoses and treatment options. Providers should remember that patients compliance with treatment regimes depends on how well they understand the nature of their illness and how they feel about the prescribed treatment. Explore patient understanding Find out patients opinions of their illness by asking how they contracted it, whether they had the problem before and what they did about it at that time. For example, if a mother is seeking care for a child with diarrhea, the provider might ask, How do you think children usually get diarrhea? How do you think your child got it? How did you take care of it in the past? Correct misunderstandings or misinformation Sometimes clients hold inaccurate notions about the etiology or effects of a disease, which can affect their behavior toward treatment and adversely impact on their recovery. Providers should determine a patient s understanding of his or her problem, and politely correct any misconceptions the client may have. For example, a provider might say, While many people believe that taking the birth control pill right before intercourse will be effective, that s incorrect. You need to take the pill every day, whether you are going to have sex or not. Providers should be careful not to make the client feel uneasy or inadequate for having inaccurate ideas or information, and should strive to educate by providing appropriate information. Use appropriate vocabulary Providers should avoid using jargon or technical language when speaking with patients, making instead every effort to use terms that are meaningful to patients. For example, instead of asking Have you 18
18 had any respiratory difficulties lately? the provider might say, Have you had any difficulty breathing lately? or Tell me about your breathing? Present information in blocks It is important to present information in a way that the patient can easily absorb and remember. Providers should explain the diagnosis in a clear and comprehensible fashion, never in a condescending or patronizing manner. Subdividing the information into separate categories may help this process. Presenting separate blocks of information sequentially, enables the provider to monitor for understanding and absorption before moving on to the next block. This kind of presentation helps patients internalize the information presented and enhances the likelihood of effective compliance with the treatment prescribed. For example, the provider may address and sequentially convey brief information on the following topics: name of the disease and its etiology recommended treatment for the patient ways to prevent recurrence of the disease other relevant information. Use visual aids and/or printed materials when possible When conveying information to patients on diseases, preventive or treatment programs, or medical devices, it is often helpful to refer to a visual display. Visual aids help patients better understand and remember the information provided. It is also helpful to make use of pamphlets with simple text and pictures about important health problems, their prevention, and their treatment. Recommend concrete behavioral changes After making a diagnosis and prescribing a treatment regime, providers may recommend certain behavioral changes to their patients that would prevent the illness from recurring. These recommendations should take into consideration the patient s ability to implement them. Rather than simply emphasizing the end results of the behavioral change, providers should identify and suggest specific steps in the behavioral change. For example, instead of telling a hypertensive patient that he needs to lose 30 pounds, the provider might say, I d like you to try to lose some weight by taking a 20 minute walk every day and cutting down on the amount of sugar and oil you eat. Select an acceptable and feasible treatment To the extent possible, provide the patient with a range of treatment options from which to select the one he or she prefers. For example, in providing family planning services to a mother, discuss available options and help her select the one that is best suited to her lifestyle. Conditions such as pain management, weight loss, etc., may have a number of treatment options from which the patient may choose. Motivate patients to comply with treatment Once a treatment has been mapped out, the provider should try to motivate compliance with the treatment prescribed by pointing out to the patient the importance and benefits of such action. For example, in prescribing antibiotic treatment, a provider might say, 19
19 It is important for you to take your medicine three times a day until all the pills are gone. You may feel better after a few days, but if you don t take all the pills the illness will come back, and it may be harder to cure the next time. Summarize Restate the diagnosis, treatment and its recommended steps in simple terms. In summarizing, repeat only key points. For example, a provider might conclude a counseling session by saying I think you have a respiratory infection. Take these antibiotics with every meal until they are all gone. I d like to see you again in two weeks to make sure you ve completely recovered. Check for understanding and absorption Ask the client to repeat or describe the treatment instructions. Then clarify any misunderstandings the patient might have and find out whether there are any reasons that would impede the patient s compliance with the prescribed treatment. For example, a provider might say Just to be sure you understand how to take your medicine, would you tell me how much and how often you ll take it? Additional questions Urge patients to ask any additional questions they may have on their current or any other medical problem. Allow ample time for a response. Avoid missing the opportunity to consult. For example, if prompted to share any additional health concerns, a mother seeking care for a baby with diarrhea may mention that she is interested in exploring birth spacing techniques, or that she is not sure of the vaccination schedule for another of her children. Confirm follow-up actions Remind the patient of the next appointment date or of the next treatment action he or she will need to take. Remind the patient what to do if symptoms persist or worsen, and about danger signs that indicate he or she should seek prompt medical assistance. In this section, we have presented a set of specific guidelines for improving the IPC skills of health care providers. The next section will outline steps in planning and implementing a training program designed to further develop these skills. VI. Planning and Implementing Training Activities This section deals with planning and implementation of training activities. The information provided should enable health care providers to conduct small training workshops in their own clinics or enable outside experts to train health care providers in their areas or communities. The training format and methods presented here have been tested in a variety of settings and have proven effective in the IPC training of health care providers. We have found that revisions in our training methods are always necessary to adapt the techniques to local circumstances and insights. We, therefore, encourage providers and trainers to use their own ingenuity and expertise to modify the techniques to suit local realities. 20
20 Improving IPC skills generally implies some behavior change on the part of health care providers. Programs inducing effective behavior change require both an understanding of the issues and skills involved and practice sessions in the new skills. Practice may entail first conducting exercises among peers in a controlled environment (involving self-evaluations or evaluations and feedback from colleagues or supervisors), then holding supervised or selfmonitored practice runs with actual patients and leading eventually to internalization of the new skills when they become second nature to providers who apply them instinctively. Overall Training Approach The IPC training program is highly flexible, allowing participants to adapt the program to local socio-cultural realities or to pinpoint specific techniques that can improve daily operations. The training activities employ a variety of methods to ensure that participants develop and learn to effectively apply new IPC skills. The methods used include: participatory plenary sessions that employ brainstorming and question and answer sessions, allowing participants to discover and tailor new IPC skills; dynamic role playing which illustrates various communication strategies and allows participants to practice them; mental rehearsal techniques which allow participants to test the degree of difficulty of individual IPC skills and to develop methods to master them; videotapes on non-verbal communication skills which are used as instructional tools. Prior to the course, we developed: a guide to help participants practice the skills, which is referred in the text as the pocket guide, or job aid ; 8 a training manual which allows the trainer to adapt the manual to the participants needs and to local realities. Training Agenda and Format Our IPC training program consists of approximately 20 course hours covering a 3 to 4 day span. The initial session focuses on the relevance of the skills. The following session deals with the guidelines and gives participants an opportunity to practice the new skills. The training course has a prepared list of skills or behaviors the trainer introduces to the group (Table 1). 9 Each type of behavior is discussed and practiced in the participants native language aiming for potential improvements and adaptation to the local environment. 8 The job aid guide is included in Appendix A. 9 Please note the differences between the list and the Section V (Guidelines and Norms for Effective Communication). Section V incorporates revisions that had not yet been made at the time of the training. 21
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This is due to the effect known as 'Gravitational Locking'. The Earth's gravitational field slowed the Moon's spin over time and now the Moon spins about its axis at a rate such that the time to rotate once on its axis is exactly equal to the time it takes to go round the Earth. The diagram (click on the figure to see it clearly) explains how this results in effectively the same side of the Moon facing the earth all the time.
Gravitational Locking is observed in the case of other planets as well whose satellite moons are locked in the same way as the Moon is locked to the Earth.

subset: commoncrawl


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I think I've finally cracked it when it comes to making the perfect deep fried chicken. With the most delicious meat I've ever eaten on a chicken thanks to it having been in a bath of buttermilk overnight, I bring you my crackin' cornflake fried chicken. Not only does the crispy coating of the chicken taste delicious thanks to the combination of herbs and spices in the flour mix but there is also the best crunch ever to them thanks to the addition of oodles of crushed cornflakes. Perfect weekend comfort food after a long week in work!
This is definitely a recipe I'm not going to advise you to tamper with as I think it's perfect but the only thing I will say is that if you don't want to use drumsticks then feel free to use thighs, wings or even strips of chicken breast but just make sure you adjust the amount of time the chicken sits in the oven baking for dependent on the size of your cut of meat. Use the regular cooking times of the meat as a guideline.
Only thing left to say is to just be careful with hot oil. Keep a damp tea towel handy in case of fire and make sure all children and animals are out of the way. If we're all set, let's get cooking some fabulous fried chicken!
6 Chicken Drumsticks
250ml Buttermilk
1 Tbsp Worcestershire Sauce
100g Cornflakes
200g Plain Flour
2 Tsp Sea Salt
1 Tbsp Paprika
1/2 Cayenne Pepper
1 Tsp Ground Black Pepper
2 Tsp Oregano
Sunflower Oil For Frying
Sunflower Oil For Frying
- Begin by placing the chicken drumsticks into a large bowl and pour the buttermilk and Worcestershire sauce over them. Get your hands in and make sure all the chicken is coated in the buttermilk (wear gloves for this or make sure you have hot soapy water ready to wash your hands afterwards). Leave to rest covered in the fridge for at least 2 hours (preferably overnight).
- Once the chicken has finished it's buttermilk bath, take the cornflakes and bash them up into smaller pieces (pieces around the size of your little finger nail). Mix these bashed cornflakes with the flour, sea salt, paprika, cayenne pepper, black pepper and oregano and arrange them evenly on a large plate.
- Next, turn your oven on to 190 degrees (170 fan), have a non stick baking tray ready and get a large frying pan on the hob with enough oil to be 2 inches deep. Carefully heat the oil to 180 degrees using a thermometer (or you can test by throwing in some of the cornflakes mixture - it should fizz and brown within 3 minutes).
- With everything ready you can begin frying. Take the chicken out of the fridge. Take one drumstick out and allow any excess to drip off before placing in the plate with the cornflake mixture. Coat the chicken all over with the cornflake mixture and then add the drumstick carefully to the oil.
- Fry for around 3 minutes, turning the drumstick halfway through until all the coating on the chicken is golden brown. Remove the chicken from the oil with metal tongs and place on the baking tray. Dab off any excess oil with kitchen paper.
- Repeat this process with all the chicken pieces until they are all golden brown. Make sure the temperature of the oil stays around 180 degrees and you can fry more than one drumstick at a time if your pan is big enough. Make sure to wear gloves or have warm soapy water to hand so you can wash your hands if you need to step away from the chicken at this point.
- Once all the chicken had fried and is on the baking tray, pop the baking tray in the oven to bake for 15 minutes.
With that, your chicken should be done and ready to eat! Check one piece carefully before you do serve just in case but mine were spot on with these timings so you should be OK. That golden brown cornflake coating to the chicken is so satisfyingly crunchy and the noise as you bite through it is so heavenly and that's even before you get through to that plump, juicy and moist chicken inside. For a chicken lover like me it's quite simply divine and totally worth the buttermilk marinating time the night before. Grab a drumstick and tuck in to some crackin' cornflake fried chicken!


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Palmyra Animal Clinic has four locations, serving Harrisburg, Mechanicsburg, Palmyra and Pine Grove, PA. We have been serving our community since 1985, and are looking for enthusiastic veterinarians to help us continue this tradition. For better quality of life, we have recently revised our schedule and decreased doctor work hours! Recent changes in the practice are also allowing us to focus on a very positive work environment that is worth your consideration.
We are a full service practice, offering the best in medical and surgical care. To support this, we have full in house labs, digital radiology, ultrasound and laser therapy, as well as rehab services.
Located around Harrisburg, the Capitol of Pennsylvania, our four practices are well positioned to enjoy all Pennsylvania has to offer. From farmers markets, to July 4th celebrations, to holiday parades, there is plenty to do. Within two hours, you can go west to the Bald Eagle State Forest or east to Philadelphia. In 2.5 hours, you can go south to Washington, DC.
We offer competitive pay and a full range of benefits, including insurance, licensing, 401k, CE, signing bonus/relocation, and above average PTO. We recognize that working hard is balanced by time away from the practice to enjoy friends, fun, and time with family. To apply for this position confidentially, email your CV to email@example.com.
|Norman, Oklahoma
|Rose Rock Veterinary Hospital & Pet Resort
|1 Month Ago
|Associate Veterinarian opening just outside of Erie, Pennsylvania
|Edinboro, Pennsylvania
|Camboro Veterinary Hospital
|Shelter Veterinarian
|Evans, Colorado
|Humane Society of Weld County


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Saint Nicholas has probably put away his big red suit and black boots and decided to shave his beard and let Rudolph and the gang rein free, whilst making plans to lay on a beach to bask in the sun with his flip flops and sun hat on. He'll have no more mention of the 'C' word, until that time of year comes around once again!
Just how I'm feeling right now, that limbo land between the Holidays and New Year! Mind you.. sounds like I'm complaining, but I assure you, I'm feasting on copious amounts of leftovers, whilst wearing super cozy fleece pajamas and socks and watching movie marathons up to my eyeballs. My only course of action is scouring the sales online!
Footwear and handbags are on my main agenda, I've had my eye on the Aldo Agreda shoe, which has that Walter Steiger's signature curve heel look. Good Luck scouring the SALES everyone!! http://www.aldoshoes.com/ca Thank You for being a lurker, follower and a friend. See you all in 2013.
Love always,


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As the Muslim migrant crisis in Europe continues unabated, with politicians doing next to nothing to address the increasingly tense situation, some segments of the local population have resorted to taking matters into their own hands to express their displeasure at the status quo.
That is exactly what happened Sunday in the town of Elk in Poland, when several hundred Poles protested and rioted outside an Algerian-owned kebab restaurant after a group of Muslim migrants chased down and murdered a local man following an argument.
According to the BBC, a 26-year-old Tunisian cook has been arrested and charged with murder for the stabbing death of a man named only as Daniel R.
Daniel had been accused by employees of the restaurant of stealing a drink and had been chased off the premises by a "group of Arabs," actually migrants of North African descent, at least one of whom ultimately stabbed Daniel twice in the chest during a scuffle in the street late Saturday night.
It didn't take long for several hundred angry local citizens to show up outside the restaurant the next morning and exact their revenge, smashing out windows and tossing firecrackers inside the building, as reported by the U.K. Express.
TRENDING: Ocasio-Cortez Plays the Race Card To Attack 'Unacceptable' Team of Journalists
"In the crowd, numbering between 200 and 300 people, dozens were behaving aggressively," witness Rafael Kackowski reportedly told local police.
Those local police were forced to turn out in riot gear and use tear gas to disperse the angry crowd, some of whom shifted their wrath to the law enforcement officers by pelting them with rocks and bottles and abusive language.
You can watch part of the violent protest and riot here:
"There has been a great tragedy. I would like to appeal and ask residents for calm and to respect the tragedy the family of the 21-year-old Daniel is experiencing," said Elk Mayor Tomasz Andrukiewicz. "I offered psychological help to this family."
In all, more than 25 rioters were arrested and charged with various offenses following their destructive act of revenge on the North African restaurant.
Obviously it should go without saying that we don't approve of or condone violent behavior or acts of vigilante justice like this.
Nevertheless, we understand the frustration these locals are feeling as they see increased rates of crime and an upheaval of their longstanding traditions in conjunction with the massive influx of Middle Eastern and North African migrants.
Please share this on Facebook and Twitter so everyone can see what these Polish citizens did after one of their own was murdered by a group of Muslim migrants.
What do you think of what these local Polish citizens did to the restaurant at the center of a murder? Scroll down to comment below.


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Pinball players in Germany are now able to participate in an exciting new nationwide contest; with the launch of the IFPA German Championship Series.
All results from IFPA-recognized tournaments within Germany during the calendar year (excepting 2016: here we start with the German Pinball Open in May) will count towards the IFPA German Championship Series.
At the end of the year, the 32 top-ranked players will qualify for the national Series Final to be held the following quarter.


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There's no reason why baked goods can't be enjoyed as part of a healthy diet. But by baking your morning muffin at home instead of picking one up at the drive thru on your way to work or popping into your favourite cafe, you control the nutritional value and portion size. Loading up your homemade baking with whole grains, healthy fats, and keeping the sugar content in check can really boost the nutritional value and make your treat more of a nutrition powerhouse than a guilty pleasure. If you missed it, check out my post on Healthy Baking Hacks for all the details!
Zucchini loaf with lemon + raspberries
I've been learning a whole lot about the gut, digestive health, Irritable Bowel Syndrome (IBS) and the low FODMAP diet as of late. It's fascinating stuff! The low FODMAP diet is a relatively new protocol for managing symptoms of IBS, and research has proven it to be successful in relieving the symptoms of 75% of people dealing with IBS and digestive health issues. Diet is an obvious factor when it comes to our digestive health, but other factors like gut bacteria, stress, caffeine consumption, exercise, hydration, and eating patterns can also have a significant impact on how well our bodies absorb nutrients and whether or not the digestive process causes us uncomfortable symptoms like gas, bloating, abdominal pain, and abnormal bowel movements. These things can really impact your day to day life, and prevent you from living fully and confidently. Sometimes, the only advice given to people with digestive health issues (diagnosed or not) is to eat more fiber and drink more water, which usually doesn't help. The low FODMAP diet is a welcome addition to IBS and digestive health symptom management, and it's seeing real results!
Banana pancakes
Work-life balance. What does it mean to you? Give and take, push and pull, sacrifice. How about work-life integration? Combine, compliment, coordinate. Maybe we've been striving for the wrong thing.
Just the other day, someone I work with commented on my appearance in the following way: "You look very 'city' today!" To provide some context, I am currently working at an outdoorsy over night summer camp where everyone looks just a little bit disheveled almost all of the time. Dirty clothes, sweat pants, hoodies, old t-shirts, greasy hair – it's a busy little world over here and staff don't always have a ton of time to take care of themselves. The daily grind here at camp can wear you down, and sometimes it shows.
Cherry + cocoa green smoothie
While some people may be new to the Green Smoothie Club, others have been adding handfuls of spinach, kale, celery, and parsley to their blends for years. For all you prospective members who may be hesitating due to the muddled green colour of some of our green smoothie concoctions, I've got a smoothie recipe for you. Full of healthy greens, but no green colour in sight! How about that?
Green smoothies have been all the rage as of late. A more substantial alternative to juicing, blending up your ingredients instead of separating the juice from the pulp drastically increases fiber content which helps slow digestion, keeping your fuller, longer! Smoothies are also a quick, easy and convenient way to pack a few extra servings of fruits and veggies into your busy life, and I think it's safe to say we could all use a little more of that. Read More
Gingerbread cookie dough bites
Sometimes, life can feel like a race – a competition. As if there is this pressure to be everywhere, do everything, and jump on every opportunity that comes your way, for fear of missing out or falling short. As a dietetic student in Ontario, competing for internships upon graduation puts me in this exact situation. Even though I won't start my applications for another 2 years, time is of the essence when it comes to building my resume and accumulating experiences that will get me where I need to go.
Read More


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Aristotelia fruticosa
Aristotelia: Named after Aristotle, the Greek philosopher and polymathfruticosa: shrubby
Mountain wineberry
2012 - Not Threatened
2009 - Not Threatened
2004 - Not Threatened
Aristotelia fruticosa Hook.f.
A small-leaved shrub with hairy branchlets and veins evident on the underside of leaves
Vascular - Native
Dicotyledonous Trees & Shrubs
Endemic. North, South and Stewart Islands. Throughout, but often localised in occurrence
Lowland to subalpine forest understory and shrubland, commoner at hgher altitudes
Dioecious, variable, much branched erect or low growing shrub, sometimes spiny, to 2 m tall; trunk and branches sub-divaricate to upright, rigid, sometimes entangled; bark reddish brown; branchlets reddish brown, pubescent. Leaves opposite or in opposite fascicles on arrested branchlets; petioles c. 2 mm long, widening into lamina; midvein inconspicuous above, midvein and secondary veins obvious below; lamina either 5-7 x 4-5 mm, obovate to oblong, coriaceous, dark green, or c. 15 x 9 mm, ovate to lanceolate, thinner, lighter green, margins distinctly serrate, tip acute to obtuse, base cuneate, undersides pale green. Juvenile leaves larger, thinner, irregularly lobed and serrate. Inflorescences inconspicuous, lateral along branchlets, flowers c. 2-3 mm diam., solitary, in opposite pairs or in 3-6 flowered cymes, on short pubescent pedicels 1-2 mm long. Sepals 4, oblong, pubescent; petals 4, slightly > sepals, with 1-4 crenate teeth, white to light pink to red. Stamens 4-6, not projecting beyond corolla, anthers > filaments. Ovary 2- celled(?), styles 2(?). Fruit a c. 2(?)-seeded fleshy berry, 3-4 mm diam., pale, white, pink, bright red to black, bitter to taste. Seed irregularly angled, ventral surface flattened, elliptic, 2.0-2.6 mm, surface irrregular, attachment scar obvious, small orange aril sometimes present.
Similar to other small leaved shrub species with veins conspicuous below, particularly Raukaua anomalous (which has a flattened, jointed petiole) and Melicytus micranthus (which has a pale blotch at the base of the lamina)
Red / Pink,White
November to April
2n = 28
Fleshy berries are dispersed by frugivory (Thorsen et al., 2009).
Description adapted from Allan 1961, Heenan and de Lange 2006, Eagle 2000 and Webb and Simpson 2001.
Allan, H.H. 1961. Flora of New Zealand. Government Printer, Wellington
Heenan, P.B, de Lange, P.J. 2006. Pseudowintera insperata (Winteraceae), an overlooked and rare new species from northern New Zealand. NZ J. Botany 44: 89-98
Eagle, A. 2000. Eagle's complete trees and shrubs of NZ. Te Papa Press, Wellington
Thorsen, M. J.; Dickinson, K. J. M.; Seddon, P. J. 2009. Seed dispersal systems in the New Zealand flora. Perspectives in Plant Ecology, Evolution and Systematics 2009 Vol. 11 No. 4 pp. 285-309
Webb, C.J. & Simpson, M.J.A. 2001. Seeds of NZ gymnosperms and dicotyledons. Manuka Press, Christchurch
Wilson, H; Galloway, T. 1993. Small-leaved shrubs of New Zealand. Manuka Press, Christchurch
This page last updated on 10 May 2014
© 2019 New Zealand Plant Conservation Network
Web design by Cerulean / Development by Propel
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Xcel Energy (Weighted Average Cost of Capital (WACC) Analysis)
Improve your investment analysis with by seeing the Xcel Energy's Discounted Cash Flow analysis, Xcel Energy's Warren Buffet analysis, and Xcel Energy's Comparable Multiple analysis.
Helpful Information for Xcel Energy's Analysis
What is the WACC Formula? Analyst use the WACC Discount Rate (weighted average cost of capital) to determine Xcel Energy's investment risk. WACC Formula = Cost of Equity (CAPM) * Common Equity + (Cost of Debt) * Total Debt. The result of this calculation is an essential input for the discounted cash flow (DCF) analysis for Xcel Energy. Value Investing Importance? This method is widely used by investment professionals to determine the correct price for investments in Xcel Energy before they make value investing decisions. This WACC analysis is used in Xcel Energy's discounted cash flow (DCF) valuation and see how the WACC calculation affect's Xcel Energy's company valuation.
WACC Analysis Information
1. The WACC (discount rate) calculation for Xcel Energy uses comparable companies to produce a single WACC (discount rate). An industry average WACC (discount rate) is the most accurate for Xcel Energy over the long term. If there are any short-term differences between the industry WACC and Xcel Energy's WACC (discount rate), then Xcel Energy is more likely to revert to the industry WACC (discount rate) over the long term.
2. The WACC calculation uses the higher of Xcel Energy's WACC or the risk free rate, because no investment can have a cost of capital that is better than risk free. This situation may occur if the beta is negative and Xcel Energy uses a significant proportion of equity capital.


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|how we wished we could have seen Pergamom
We were to follow the signs to Karşıyaka, Bornova, Menemen, Aliağa, and finally Bergama - which sounded straightforward. We went off assuming we'd just follow the signs with any or all of these words on it and we'd be fine.
Except after Bornova, no signs used any of those words.
It took me a while to finally figure out, from the backseat after frantically looking at the large map that what we needed to do was go in the direction of "Çanakkale"... meaning Çanakkale the province.... (at this point we had turned around once in Bornova and were back on the road of what we thought as "on our way" only to have the highway suddenly dwindle to nothing in the midst of signage that said we were welcomed into a brand new bird sanctuary!
We turned around again, and I suggested we lookout for the signs to Çanakkale which meant nothing to anyone, but it ended up working just fine and soon we were on our way, passing signs directing us to all the other names on our list til finally we'd arrived into the outskirts of Begama.
Ideally you are meant to visit the Acropolis first, then the Asklepion, and finally the Red Basilica, more accurately known as the Temple of Serapis (an Egyptian god). But we ended up doing the tour completely back to front. In the windy icy cold! Still we were so pleased we'd found it that we jumped out of the car and into our view of the Asklepion.
Pergamum had the fame to be the first city who showed reaction to the functional urbanism of Hippodamus as they preferred ornamental urbanism. Acropolis buildings were built and designed with the aim of impressing the ones viewing the city from the valley.
We were in the valley below. Even the ruins were impressive!
Pergamon's Asclepion translates as 'place of Aesklepios', the son of Apollo and the god of healing and health, and was an important health center in Greco-Roman times. Among the types of therapy practiced here were mud baths, sports, theatre, psychotherapy and use of medicinal waters.
We walked through the whole of the Asklepion, down below and onto the Sacred Way. (now i'll just post some pics with captions...)
|Sacred Way
|Roman theater
|theater closer (nice human sized space)
|entrance to the underground passageway
|entrance to eventually get to the treatment rooms
|a really long and slightly Freudian walk
|one of the three still flowing fountains from the sacred spring
|dear C taking the sacred (and still slightly radioactive) waters
|It was still pretty cold and windy so there weren't very many people around
|one of the two towers we could explore
|the other tower in use by the archaeologists
|and looking up!
So there we were at the top of what felt like the world and it was so cold and windy it brought tears to our eyes. (again with the pictures...)
|on top of the world
|dramatic theater sat 10,000 people
|standing on what remains of Temple of Athena (not much)
|Temple of Dionysus and the theater terrace
|what's left of the Great Altar of Zeus (that's not in the Berlin museum)
|Temple of Trajan
|more bits of Trajan's temple
|details of Roman Corinthian capitals
So that's our day in Pergamon. The ride home (once we got down from the Acropolis) was fairly unevenful. We got back with time enough to freshen up a bit and join some more special friends (and ex neighbors!) for dinner in Güzelbahçe near where we used to live. We had such a lovely evening - and we ate the most incredible seafood!! Stuffed mussels, fresh greens, lightly battered calamari, and shrimps (etc) then for the main course a simple grilled sea bass with chips (french fries) on the side.
|dear friends
|beautiful starters
|the main event!
All in all a lovely day and a great evening. We got back to the hotel late, but not bad and we all slept quite soundly and woke up for breakfast at 8.
We hit the road at 9 and acted like we knew what we were doing.
I almost feel like I'm reliving the entire vacation in real time all over again! So. It's just past 10 and I'm done for today. Tomorrow I may or may not post Priene, Miletus and Didyma. [I'll give it a try, but it may be a Tuesday post... I have to get groceries SOME time.]
I hope you are enjoying this as much as we did when we all took the trip. Thanks for reading it.


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So this weekend I spent the last of my Funemployed days helping K say goodbye to the single life. Along with 7 of other gals from parts of K's life, I had a fantastic weekend wining and dining around DC and Charlottesville.
We spent Friday night in DC with a delightful dinner at Ripple in Cleveland Park (mmm cheese plates!), before retiring to the Omni in Woodley Park. Early Saturday we awoke and got on the road, accompanied with Starbucks and Bethesda Bagels.
It was smooooth sailing, until about 15 miles from our hotel, when the car I was in broke down … The exhaust may or may not have fallen off. So the entire caravan pulled over and waited for our soon-to-be BFF Gene, the AAA tow truck driver, to arrive.
After dropping the car off at a local auto body shop, we booked it and managed to make it to the hotel just in time to hop in our private van for a day winery hopping around Charlottesville. We made it to three — King Family, Stinson, and Veritas. They were all great, but everyone agreed the first was their favorite. Dinner was at this fantastic restaurant, The Local. Go there and get the truffle Mac and cheese and the trout with crispy avocado. So good.
The rest of the weekend was spent drinking, dancing, brunching, etc etc.
Now I'm at home, exhausted, and gearing up for my big first day at the new job TOMORROW. Ah, time flies.
I'll update soon with a reflection on this whole experience. Until then.


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Application Period: April 11, 2017 - April 14, 2017
Contact: Please email your cover letter and CV to firstname.lastname@example.com by April 14th, 2017
Programmer or Web Application Developer
30 week (approximately 7-month) contract position
KinCO is a Quebec-based fitness and wellness business created by two exercise science specialists. Our business is committed to empowering people to be healthy by bringing the best health services to corporations and communities through its innovative health and wellness programs. KinCO aims to represent, inspire and support the improvement in standards of the fitness industry, ultimately changing the way fitness is done.
Job Description
KinCO is currently searching for a Programmer/Web Application Developer to join the development team of an application designed to educate and facilitate the work done by fitness professionals.
Primary Role: Develop the back end components of the application in conjunction with lead engineer, project leader and software analyst.
Post-secondary graduate
Code in ASP.net
Knowledge of C#, HTML, JavaScript, Bootstrap
Strong critical thinking and problem solving skills
English (written and spoken); French an asset
High level of integrity and strong attention to detail
Organizational and time management skills
People skills; team building, communication skills
Applicant must meet CNRC (http://www.nrc-cnrc.gc.ca/eng/irap/services/youth_initiatives.html)
Commitment Details:
Performance expectations are task/project based deliverables established within the overall application development timeline. At minimum, the applicant would be required to commit 33 hours per week to the project, though this may vary depending on skill level.
Contract remuneration for 30 weeks: 22, 750$
There is the opportunity for the transition to a long term position following the contract.
To apply, please email your cover letter and CV to email@example.com by April 14th, 2017.


text: Construction management services were provided for this 15,023-SF fire station and training facility. The 30-room facility includes one of Newport Beach's Emergency Operations Centers, which is also utilized as a training center for both the fire fighters and city residents. The premier four-level training tower on site has special features including a smoke machine, rappelling apparatus, roof vent, enclosed spaces and multiple floors with movable walls for training exercises. Abandoned asbestos piping, septic tank, cesspool, and other unforeseen conditions made this project a challenge in the early stages. Our team worked together to resolve all problems encountered in the grading and underground utility portion of the project.