Genevieve Antoine Dariaux, "To be elegant is first of all to know oneself, and to know oneself well requires a certain amount of reflection and intelligence."

Refinement is an act of improvement.

Let’s Bring Back Some Class by Hairfinder.com

Is it my imagination? Are my eyes deceiving themselves when I see the baby beginnings of lush waves coming back to our society? Could this mean the comeback of class?

Ho- hum and yawn, goes to those who wear expensive designer gowns with their hair spilling over their bare shoulders without any jewelry, simply because this is the trend for today. Trends come and go, but if you would like people to remember you, strive to have class.

Let’s talk about class. The word itself is exciting because it means “social rank, high social rank, high quality elegance.” Have you ever given thought to what it would be like to be tabbed “elegant?” This is when you walk into the room and both women and men alike murmur their ooohs and aaaahs because they’ve become dumbstruck just by your presence. We are talking about nice whisperings. I’m not talking about the queen either, but a simple well fashioned, well coiffed lady. Notice, I said lady. Non ladies cannot be elegant only because haven’t given much thought about the issue. For some, this would seem old fashioned. However, if they decide a change is in the wind, they too can always strive to be elegant. When a lady is elegant she has learned social manners. This does not make her a prude; it is simply because she cares to guard her reputation in all areas of her life. How many elegant ladies can you count upon your fingers today? If there is one elegant lady to every 25 to 50 ladies today, think how popular she must be because she stands out in the crowd. Pure class, they say! How can they really tell the difference? For one, it is the way she holds herself when she stands. Her posture is straight, she doesn’t slump, this means she always holds in her tummy. When she sees someone across the room who is staring at her, she simply nods in acknowledgement and turns her head. Never for a minute will she stare, so unlike Hollywood’s films. Some would call her uppity or stuck up, but she knows her worth and has set her standards high and will not relent for a minute. She walks with her head held up, yet; still greeting others with a smile. Her thinking is such that, why expose what she has in the public arena, it is precious; for her future husband and besides, what mystery would be left? She is modest, (a seemingly dying virtue of today) as she sits down, she moves her legs over to one corner of the chair and crosses one ankle over the other as a well trained lady. She dresses tasteful and conservatively, never revealing too much, for she isn’t there to be sexy, but classy. A classy lady goes more for tailored clothes instead of the flash of trends. She shops for quality instead of quantity, this means cotton, silk and linen instead of polyester. Her choices in color would be wine instead of bright red, gold instead of yellow and a muted teal instead of turquoise. In that way, she is not shouting to the world, but instead confidently saying: “I am.” She also refuses to be hypocritical in her shoes and refuses to wear stilettos if she knows they will hurt her later on in life. Class has wisdom and thinks about tomorrow.

Her hair is awesomely beautiful. If it is short, she might wear it in an easy to style elfin pixie type that frames her lovely eyes and Mona Lisa smile. She might have a few subtle highlights in the front. If her hair is short to medium length, she could have lovely deep rich waves that promote her feminine appeal and soften the curves around her face. This lady doesn’t care for trends, or what is the latest fad, but she has learned to buy only what brings out the best for her, like her hairstyle does. If she has long hair, she wears it up when she goes out, unless she is going to be playing tennis, and then it is in a ponytail or a bun; her hair is neat, unless she is playing sports. She knows the value of a good haircut.

Her jewelry would be small to medium rather than large and gaudy. Her makeup is very light and neutral. Her finger and toe nails are meticulously kept up, but this doesn’t unavoidably mean that she doesn’t try to wear gloves in the garden or get her hands dirty cleaning the house or wash her dogs. A classy woman is you and me, when we decide to live with high values that are exhilarated by a progressive mind set.

Being a classy woman isn’t necessarily a woman born with a silver spoon in her mouth. But it does mean she is someone who cares for her reputation, has high standards and cares the way she carries herself in her conversation, her actions, her dress and lifestyle. She has given herself a set of high principles to live by and doesn’t see herself yielding her beliefs for anyone.

more? visit another good source. http://www.elegantwoman.org

Voyage of Discovery.co.uk

There’s a whole world out there waiting
to be discovered. The time to start is now.

The key to a Voyages of Discovery cruise is simplicity itself – see more, do more. So you’ll discover some of the great cities and monuments from the ancient and modern worlds. And along the way, you’ll also share the stories and insights not everyone gets to see. Our renowned guest speakers unlock the secrets, while our ships Discovery and Voyager are the perfect way to get to any destination.

Small enough to reach out-of-the-way ports, yet large enough to make light work of crossing the great oceans, Discovery and Voyager avoid the excesses of today’s mega-liners. Instead they have been expressly conceived for our special brand of discovery cruising to create an atmosphere on board that is friendly and relaxed.

During our voyage you will be accompanied by around 550 like-minded passengers on Voyager, with 650 on Discovery. Complementing the talks given by our own lecturers, who will preview the destinations ahead, the programme features historians, explorers, naturalists and diplomats, who will share their expertise, anecdotes and interests with you.

Be bolder, brighter, and better

and wie ein Rennauto: schön, schnell und TEUER :)

7 Most Important Interior Design Principles from Freshome

At the end of this article you’ll be able to recognize and use the basic interior design principles used by every interior designer to create a great design, and who knows maybe you’ll also save some money, or start a new career ! Now let’s begin with the beginning, and undestand what interior design is …

“Interior design is the process of shaping the experience of interior space, through the manipulation of spatial volume as well as surface treatment. Not to be confused with interior decoration, interior design draws on aspects of environmental psychology, architecture, and product design in addition to traditional decoration.

An interior designer is a person who is considered a professional in the field of interior design or one who designs interiors as part of their job. Interior design is a creative practice that analyzes programmatic information, establishes a conceptual direction, refines the design direction, and produces graphic communication and construction documents. In some jurisdictions, interior designers must be licensed to practice.” – Source :Wikipedia

Now that you have an idea about interior design, we can move forward and learn something really useful, the principles of 
interior design. Let’s begin !

When doing interior design it is necessary to think of the house as a totality; a series of spaces linked together by halls and stairways. It is therefore appropriate that a common style and theme runs throughout. This is not to say that all interior design elements should be the same but they should work together and complement each other to strengthen the whole composition. A way to create this theme or storyline is with the well considered use of color. Color schemes in general are a great way to unify a collection of spaces. For example, you might pick three or four colors and use them in varying shades thoughout the house.

In a short sentence for those who just scan this article balance can be described as the equal distribution of visual weight in a room. There are three styles of balance: symmetrical,asymmetrical, and radial.

Symmetrical balance is usually found in traditional interiors. Symmetrical balance is characterized by the same objects repeated in the same positions on either side of a vertical axis, for example you might remember old rooms where on each side of a room is an exact mirror of the other. This symmetry also reflects the human form, so we are inately comfortable in a balanced setting.

Asymmetrical balance is more appropriate in design in these days. Balance is achieved with some dissimilar objects that have equal visual weight or eye attraction. Assymetrical balance is more casual and less contrived in feeling, but more difficult to achieve. Asymmetry suggests movement, and leads to more lively interiors.

Radial symmetry is when all the elements of a design are arrayed around a center point. A spiral staircase is also an excellent example of radial balance. Though not often employed in interiors, it can provide an interesting counterpoint if used appropriately.

Interior design’s biggest enemy is boredom. A well-designed room always has, depending on the size of it, one or more focal points. A focal point must be dominant to draw attention and interesting enough to encourage the viewer to look further. A focal point thus must have a lasting impression but must also be an integral part of the decoration linked through scale, style, color or theme. A fireplace or a flat tv is the first example that most people think of when we talk about a room focal point.

If you don’t have a natural focal point in your space, such as a fireplace for example, you can create one by highlighting a particular piece of furniture, artwork, or by simply painting a contrasting color in one area. Try to maintain balance, though, so that the focal point doesn’t hog all of the attention.

If we would speak about music we would describe rhytmas the beat of pulse of the music. In interior design, rhythm is all about visual pattern repetition. Rhythm is defined as continuity, recurrence or organized movement. To achieve these themes in a design, you need to think about repetition, progression, transition and contrast. Using these mechanisms will impart a sense of movement to your space, leading the eye from one design element to another.

Repetition is the use of the same element more than once throughout a space. You can repeat a pattern, color, texture, line, or any other element, or even more than one element.

Progression is taking an element and increasing or decreasing one or more of its qualities. The most obvious implementation of this would be a gradation by size. A cluster of candles of varying sizes on a simple tray creates interest because of the natural progression shown. You can also achieve progression via color, such as in a monochromatic color scheme where each element is a slightly different shade of the same hue.

Transition is a little harder to define. Unlike repetition or progression, transition tends to be a smoother flow, where the eye naturally glides from one area to another. The most common transition is the use of a curved line to gently lead the eye, such as an arched doorway or winding path.

Finally, contrast is fairly straightforward. Putting two elements in opposition to one another, such as black and white pillows on a sofa, is the hallmark of this design principle. Opposition can also be implied by contrasts in form, such as circles and squares used together. Contrast can be quite jarring, and is generally used to enliven a space. Be careful not to undo any hard work you’ve done using the other mechanisms by introducing too much contrast!

Another important element of interior design where it is necessary to take infinite pains is details. Everything from the trimming on the lamp shade, the color of the piping on the scatter cushion, to the light switches and cupboard handles need attention. Unlike color people find details boring. As a result it gets neglected and skimmed over or generally left out. As color expresses the whole spirit and life of a scheme; details are just as an important underpinning of interior design. Details should not be obvious but they should be right, enhancing the overall feel of a room.

Scale and Proportion – These two design principles go hand in hand, since both relate to size and shape. Proportion has to do with the ratio of one design element to another, or one element to the whole. Scale concerns itself with the size of one object compared to another.

Color – Colors have a definite impact on the atmosphere that you want to create when doing interior design. A more detalied post about how colors affect our moods you can find here.

The spirit of flamenco is the art of living each day to its fullest, physically, spiritually, emotionally and mentally as an individual and fulfilling your individuality as a unique creative expression of life. (BCN travel report)

Land of Wasted Talent

Unlike an earthquake, a demographic disaster does not strike without warning, The Economist’s Schumpeter blog reminds us this week. Take Japan for example; its population of 127m is predicted to fall to 90m by 2050. As recently as 1990, working-age Japanese outnumbered children and the elderly by seven to three. By 2050 the ratio will be one to one. As Japan grows old and feeble, where will Japan’s companies find dynamic, energetic workers, the author ponders. The answer may be across the kitchen table.
Nearly half of Japanese university graduates are female but only 67% of these women have jobs, many of which are part-time or involve serving tea. Japanese women with degrees are much more likely than Americans (74% to 31%) to quit their jobs voluntarily. Whereas most Western women who take time off do so to look after children, Japanese women are more likely to say that the strongest push came from employers who do not value them. A startling 49% of highly educated Japanese women who quit do so because they feel their careers have stalled.
Some 66% of highly educated Japanese women who quit their jobs say they would not have done so if their employers had allowed flexible working arrangements. The vast majority (77%) of women who take time off work want to return. But only 43% find a job, compared with 73% in America. Of those who do go back to work, 44% are paid less than they were before they took time off, and 40% have to accept less responsibility or a less prestigious title. Goldman Sachs estimates that if Japan made better use of its educated women, it would add 8.2m brains to the workforce and expand the economy by 15%—equivalent to about twice the size of the country’s motor industry.

theeconomist

Umberto Eco: 'People are tired of simple things. They want to be challenged'

"As a scholar I am interested in the philosophy of language, semiotics, call it what you want, and one of the main features of the human language is the possibility of lying. A dog doesn't lie. When it barks, it means there is somebody outside." Animals do not lie; human beings do. "From lies to forgeries the step is not so long, and I have written technical essays on the logic of forgeries and on the influence of forgeries on history. The most famous and terrible of those forgeries is the Protocols."

"Berlusconi is a genius in communication," says Eco. "Otherwise he would never have become so rich. From the beginning he identified his target – middle-aged people who watch television. Young people do not watch television; they are on the internet. The people who support Berlusconi are 50- and 60-year-old ladies and retired people, who, in a country with an ageing population, make a powerful electoral force. So even some of his famous blunders may be blunders for me and you, but probably for the provincial 60-year-old lady or gentlemen they are not. His appeal was 'pay less taxes'. When the premier says you are right not to pay taxes, you are pleased."

How could a culture as intellectual and artistic as Italy's have elected such a buffoon? "Berlusconi was strongly anti-intellectual," he says, "and boasted that he hadn't read a novel for 20 years. There was a fear of the intellectual as a critical power, and in this sense there was a clash between Berlusconi and the intellectual world. But Italy is not an intellectual country. On the subway in Tokyo everybody reads. In Italy, they don't. Don't evaluate Italy from the fact that it produced Raphael and Michelangelo."

It happened to me as it happens to people when they fall in love. 'Why did you fall in love that day, that month, with that person? Are you crazy? Why?' You don't know. It happens."

Life, like fiction, is a wonderful game.

He has called books "the corridors of the mind"

The fact that he can accommodate everything from illuminated manuscripts to iPads is typical. He is optimistic, eclectic, eternally young, interested in everything, as at home discoursing on Peanuts as he is on Proust. I ask him how he will be remembered – as novelist, critic or polymath? "I leave it up to you," he says. "Usually a novelist has a longer-lasting life than an academic, unless you are Immanuel Kant or John Locke. Illustrious thinkers of 50 years ago have already been forgotten."

So is he resigned to being remembered for The Name of the Rose rather than his contribution to semiotics? "At the beginning," he says, "I had the impression that my novels had nothing to do with my academic interests. Then I discovered that critics found many connections, and the editors of the Library of Living Philosophers decided that my novels had to be taken into account as a philosophical contribution. So I surrender. I accept the idea that they match. Evidently I am not a schizophrenic."

In the name of ROSE

source: theguardian

Diakah yang mengakui?
Dan percaya?

Diakah yang mencintai?
Atau hanya sekedar memiliki?

Bilakah dia hanya mengakui tanpa percaya?
Dan memiliki tanpa mencinta?

German:
Adidas, Aigner, Braun Büffel, Hugo Boss, Escada, Jil Sander, JOOP, Marc O'Polo, Puma, Tom Tailor
Mercedes, BMW Mini, VW, Porsche, Audi
Rodenstock,

France:
LV, Hermes,
Promod

Spain:
Zara, Mango, Desigual

US:
Nike, GAP, Levi's, Esprit
Chanel,

Swiss:
Rolex, Tissot,

Italy:
Armani, Gucci, Prada, Miu-miu

Turkey:
Kilims

The Year's Best Medical Practice Management Tips: 2011 by Leslie Kane, MA

Savvy Strategies to Consider

Medical practices are going through seismic changes, and physicians are looking for ways to increase revenue or lower costs. There are many tactics that address the myriad ways to do both of those: by changing practice strategy; adding services; solving patient-flow and workflow problems that have been ignored; and focusing more on getting money that is owed to you.

Throughout the year, Medscape has offered expert advice on ways to build a more successful practice. Here are some of the tips that physician readers found most helpful.

1. Offer Your Patients One-Stop Shopping

For your patients' convenience, do everything possible in-house: Draw blood, conduct urinalyses and stool guaiac tests, and so forth on your own. You should be able to bill for these items, and your patients won't have to wait at an outside lab to get the services that they need.

When your patients need outpatient procedures that you cannot offer in-house, help them schedule appointments while they are in your office so that they won't have to hassle with the bureaucracy. Make their lives easier and they will reward you for it.

2. Get New Patients by Creating a Niche

You'll go broke if you wait for sick patients to walk through the door. There aren't enough of them to go around. Consider doing wellness medicine, which widens the scope of potential patients to include everyone.

Develop a subspecialty such as in dermatology, thyroid disorders, diabetes, or geriatrics. Get into occupational health -- pre-employment physicals, drivers' physicals, flight physicals, workers' compensation for minor injuries, drug screening, etc -- and advertise that you offer these services. A river of money may run by lawyers, but it doesn't run by physicians. We have only rivulets, but add them up and you will have a mighty stream.

3. Avoid Gaps in the Schedule Due to No-Shows

Start with the basics: Have a no-show policy that charges patients either for the first or the second no-show appointment. It may be difficult to collect, but if patients wish to return to the practice, collect it via credit card when booking an appointment. Communicate the no-show policy to patients.

Confirm all new patient visits 36 hours prior to the visit. If a patient cancels, that gives the practice time to fill the slot. Develop a cancellation list of patients who want to be seen sooner, and call them for cancellations. Track no-show patient characteristics. Are they emergency department referrals? Follow-ups? Is the no-show rate so high that the group needs to book extra patients to keep gaps from the schedule?

Monitor the number of no-shows at baseline, implement changes, and set a goal that reduces the number. Graph your progress, and involve all staff members in meeting this goal.

Bringing in Payment and Revenue

4. Try to Get Paid on the Basis of RVUs Rather Than Collections, if You're in a Hospital or Large Group

Many hospital billing services are really bad. Relative-value units (RVUs) are directly tied to the coding. It's a better measure of patient acuity than collections, and it eliminates contractual discounts.

One problem for doctors starting a new job is that they may not get a productivity bonus in the first year if their incentive is based on collections that are measured annually. Because there's typically a 3-month lag before their charges are collected, the extra revenue that they generated through hard work won't show up in the first year.

In contrast, they can get a productivity bonus in the first year if they're rewarded for hitting RVU targets, notes Tommy Bohannon, Senior Director of Recruiting and Development Training for Merritt Hawkins & Associates in Dallas, Texas.

If a hospital or group includes quality metrics in its payment calculation, that will usually constitute about 10% of compensation. Sometimes a contract will specify that various percentages of the potential productivity bonus be paid to doctors, depending on how well they score on the quality measures.

Intangible factors may account for another 10%. Among those factors are patient satisfaction, participating in committees, doing community service or community education, and public speaking, he says. In some cases,physicians who work harder and see more patients can earn more than those who spend a lot of time being good citizens.

5. Make Sure That All Physicians Are Pulling Their Own Weight, and Deal With Those Who Aren't

Though a daunting prospect, you must have a frank discussion with the physicians who are dodging a share of the duties, regardless of seniority. "The senior doctor shouldn't carry more weight than the other partners. We should all be even stakeholders who are looking out for the common good of the practice," says Practice Management Expert Judy Capko, of Capko & Company, in Thousand Oaks, California.

Advance preparation is essential. "There's a certain baseline cost for carrying a doctor, whether 10 or 20 patients are being seen. You need to gather a lot of data to see what the financial impact of this physician's routine is on the practice," Capko says. Determine what you need an underperforming physician to do; discuss the best way to lay out your position; and present it as a united group.

The group spokesman should be someone who this physician greatly respects. Although some practices engage a management consultant as a facilitator, "you have a much better chance of succeeding if a physician expresses the group's viewpoint than if the consultant is given the role of dealing with this. Otherwise, the doctor who feels challenged is just going to attack the consultant. He or she is not going to see that the doctors agree with that consultant unless that's voiced," Capko says.

Steer the discussion away from the physician's behavior and focus on the long-term health of the practice. Capko recommends: "You have been the foundation of this practice. We owe you a lot, but this practice -- your practice -- is struggling with some issues, and we need to address these for the future." Then you can delineate your concerns.

How to Be More Money Smart

6. Get Payment Even if Your Patient's Check Bounces

Your practice's financial policy needs to include your policy on bounced checks and what steps the practice will take to recover that payment. If there are bank charges, stipulate that the patient will be charged for those fees. If you're in a state that allows you to collect a processing fee above the bank charges, that needs to be stipulated in the financial policy that a patient signs.

For example, in Illinois the value of what can be collected is 3 times the face value of the check plus court costs if litigated. In North Carolina it is the cash amount of the check, bank fees, plus $35 for the handling fees. In Florida, you're only allowed to charge $20 above the check value and bank fees. The National Check Fraud Center lists the bad-check laws for each state. It is helpful to publish or reference the consumer credit laws in your financial policy. These simple steps will keep everyone on the same page and establish the financial component of the medical care relationship.

Successful practices will make every method available for patients to pay bills. Cash, checks, postdated checks, credit cards, debit cards, and online services such as PayPal are all viable means for patients to settle their debts. Postdated checks are a good collection tool unless they bounce. Postdated checks are considered "promissory notes" rather than checks unless they are truly held until the date written on the check by the debtor before deposit.

Consider using a check-scanning system from a company that guarantees the check if it clears. This will protect the practice as well. The monies are immediately deposited into your practice's bank account without the added burden of a trip to the bank.

Almost all of these payment methods have some amount of service fee attached to them. However, the fees paid are a small price to pay for the general practice's cash flow. The smart practice will shop around for the bank with the best small-business service package available or will look to build a hybrid system with a couple of different vendors for the various services needed. No matter how you build your financial recovery process, you're wise tomake as many methods available as possible as long as those methods protect the practice.

7. Be Money Smart When You Move to an EHR

Take a closer look at application service provider (ASP) technology. ASP technology means that the electronic health record (EHR) program and data are housed securely at a vendor's or an institution's location; you don't need to have expensive servers and tech support in your office if you have high-speed Internet access.

The ASP EHR model will range from about $350 to $650 per month, plus training. Billing software will be an additional cost. The other option is buying an EHR that requires an in-house server and software. Systems like this that I reviewed averaged between $40,000 and $60,000 depending on the amount of bells and whistles added.

With ASP models, benefit changes and software improvements are continually updated on your site so that your practice is always using the most recent data and advanced software. You don't need proprietary hardware or additional servers. You do not need to house your own server, and many systems have a minimal cost up front. You also will be able to log in from home to view patient data and reports.

The downside to ASP technology is that when the Internet is down, so are you. Make sure that you have good, stable Internet service before considering this option.

Be Alert about Contracts and Reinbursement

8. Think About a Professional Services Agreement if You're Considering Employment

Professional services agreements (PSAs) have been around for many years but are now growing in popularity. Physicians may view a PSA as a way to get the advantages of employment without selling their practices, and hospitals see it as a mechanism for controlling doctors without employing them directly.

"In a PSA, the physicians maintain their own professional corporation," explains Alice Gosfield, a Philadelphia, Pennsylvania, healthcare attorney. "The physicians assign the right to payment to the hospital; the hospital bills for them; and the physicians receive a base salary, usually with productivity bonuses. In more and more PSAs, the physicians also get bonuses that are based on quality metrics."

Despite doctors' retention of practice ownership, Gray Tuttle, a practice management consultant in Lansing, Michigan, says that a PSA "is very similar to an employment relationship. The end results financially are close to identical. The difference is that the physicians are employed by a practice that they own. Typically the hospital will employ everybody else including the receptionists, nurses, and technicians. The providers -- physicians and even midlevels -- retain their relationship with the professional corporation."

The physicians still own the practice assets including ancillary services, which, notes Tuttle, they lease to the hospital. The hospital must factor revenues from those ancillaries into the amount that it agrees to pay the physicians or the doctors won't sign up, he adds.

"Typically the hospitals provide reasonably long guarantees with no pay cuts and, in many cases, enhanced reimbursement," says Tuttle, adding that the guarantees may last up to 5 years for specialists and 3 years for primary care doctors.

One reason why PSA reimbursement may be higher than what the doctors previously earned is that the hospital can often negotiate higher rates than most practices could on their own. In addition, some hospitals will pay doctors extra for quality and efficiency.

9. Be Aware of Which Aspects of Prevention Care Are Now Reimbursed

The Patient Protection and Affordable Care Act has given physicians new tools to offer patients easier access to preventive care. Starting in January 2012, Medicare will eliminate its Part B deductible and copayments for a host of proven preventive services including bone mass measurement; some cancer screenings; diabetes and cholesterol tests; and flu, pneumonia, and hepatitis B vaccinations -- among other services.

Medicare now covers annual wellness visits. It covers smoking cessation counseling. It began paying a 50% rebate for the brand-name medications that seniors need to manage chronic conditions when they reach the coverage gap known as the "doughnut hole."

Your patients in new private insurance plans also won't pay out of pocket for many preventive services including screening blood pressure, diabetes, cholesterol, and for certain cancer screenings; counseling to quit smoking or cut alcohol consumption; routine vaccinations; and regular well-baby and well-child visits from birth to 21 years of age.

The Centers for Medicare & Medicaid Services is working to make sure that you and your patients have the support that you need to achieve better health. Our investment in prevention takes a big step in that direction. If you or your patients are looking for more detailed information, go to healthcare.gov and click on "Learn About Prevention" at the top.

Avoid Billing Lags with ICD-10

10. Prepare for IDC-10 So That You Won't Have Billing Lags and Mistakes When It Is Live

In 2012, talk to vendors. Confirm again that you are on the most up-to-date version of your office coding software and that your vendor will be ready. Confirm that the system can handle both code sets at once and can flip the switch overnight. Confirm that the vendor can move from diagnosis codes that were 3-5 digits in length to codes that will be 3-7 digits in length.

Nonclinical coders in your office should take medical terminology and anatomy and physiology courses. This is the year to lay a solid clinical foundation. There are online courses and community college courses. Maybe your local hospital would sponsor courses for physician staff members.

Practice using the International Classification of Diseases, Tenth Revision (ICD-10). Every month, print out a list of 15 more diagnosis codes for each clinician and try to code them. Keep a list of those that are causing questions and problems. Re-educate clinicians about the detail that is required in their documentation for specific conditions and symptoms that they treat. Expand the focus of practicing. Look up codes that clinicians use less frequently.

Train the trainer. At what point in the year you train the trainer (or trainers) in 2012 will depend on the size of your group. In a small group, it might be prudent to wait until the end of the year. If you are a large, multispecialty group, begin earlier. Some large, multispecialty groups may be planning this step for 2011.

Review encounter forms or electronic charging documents. With the increase in codes, it is less likely that a paper encounter form will work for most practices. There will be too many codes. The favorites list in an electronic charging system will need to be updated for each clinician.

Thanks to MedscapeBusiness

Disaster Medicine by Prof.Aryono

Penanggulangan bencana / korban masal harus dilakukan secara ilmiah. Penanggulangan ini tidak cukup dengan Medical Support  saja seperti  penanggulangan secara ilmu bedah & ilmu kedokteran lainnya saja, tetapi harus ditunjang dengan Management Support yang  baik. Ini dapat terlaksana bila kita ada persiapan / preparedness, mitigasi, latihan dan penanggulangan gawat darurat yang sehari – hari yang baik.

 Pada saat ini dikenal UTSTEIN STYLE yang merupakan THE LANGUAGE OF DISASTER. Yang merupakan structured approach to disaster research, evaluation and management of disasters. Ada beberapa istilah yang perlu kita sepakati ;

BENCANA : suatu kejadian yang menyebabkan / menimbulkan kesusahan, kerugian dan penderitaan. KORBAN MASAL / Mass Casualties : Keadaan di mana jumlah korban melebihi kemampuan fasilitas medis yang ada. Istilah yang sekarang dipakai adalah MAJOR INCIDENT : Semua kejadian yang melibatkan manusia di mana lokasi, jumlah korban, beratnya cedera dan tipe korban memerlukan sarana kesehatan yang di luar kebiasaan. Major Incident dapat berupa : 1. NATURAL / ALAM DAN MAN MADE / ULAH MANUSIA yang melibatkan jumlah manusia (Mass Gathering) seperti pada gempa, banjir, api, Kecelakaan Lalu Lintas (KLL), olah raga, demo, Hazardeous Material (HAZMAT) / Nuklir, Biologi dan Kimia (NUBIKA) dll. 2. Simple Major Incident (infrastruktur intak), 3. Compound Major Incident (Infrastruktur rusak ), 4. Compensated Major Incident (Dapat diatasi dengan eskalasi Sistim Penanggulangan Gawat Darurat (SPGDT) sehari – hari. 5. Uncompensated Major Incident di mana sistim kolaps seperti WTC 9/11, Bom Bali Gempa & Tsunami Aceh dan Gempa Jogyakarta.

Di INDONESIA pola penanggulangan bencana mengalami perubahan dalam 4 fase :

I.             Fase 1970 -1995, dengan apa adanya

II.           Fase 1995 – 2000, dipengaruhi oleh introduksi ATLS, SPGDT dan dibentuknya AGD 118 oleh IKABI.

III.          2000 – 2007, dipengaruhi oleh pencanangan Konsep Safe Community dan kursus Hospital Preparedness for Emergencies & Disasters (HOPE) oleh IKABI, PERSI dan DEPKES. Selain itu Kolegium Ilmu Bedah memulai kursus – kursus Basic Skill for Surgeons (BSS), Definitive Surgery for Trauma Care (DSTC) – Damage Control Surgery (Stop Bleeding & Contamination) dan Triad of Death (Hipotermi, koagulopati, asidosis tidak terkontrol) – Compartment Syndrome dan Peri Operative Critical Care)

IV.          2007 - .... IKABI, PERSI dan DEPKES sepakat mengembangkan   Local Capacity Building untuk 33 propinsi sehingga setiap propinsi mampu YO YO 24 – 48 hrs (You are On Your Own for 24 – 48 hours) dengan meningkatkan kemampuan penanggulangan GADAR sehari – hari.

Dalam Penanggulangan Bencana / Korban Masal, yang harus dicapai adalah Order in Chaos (IKABI). Di Aceh masalahnya adalah terlalu banyak mayat yang terlantar dan masyarakat tidak dapat sholat jumat d masjid. Sedangkan di Jogyakarta masalahnya adalah terlalu banyak pasien yang tidak dapat dilakukan triage.

Dalam rangka mencapai Order in Chaos, IKABI telah melakukan :

1. 1995 mengadopsi ATLS di Indonesia
2. 1997 mencanangkan SPGDT sebagai suatu sistim yang dapat dilaksanakan di Indonesia dengan kata kunci TERPADU, yaitu memanfaatkan apa yang ada.
3. 2000 mencanangkan Safe Community bersama Depkes di Makassar, di mana kita harus dapat menjamin di manapun kita berada, kita aman.
4. 2003 IKABI mulai mengadakan kursus HOPE bekerjasama dengan PERSI & Depkes. Kursus HOPE merupakan gabungan dari MIMMS, HEICS dan SPGDT. Kursus ini disusun bersama oleh anggota IKABI dari Indonesia, Pilipina, India dan Nepal dengan sponsor dari USAID. Dalam HOPE ditekankan pada masalah Risk Assessment & Risk Managenent, Structural Collapse & Functional Collapse dari Rumah Sakit (RS), Management Support & Medical Support, Command & Control terutama Horizontal Control antara Security (Polisi), Rescue (Dinas Kebakaran) dan AGD 118. Dengan tujuan akhir : The Right Patient To The Right Hospital By The Right Ambulance At The Right Time.

Masalah GADAR dan penanggulangan bencana, tidak mungkin dapat diselesaikan oleh IKABI sendiri. Karena itu diadakan kerjasama dengan PERSI, DEPKES dan instansi lain yang terkait. IKABI, PERSI dan DEPKES sepaham bahwa :

1. Tidak mungkin kita dapat menanggulangi bencana / korban masal dengan baik , bila penanggulangan GADAR kita sehari – hari buruk. Dan penanggulangan GADAR sehari – hari kita memang tidak memadai.
2. Jumlah sarana kesehatan di  Indonesia berupa Rumah Sakit / UGD, Puskesmas / UGD dan Ambulans jumlahnya memadai dibanding dengan jumlah penduduknya, tetapi tidak terkoordinasi dan tidak terlatih.
3. Organisasi Profesi Kedokteran seperti IKABI mempunyai kursus – kursus Post Graduate yang berstandar internasional.
4. SPGDT, AGD / AGDT / BLUD 118 dan Safe Community dapat kita capai dengan melatih orang awam (BLS), polisi, dinas kebakaran (MFR & CSSR), paramedik AGD 118, Emergency Nurse (BTLS, BCLS, BNLS, BPLS & Disaster Management), Emergency Physician (ATLS, ACLS, ANLS, APLS & Disaster Management), Trauma Surgeon / Konsultan Trauma (ATLS, BSS, DSTC, Peri Op CC & Disaster Management) dan Manajemen RS (HOPE) dengan kursus – kursus tersebut.
5. Setiap Kota, Kabupaten dan Propinsi harus mampu menanggulangi Bencana / Korban Masal secara mandiri (YO YO 24 – 48 Hrs, You are on Your Own for 24 – 48 hrs) dengan meningkatkan kemampuan penanggulangan GADAR sehari – hari.
6. Direktur RS adalah Agent of Change dalam mengembangkan Safe Community dan YO YO 24 – 48 hrs, karena IKABI telah melatih lebih dari 15.000 dokter dalam ATLS, PERKI lebih 8.000 dokter dalam ACLS dan Yayasan AGD 118 lbih dari 10.000 perawat dalam BTCLS, tetapi tidak terjadi perubahan yang signifikan karena pemilik UGD & Ambulans adalah direktur RS.

Disaster Medicine merupakan gabungan dari Ilmu Bedah – Ilmu Kedokteran lainnya dan Ilmu manajemen.

Pada Language of Disaster dari Utstein Style menggambarkan masalah yang dihadi dari adanya Hazard samapai terjadinya bencana / korban masal. Disini tampak bahwa kita dapat melakukan penelitian, evaluasi dan penanggulangan bencana yang terstruktur. Selain itu juga tampak bagai mana mencegah, memodifikasi dampaknya dari segi manajemen maupun dari segi ilmu bedah / kedokteran.

Hazard dapat diubah sedemikian rupa sehingga tidak terjadi event (kejadian). Dan event (kejadian) meskipun terjadi dapat dicegah terjadinya damage (kerusakan) bila absorbing capacity (kemampuan menahan) nya dapat ditingkatkan. Sedangkan damage (kerusakan) dapat dicegah menjadi disaster (bencana) bila buffering capacity (kemampuan menyagga / menahan) nya ditingkatkan. Demikian juga dengan local response (respons SPGDT – AGD / AGDT /BLUD 118) berfungsi dengan baik pada fase pra RS maupun fase RS / UGD (YO YO 24 – 46 hrs). Dan bila tidak mampu, bantuan dari luar dapat berfungsi dengan baik / tidak.

Jadi dalam penanggulangan bencana / korban masal yang penting adalah Resilience (ketahanan – kemampuan bertahan) yang merupakan Absorbing Capacity, Buffering Capacity & Local – Outside Response. Mengembangkan Resilience dari suatu Kota, Kabupaten dan Propinsi bahkan suatu RS di Indonesia dapat dilakukan dengan mengembangkan Safe Community, SPGDT dan AGD / AGDT / BLUD 118dengan Disaster Plan nya masing - masing.  Dengan demikian dalam GADAR sehari – hari maupun bencana / korban masal setiap kota, kabupaten dan propinsi akan siap menanggulangi sendiri.

Dalam penanggulangan bencana / korban masal selalu ada masalah manajemen dan masalah medik. Masalah manajen diselesaikan dengan Management Support. Management Support sebaiknya dipimpin oleh seorang Incident Commander yang menguasai ilmu manajemen bencana maupun ilmu bedah / kedokteran GADAR & bencana / korban masal. Incident Commander dibantu oleh :

Bagian Operasional yang melaksanakan penanggulangan bencana / korban masal dari segi Security, Rescue, Medik (AGD 118, RS Lapangan dan fase RS) dan Identifikasi yang meninggal.

1. Bagian Logistik yang menujang kebutuhan Bagian Operasional dalam bidang Security, Rescue, Medik (Alkes, SDM, Air Minum, Makanan, Listrik, Komunikasi dll).
2. Bagian Keuangan yang menunjang kebutuhan Bagian Logistik.
3. Bagian Planning (Perencanaan) yang dalam keadaan sehari – hari membuat Disaster Plan, Sosialisasi, Latihan. Dalam keadaan bencana / korban masal, bagian ini melakukan data collection, data analysis, yang diperlukan Incident Commander untuk mengambil keputusan dan dilanjutkan dengan evaluasi. Data yang dikoleksi adalah :
   1. Jumlah pasien,
   2. Laki – laki, wanita, anak / umur
   3. Jenis cedera, tindakannya & angka infeksi
   4. Penyakit menular & jenisnya
   5. Pasien dirujuk, kemana
   6. Meninggal, sebab kematian dan dimana meninggalnya
   7. Identifikasi yang meninggal

Tindakan Bedah / Kedokteran yang dilakukan adalah sesuai dengan yang kita pelajari dari :

1.    ATLS è A, B, C, D, E & Traige

2.    BSS è Jahit menjahit, debridemen & fiksasi eksternal

3.   DSTC è Damage Control Surgery (Stop Bleeding & Stop Contamination),Triad of Death (hipotermi, koagulopati dan asidosis yang tdak terkontrol) & Compartment Syndrome.

4.    Peri Operative Critical Care è Total Care

Refference :

1. Pusponegoro A.D. Grand Design Penanggulangan Bencana. Editor : Pusponegoro A.D, Paturusi I. Proceedings Konferensi Penanggulangan Bencana. Bandung : Depkes. 2007 : 1-12
2. Sundnes K.O, Birnbaum M.L, Fisher J.M. Pre Conference Workshop 8th Asia Pacific Disaster Medicine Conference. Editor : Yamamoto Y. Proceedings 8th Asia Pacific Disaster Medicine Conference. Tokyo : Asia Pacific Disaster medicine. 20th November 2006 : 1- 18
3. Pusponegoro Ad, Boen T, Herbosa T, Shresta R. Hospital preparedness For Emergencies and Disasters (HOPE). Jakarta : IKABI, 2000
4. Skinner I. Basic Surgical Skill Manual. Sydney : McGraw Hill, 2000
5. Advanced Trauma Life Support (ATLS) for Doctors. 7th Edition. Chicago : American College of Surgeons, 2004.
6. Definitive Surgery for Trauma Care (DSTC). Ed. Surarso, Pusponegoro A.D. Jakarta : Kolegium Ilmu Bedah Indonesia, 2000.
7. Peri Operative Critical Care. Ed. Surarso, Pusponegoro A.D. Jakarta : Kolegium Ilmu Bedah Indonesia,2003.

Culinary curiousity

Thinking that high class culinary adventure is much more interesting not in a big and world city but in small town with its unique culture.

Mikul dhuwur mendem jero rame ing gawe ngerti ing pamrih

Ngurmati sing tuwo, sregep nyambut gawe

Unwritten, unspoken and another without-words language

To the astute observer, artists speak eloquently of themselves in pictorial language, just as writers speak in word language and composers in the language of musical sounds. In every case, the work reflects the person.

Children are able to convey in their drawings thoughts and feelings they cannot possibly express in speech or writing. They simply do not have the words with which to do it, and like our ancient ancestors, must learn to draw  before they learn to write.

Drawing communication, is elemental and basic, also universal, can across any existing language barrier with the greatest of ease.

A wise, compassioate man in charge of one of the many preschool orphanages makes drawing a routine activity for the youngsters.

Drawing speaks louder than words.

From: Children Draw And Tell: An Introduction To The Projective Uses Of Children's Human Figure Drawing.

http://www.amazon.com/s?ie=UTF8&rh=n%3A283155%2Ck%3ADie%20Entwicklung%20der%20zeichnerischen%20Begabung&page=1

http://www.schroedel.de/kunstportal/bilder/forum/2010-10-miller.pdf

Teaching Visual Culture: Curriculum, Aesthetics, and the Social Life of Art.

While there is a super-wealthy, corrupt upper class, the rest of the country remains poor.


"Some students complain about having to learn a lot of material quickly and then regurgitate it soon thereafter during exams," she says, referring to this situation as "academic bulimia."

It's better to be single and happy rather than to be with someone who does nothing while you're doing everything.

Joining Your First Practice: Avoiding the Most Common Errors

Expert Outlines What To Look for, What To Consider When Signing a Contract
By Christina Frangou

This year, about 1,000 new general surgeons are expected to enter the workforce. That’s about 1,000 new contracts that will be signed for the first time.
These contracts can set the course for a surgeon’s career and life outside work. Yet, they often contain major issues and errors, says Scott Ransom, DO, MBA, MPH, FACS, president of the University of North Texas (UNT) Health Science Center, Fort Worth.
“I daresay that half the physicians I deal with blunder through that first contract in a major way with life-altering consequences,” said Dr. Ransom.
Dr. Ransom has spent many years working with young physicians and health care recruiters. In that time, he’s seen many physicians make mistakes by signing contracts that they have not reviewed thoroughly.
Take this example: In 1994, a new OB/GYN joined a practice in a small town in Georgia. The doctor was offered a $300,000 first-year salary with no income guarantee beyond the first year, an impressive salary for a young doctor with significant student loans.
Just one year later, however, the physician realized that the job wasn’t working out and he wanted to leave. He had been recruited with a claims-made malpractice insurance policy, which did not cover any claims made after he left the practice. He sought tail coverage to cover him for any claims that might come up in future. The cost, $125,000, to be paid in cash.
“That wasn’t a very good thing when he was trying to pay off more than $100,000 in school loans,” said Dr. Ransom.
Such errors are not uncommon, according to Dr. Ransom.
Trainees spend years in medical school, residency and fellowship sharpening their clinical skills. But few programs provide the business and management skills needed for things like contract negotiation and setting up a practice.
With recruiting season kicking into high gear over the next few months, General Surgery Newsput together an edited summary of a speech Dr. Ransom made at the 2010 Clinical Congress of the American College of Surgeons, held in Washington, D.C., in which he outlined practical tips for young surgeons looking to enter their first practice.


Knowing the Goals: Key First Step
The first step is to establish your short- and long-term goals. “That’s absolutely critical,” said Dr. Ransom.
That means goals in every aspect of life. How important is research, teaching, location, family? Is it important to you to leave at 4 in the afternoon or walk your kids to school? Do you want to be on the forefront of minimally invasive procedures?
Have an open discussion with your significant other, too, about his or her needs and interests. Family concerns are among the top reasons that physicians leave their practice. A 2006 analysis from the Cejka Search and the American Medical Group Association’s Physician Retention Survey showed that of physicians who voluntarily resigned from their practice, 14% cited spousal issues and another 21% said they wanted to change location, often for family reasons. (The most common reasons for leaving were practice issues, at 44%, and compensation, at 21%.)
Consider, too, the hospital amenities that are important to you. If you’ve trained in robotic surgery, is that something you want to pursue in your own practice? Do you want a dedicated minimally invasive suite?
It’s important to assess your goals for call schedules outside of the 80-hour workweek mentality, said Dr. Ransom. Younger surgeons who sign on with senior partners are often expected to take on extra call shifts, which can help build their own practice. But remember that no mandatory rest periods exist for practicing surgeons after a busy night’s call. And so, surgeons must evaluate their tolerance for night call both in the short and long term.
“Those things might seem obvious if you already practice, but they don’t always seem so clear in the initial part of the recruiting process.”


Know What You’re Getting Into
Surgeons often only look at what they want from an organization. However, ask why a practice wants to hire you. They may be seeking a surgeon who is willing to work extra hours, who will work all holidays. They might want someone who can perform new minimally invasive techniques or someone who won’t rock the boat. Critically evaluate the organization and the surgeons there by looking at things like financial status, long-term goals, employee turnover and patient population. Find out about the quality of the practice, risk management and state licensing issues.
“Who are you joining? This is something that’s absolutely critical to ask. Is this the best practice in town or the worst practice in town? Is there a huge malpractice risk component to that practice? That’s something you can look up easily online and certainly ask.”
The best sources of reputational information are often residents, the operating room staff and office/hospital staff. “These are all folks who could give you some pretty good insight as to the reputation of a surgeon or a surgeon’s group in practice.
“You yourself might have the greatest reputation in residency, but if you join the wrong practice, your reputation might be ruined permanently and you might be overlooked for that next new job.”


Contract Considerations
When you decide that a practice is the right fit, only sign a contract that is reviewed by a lawyer who specializes in physician agreements.
Contracts should outline precisely what your responsibilities will be and what the organization’s responsibilities will be. Issues and expectations like malpractice, vacation, continuing medical education (CME), travel and professional expenses, plus call coverage and pregnancy leave should be dealt with up front and included in the agreement. Confirm whether there is financial support for licensure, CME and professional dues. And, importantly, every contract should clearly define the salary, including potential bonuses and targets. Ideally, the contract will also outline or incorporate the organization’s process for becoming an equity partner in the practice.
Most contracts will include a restrictive covenant, one of the most frequent sources of frustration for physicians who desire to leave a practice, said Dr. Ransom. A restrictive covenant is a contractual provision between a physician and his or her employer, that prevents the physician from practicing in his or her specialty in a specified geographic area for a given time after a physician’s employment terminates. These clauses help the practice shield its existing patient base and protect employers’ investment in a new physician employee. According to the American Medical Association, most practices use a mileage radius that covers 80% of the patient practice base as the scope of its geographic restriction.
“Know your restrictive covenant and look practically at how it might impact you if the practice situation does not work out as expected,” advised Dr. Ransom.

How To Determine the Best Practice For You Establish your short- and long-term goals. Weigh the importance of research, teaching, location, family, etc. A 2006 study showed that the most common reasons for leaving were practice issues (44%), compensation (21%), and spousal issues (14%). Know what areas you want to focus on. For instance, do you want to be on the forefront of minimally invasive procedures? Assess your goals for call schedules outside of the 80-hour workweek. Critically evaluate the organization and the surgeons at a practice before joining. Look at things like financial status, long-term goals, employee turnover and patient population, and find out about the quality of the practice, risk management and state licensing issues. When you decide that a practice is the right fit, only sign a contract that is reviewed by a lawyer who specializes in physician agreements. Approach the contract as if you will leave the practice in two or three years. Studies show that 44% to 70% of new physicians and new surgeons will move from their first practice within three years.

UNT Health Science Center employs about 250 clinical providers and its restrictive covenant covers five miles from any practice site in the network.
“That sounds like a pretty limited distance until you realize that we have 30 practice sites. That represents almost the entire county. Our contract stipulates you can’t practice for a year in the area without paying the contractually outlined costs equating to the up-front practice expenses for starting the new physician’s practice until the group has had an opportunity to recoup these costs. That’s protecting our interests while recruiting new physicians.”
Approach the contract as if you will leave the practice in two or three years, Dr. Ransom suggested. Studies show that 44% to 70% of new physicians and new surgeons will move from their first practice within three years. Issues that seem minor in the beginning, like a restrictive covenant or malpractice coverage that does not include a tail, can make leaving very difficult.
Keep that in mind, too, when buying a house. It’s best to wait for a year or two before making a major home investment, particularly with the ongoing slump in the housing market.
“If you buy a big house right away, you could be stuck for a long time,” he said. Instead, look for an adequate house or apartment to rent for the first year.
And as soon as the contract is signed, apply for state licensure and hospital privileges. “These things can take up to six months or even a year.”
Ultimately, he said, you’ve worked very hard to earn the privilege of being considered for all of these practice opportunities.
“There are a lot of great opportunities out there. Look at the big picture and make sure that you identify the right practice for you.”

SOURCE:  http://www.generalsurgerynews.com