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For loved Thomas’s loved ones who are unable to attend his Funeral Mass in person the Mass will be live streamed on Monday, April 11th starting at 10:30 AM please click on the link: https://www.youtube.com/user/Stroseshorthills Thomas H. O'Connor, 88, of New Providence, NJ, passed away at his home on Thursday, April 7, 2022. Relatives and friends are invited to attend the Funeral Mass at St. Rose of Lima Church, 50 Short Hills Avenue, Short Hills, on Monday April 11th at 10:30 AM. Interment to follow at Gate of Heaven Cemetery, East Hanover. Visitation will be held at The Jacob A. Holle Funeral Home, 2122 Millburn Avenue, Maplewood, NJ on Sunday April 10th from 2:00-6:00 PM. In Lieu of flowers, donations to Bishop Loughlin Memorial High School, 357 Clermont Ave, Brooklyn, NY 11238, www.loughlin.org or New Eyes for the Needy, 549 Millburn Ave, Short Hills NJ 07078, www.new-eyes.org would be appreciated. For more information or to send condolences please visit jacobhollefuneralhome.com. Thomas was born in Brooklyn, NY and had lived in Elmont, NY and Short Hills before moving to New Providence for the last 6 years. A proud graduate from Bishop Loughlin High School, he graduated from NYU in 1962 and worked for AT&T in NYC and Basking Ridge for 42 years. Thomas also proudly served our country from 1954 to 1956 in the US Army. Tom was an avid reader who enjoyed listening to classical music, playing Rummikub and eating at all the best restaurants in the local communities. On weekends, Tom had front row seats to watch his grandchildren play basketball, baseball, softball, lacrosse and field hockey. Thomas was a volunteer at New Eyes for the Needy in Short Hills, and a member of AT&T Pioneer Club for many years. The son of John and Mary Conroy O’Connor, brother to Mary Cadley. Thomas is predeceased by his beloved wife Mary Anne Haas O'Connor. He is survived his children Barbara Belliss (Steven), Gerard O'Connor (Jackie), Kathleen Boehm (Robert) and Ellen Kirkwood (Eugene), his grandchildren Michael, Christopher, Elizabeth, Ashley, Sarah, Emily, Thomas, Meaghan, Molly, Brighid, Connor and Ryan, and his great-grandchildren Everett, Calvin, Adeline, Nolan, Riley, and Madden.

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2022-05-20T22:50:59Z

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This is a Naira denominated debit card issued in partnership with MasterCard Worldwide. It is denominated in Naira, but can also be used to settle purchases in other major currencies. It is accepted worldwide as a means of payment for goods and services at millions of merchant locations and over 2.1 million ATMs in more than 270 countries. The Jaiz bank MasterCard card is linked online, real-time to your Current or Savings account; all transactions done using this card are reflected on the account instantly. Jaiz Bank Mastercard shall be available for issuance to customers starting December 1st, 2016.

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2022-05-21T00:00:09Z

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SUMBAWA, JALANJALANAJA- Komodo Island is an island located in the Nusa Tenggara Islands, east of Sumbawa Island, which is separated by the Sape Strait. Komodo Island is known as the original habitat for Komodo dragons. This island is one of the Komodo National Park areas managed by the Central Government. Komodo National Park consists of 3 large islands, Komodo Island, Rinca Island, and Padar Island, as well as other smaller islands. The total area of this national park is 1,817 km2. Komodo Island is located at the westernmost tip of East Nusa Tenggara Province. On the island of Komodo, Komodo dragons live and breed well, according to data, until mid-2009, the island is inhabited by about 1300 komodo dragons (+/- 2500 in all islands in TM. Komodo). Komodo is the largest lizard species in the world, with an average length of 2-3 meters, and a body weight of at least 90 kg. In the Komodo National Park area, you can also find horses, wild bulls, deer, male wild boars, snakes, monkeys, and various types of birds. In addition, Komodo National Park has amazing underwater biota. Divers say that the waters of Komodo are one of the best dive sites in the world. Route to Komodo Island If you come from Jakarta, you must transit in Bali first. From Bali, the journey continues to Labuan Bajo, a small town in the northwest of Flores which is the gateway to Komodo Island. There are several airlines that serve the Denpasar-Labuan Bajo route, with a travel time of about half an hour. Price of admission Tourists who come to this attraction do not need to spend a lot of money on tickets. Because the ticket price is very cheap. There is an additional guide fee that must be used. domestic tourists only pay 5000 rupiah, while foreign tourists pay 150,000 rupiah An additional fee of 80,000 for a Komodo tour guide, because every tourist must be accompanied by a guide. This is for the safety and security of tourists. Variety of Tourist Activities Including Komodo National Park, connected with Labuan Bajo via flights and live aboards. Tourist visits were recorded at 176,830 people with 60% being foreign tourists. The main tourist activity is to see the Komodo dragon directly physically. Sea turtles in large numbers, colorful coral reefs are also increasingly enlivening its natural wealth. Tourists can also enjoy the beach, diving, snorkeling, or climbing hills with amazing views. - Boat Tours to Komodo Island Labuhan Bajo is the initial pier to Komodo Island and a series of islands around it. At this pier there are many speed boats with various types of boats and prices. The distance from Labuan Bajo to Komodo National Park is about 3 hours by boat. - Nature Tours and Seeing Komodo Dragons Live The main activity in this tourist attraction is of course seeing the physical Komodo dragon, the pride of Indonesia's ancient animals. Getting a full treat about Komodo, tourists can understand all their life activities. Interacting with animals with hard skin and sharp claws, tourists must be accompanied by a ranger. Tourists can also pose with this giant lizard with the help of a ranger who makes it look close. Located in the Komodo National Park, its establishment aims to protect Komodo and the surrounding flora from extinction. The population of Komodo dragons (varanus komodoensis) was recorded at 3,012 individuals and was stable from the threat of extinction. Other places, Rinca Island, Padar Island, Gili Montang Island, and Nusa Kode Island are locations where these rare animals live. Located on Rinca Island, tourists can visit Loh Liang with 2,000 Komodo dragons that are released freely. If lucky, tourists can see firsthand the battle of male Komodo dragons fighting over female Komodo dragons. - Enjoy the Beach Panorama In addition to rare animals, here has the charm of the exotic natural panorama around it. Small islands nearby have clear blue sea water and still clean. Before encountering the giant reptile, Komodo, tourists must trek to reach their habitat. During the trip, tourists will be treated to a very beautiful landscape. - Diving and Snorkeling on Komodo Island Of the 137 thousand hectares of Komodo National Park Area, 60 percent is water. The waters of Komodo National Park are also famous for the beauty of coral reefs, fish, and clear blue water. The corals are presented in various forms, ranging from mushrooms, wrapped in a purple layer, and waving. For lovers of water sports, this location is a very enchanting scuba diving paradise. At some points, the beauty of the underwater world is even compared to world famous spots. Such as the Great Barrier Reef in Australia, to the Reserve System of Belize and the Galapagos in Ecuador. Snorkeling and diving can be done at Manta Point to swim with Manta fish. Tourists can also swim with turtles and sharks by diving in Batu Samsia. Or dive in Crystal Rock with Barramundi Fish, Parrotfish and various typical Komodo fish. Facilities On Komodo Island Komodo Island has a number of adequate facilities, ranging from shelters to food stands. The construction of the pier, road arrangement, toilets, and several information boards were addressed to support tourism. For tourists who want to have a culinary tour, they can visit Kampung Ujung which serves seafood menus. Being in the Komodo National Park, tourists must obey some rules. For example, it is forbidden to start a fire, it is forbidden to touch animals, it is forbidden to bring disposable drinking water bottles and styrofoam. Tourists are also prohibited from taking anything from the National Park area. Komodo National Park also organizes a management system that includes tourists, information centers, and savanna ecosystems. In addition, there is also tightening of security and control over snorkeling and diving activities. Komodo Island Location This ancient animal tourism island is located in West Manggarai Regency, East Nusa Tenggara. Visitors from outside the area can take a flight to Labuan Bajo first. After that proceed with a sea tour to Komodo Island.

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A meal substitute for some and a tasty and healthy snack for many others. Consumed by some for the value it offers and many others for its taste. Whatever the occasion, it has always been around as an instant source of nourishment. Payment & Security Your payment information is processed securely. We do not store credit card details nor have access to your credit card information.

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en

My conversations about productivity are usually about finding balance. It's something I've been striving towards for years. But a friend asked me recently - how would I suggest becoming more of a workaholic? My first thought was - Holy fuck! I really am the cautionary tale. The 80-hour week guy, the guy working on his laptop while his friends enjoy a wine-tasting, the man destined to be the absent dad at the footy game, etc. etc. - and only when recovering from this daze, did I realise it was an opportunity to examine this from a whole new angle. Because surely he deserved better advice than "brrrr just work the weekend dood". Take a step back and it's a lucky question to ask - it means life's already good enough that work can be about more than survival. But I realised the question was less geared around working a lot than having its perceived benefits - better outcomes, more money, a more sustainable business, etc. And you don't need long hours to achieve that; just well-placed effort. As runners and cyclists believe in avoiding junk miles, knowledge workers are best swerving busywork and tedious admin: automate what you can automate, delegate what you can, batch the rest. Still - as someone who's worked hard since I was in short shorts, I couldn't let it stop there. Right at the heart of this is a philosophical acceptance: that the hours I spend on my work aren't a distraction from the business of living, but a meaningful part of my life. And right at the heart of that is Step Zero: the underlying why of your work that justifies every what. No practical steps will aid someone without that spark. I believe we can build a better workaholism, that still satisfies the craving for a hard day's night. Here's a start: - Build the system Is it just money you want? That is a perfectly acceptable reason, money's awesome. Or maybe it's more esteem in your industry, pushing your potential, or the satisfaction of a better outcome. Pretty obviously - starting with a clear reason of why you want to work harder gives you something to target. Not least because there might be smarter solutions. Want more money? That might mean charging more, not working more. A clear grasp of the outcome will help you set the right inputs. Growing your business by focusing on the 100 more phone calls a week, say, not the 10 more sales. This gives it the characteristics of an infinite game, tells you where to focus and, most importantly, when to stop for the day. Because there's always tomorrow. 2. Build the space We're simple copying monkeys, and as with many things, associating with people who are ambitious, fast, productive and hard-working lets you see and absorb these qualities. A career in ad agencies meant being surrounded by smart and resilient people, often working til late on toothpaste ads while sending each other Churchill memes. So a hustle-first environment, like a friendly company, co-working space or coffee shop, might help you thrive on the energy of others. Just remember, cultivating time with successful people - as Naval says - might make you successful, but it won't make you happy. So also spend time with people you like and who like you; who don't care about your work or success, and love you anyway. 3. Build the strength Energy is a supply and demand commodity: the more you ask, the more you'll eventually have. If you're looking for endurance for hard work, it's like lifting heavier weights. Steadily increase your load, and you can strive harder and further. My only suggestion is to build the right kind of resilience: less about long hours for their own sake, and more the sustained ability to enjoyably concentrate. This is as much about rest and recovery as burning time in front of a screen, phone or client. For this, I really recommend Cal Newport's book Deep Work because it contains not only the background philosophy but the practical steps to a high volume of sustained and high-quality work. Put these three together and you might be onto something. What do you think? Disagree completely or something to add? Image credit: Jakob Soeby

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2022-05-20T23:49:39Z

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Customize your JAMA Network experience by selecting one or more topics from the list below. Interventions that alter population-level risk exposure have yielded a number of improvements in public health. Tobacco taxes are an example of such population-based approaches to disease prevention. In the case of tobacco, the harms of shifting total population exposure through taxation are minimal, because there is no safe level of consumption. However, other risk factors do not exhibit the same linear relationship between exposure and mortality—and therefore may introduce new complexities in communicating with individuals and the public. In particular, many risk factors, such as alcohol consumption, exhibit a J-shaped association when plotting health effects like mortality on the vertical axis against the magnitude of the risk factor on the horizontal axis (Figure). Smoking plot created using data from Bjartveit and Tverdal.8 Alcohol consumption plot adapted from Di Castelnuovo et al.1 Setting aside population risk, any clinician who has tried to counsel a patient about alcohol use has encountered the question: “But I thought a couple of drinks a night is good for my health?” In this way, the strategies of preventive medicine—both individual and population based—that have proven quite successful for tobacco control may be less effective when confronting the epidemiologic and perceptional challenges presented by the J-shaped curve. Three examples—alcohol consumption, body mass index (BMI), and blood pressure—help elucidate the challenges posed by J-shaped curves. With respect to alcohol consumption, a meta-analysis of 34 prospective studies, pooling findings from more than 1 million individuals and almost 100 000 deaths, showed a J-shaped relationship between alcohol intake and total mortality.1 Consumption of up to 2 drinks per day in women and 4 drinks per day in men was associated with lower mortality than zero consumption, with about one-half drink per day associated with the lowest mortality risk. BMI and blood pressure are more complex risk factors not solely based on consumption, as with alcohol. BMI is a simple, if imperfect, proxy for energy metabolism—and therefore the current standard for representing healthy weight. A prospective study of 1.46 million white adults demonstrated a J-shaped association between BMI and all-cause mortality after adjusting for potential confounders, including smoking and alcohol intake.2 All-cause mortality was generally lowest among those with BMI of 20.0 to 24.9 and higher on either side of that interval. Blood pressure is another complex modifiable risk factor because of its multiple determinants—but also because it is a commonly treated condition. A large meta-analysis of 61 prospective studies including 1 million patients without cardiovascular disease revealed a linear relationship between blood pressure and mortality risk from a blood pressure level of 115/75 mm Hg and greater.3 Yet treating hypertension may transform the linear relationship into a J-curve. A retrospective cohort study involving 400 000 treated patients with hypertension demonstrated a J-shaped relationship between both achieved systolic and achieved diastolic blood pressure and all-cause mortality.4 Although the evidence for this relationship remains disputed, this study raised questions about potential negative effects of population-based approaches to lower blood pressure in the setting of widespread hypertension treatment. Methodological issues further limit understanding of these fundamental epidemiologic relationships. Reverse causality can result in J-shaped associations in observational studies. For example, one possibility is that the lip of the J-shaped curve for BMI may result from premortality cachexia in individuals with chronic disease. Complex risk factors such as blood pressure and BMI raise questions around how to meaningfully interpret associations with disease. As illustrated by the case of blood pressure, the nature of interventions may matter as much as risk factor distributions. In the face of these uncertainties, public health policy makers must act and communicate in a way that is understandable and resonant with individuals. Framing and Public Health Communication Traditional messaging oriented around “reduce, restrict, limit, ban” may make sense for determinants that have a linear relationship with health outcomes, as with tobacco and mortality. But in the case of J-shaped associations, such unequivocal framing is problematic. The J-shaped curve complicates matters in 2 principal ways: (1) the potential for real, unintended adverse consequences for certain subpopulations and (2) magnification of potential adverse consequences by opponents of public health interventions. For instance, a primary determinant of BMI is caloric intake, which also has a J-shaped association with mortality—with the left lip of the curve representing calorie malnutrition. In countries with concurrent epidemics of malnutrition and obesity, efforts to curb either could result in harmful unintended consequences. For example, some evidence suggests that supplementary feeding programs in Chile intended to treat malnutrition may have contributed to an increase in overweight and obesity among children of higher socioeconomic position.5 Meanwhile, theoretical perceived harms to subpopulations may make any population-based approach considerably more difficult to implement. For example, the overall prevalence of alcohol use in the United States has not changed substantially between 2005 and 2012—but the prevalence of heavy drinking and binge drinking has increased in 2012-2013. Indeed, 12-month and lifetime prevalences of alcohol use disorder in the United States were 13.9% and 29.1%, respectively.6 General public support for a leftward shift in the alcohol consumption distribution might follow, particularly given links between alcohol and violence and motor vehicle crashes. However, restrictive initiatives are vulnerable to politically powerful interests who leverage the J-shaped curve—“good for you when enjoyed responsibly”—to discredit any limitation at all. Indeed, while tobacco excise taxes have steadily increased over the past 2 decades, alcohol tax rates have not been increased since 1991 and are far lower than historical levels when adjusted for inflation.7 Health Policy and J-Shaped Curves Three public health strategies may help make the challenges surrounding J-shaped curves more soluble. First, health communication should emphasize the nadir of a J-shaped curve as a healthy range for the general population. Presentation of the risk curve could be paired with information about what proportion of the population lies an unhealthy distance away from the nadir. Then conversations might focus more on what is epidemiologically important, such as curbing excessive intake, rather than on theoretical risks to small subpopulations. Second, “linearizing” elements of a given J-shaped curve enables less controversial application of traditional population-based approaches. Linearization refers to the idea that certain subcomponents of complex risk factors like BMI may be characterized by a more straightforward relationship between exposures and health effects. For example, while overall fat intake likely follows a J-shaped curve, there is no safe level of trans fat consumption; therefore, more aggressive regulation of trans fats may be justified and more feasible. Taxes and regulations on sugar-sweetened beverages can be interpreted in a similar way. Importantly, even for exposures that follow a J-shaped curve, there may be situations in which similar public health tactics are warranted. Powdered alcohol, for instance—or very sugary alcoholic beverages appealing to adolescents—are cases for which regulation would address a specific health harm that does not have a countervailing benefit. Third, when a population is variably distributed across a J-shaped risk curve, “funneling” subpopulations from either side toward a curve’s nadir could in some cases help focus on a shared objective of lower risk. For example, in low- and middle-income countries, a multifaceted approach could include addressing micronutrient deficiency and substituting empty (nutrition-poor) calories across the entire population—while also tailoring more local interventions to subpopulations that are malnourished or obese. When the evidence is clear, public health leaders should embrace the left side of the J-shaped curve to counter perception as “nannies” or prohibitionists and point out pursuit of the nadir as the goal. Ultimately, successful approaches will depend on more robust and precise mapping of the inflections of epidemiologically important J-shaped relationships as well as understanding how many people actually are distributed along different points on the curve. Further characterization should include the causal mechanisms underlying the J-shaped trajectory. Recent controversies around sodium intake thresholds, for instance, revealed the missed opportunities for clear public health strategies when the true contours of the exposure-outcome curve are not firmly established. When the existence of a J-shaped curve remains controversial, fundamental research is even more vital to formulating sound policy. Corresponding Author: Dave Chokshi, MD, MSc, NYC Health and Hospitals Corporation, 125 Worth St, Room 410, New York, NY 10013 ([email protected]). Published Online: September 21, 2015. doi:10.1001/jama.2015.9566. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Disclaimer: The views in this article are those of the authors and do not necessarily reflect the policies or views of the New York City Health and Hospitals Corporation. Additional Contributions: We thank Thomas Farley, MD, MPH (Public Good Projects), Joshua Sharfstein, MD (Johns Hopkins University), Marc Gourevitch, MD, MPH (New York University Langone Medical Center), and Sandro Galea, MD, DrPH (Boston University School of Public Health), for their insightful comments on an earlier draft of the manuscript. None of these individuals were compensated for their contributions. Chokshi DA, El-Sayed AM, Stine NW. J-Shaped Curves and Public Health. JAMA. 2015;314(13):1339–1340. doi:10.1001/jama.2015.9566 Coronavirus Resource Center

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Well, I’ve done it. After 4 years of not belonging to a gym and 4 years of no regular workouts, I am once again a member of Bally’s Total Fitness. There is a great Bally’s gym right here where I work, and another brand new one at the Metro station by my house so I as far as location, it’s very convenient. Also, after a little negotiation, I think I worked out a pretty good deal. In addition, I now also have a personal trainer. I asked for the best trainer they had and the guy that was recommended, Bernard, seems great, so I’m scheduled to meet with him bright and early Thursday morning at 6 AM. The initial meeting will be an intro workout combined with a goals meeting, expectations, etc. Initially, I’ll be meeting with him 1-2 times per week, and then eventually once per week. But he’s going to help plan all of the workouts, nutrition menus, etc. along the way. (I know nothing about any of this stuff so it’s a big help to me.) I’ll be alternating my meetings with Bernard, some days at 6 AM, other days at 4 PM. But on days that I workout by myself, it will always be 4 PM. Keep it right here for all of the details. I’ll be tagging workout entries as “workouts” so you can see them all at once (if you are really that interested) by going to: More on Thursday…

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Introduction: As part of its Next Accreditation System, the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine describe 6 competencies containing 23 sub-competencies graded by milestones ranging from level 1 (expected of an incoming intern) to level 5 (demonstrates abilities of an attending) that are used to track resident training progression. To the best of our knowledge, there have been no studies introducing a milestones-based curriculum to medical students prior to their introduction to the wards, so we sought to determine the effects that a pre-clinical Emergency Medicine Interest Group (EMIG) Milestones Elective would have on preparing the students interested in Emergency Medicine (EM) as a specialty to meet the level 1 milestones prior to their intern year. Methods: The elective hosted 15 events throughout the academic year, and pre- and post-curriculum surveys were administered. Thirteen first- and second-year medical students at our institution who completed the elective self-reported their perception of preparedness for each level 1 milestone in the 19 sub-competencies. A repeated measures design was used through identical pre- and post-curriculum surveys to determine any changes in self-reported preparedness for meeting level 1 milestones after completing the elective using Wilcoxon Signed Ranks Test. Results: There was a significant increase in the median scoring from 1 to 2 (P=0.027) in overall self-reported preparedness for meeting the level 1 milestones included in the elective, as well as significant increases in subcategories across competencies 1-4 outlined by the ACGME. There was no significant increase in preparedness for professionalism or interpersonal communication competencies. There was no significant increase in interest in EM as a result of the elective. Conclusion: Implementing a milestones-based curriculum during the pre-clinical years shows improved self-reported preparedness of students interested in pursuing EM for meeting level 1 milestones prior to residency. Additionally, a specialtybased elective such as this one offered through EMIG may further increase interest in the field during pre-clinical years. In 2013, the Accreditation Council for Graduate Medical Education (ACGME) implemented its Next Accreditation System (NAS) that requires semiannual evaluation of the milestones that are expected of residents throughout their training ( 1). This move was due in part to shifting attitudes regarding medical education, specifically moving towards an outcome-driven system of evaluating success ( 2). For Emergency Medicine (EM), the American Board of Emergency Medicine describes 23 sub-competencies with milestones that range from level 1 (expected of an incoming resident/intern) to level 5 (exceptional residents that demonstrate abilities of an attending). Since implementation of NAS, studies of incoming interns have found that many fall short of meeting level 1 milestones ( 3- 4). Santen et al. previously surveyed EM interns across the United States and reported up to 39% of interns reported never receiving instruction on certain milestones ( 3). Additionally, a previous observational study on incoming EM interns found a wide variability ranging from 48-93% competency in the milestones assessed ( 4). Challenges in implementing competency-based medical education such as NAS include barriers to creating curricula that individualize learning plans and inconsistent assessment of milestones ( 5). To our knowledge, there have not yet been studies on introducing a milestones-based curriculum in the pre-clinical years, typically the first and second year of traditional medical school curricula. Here, we describe a curriculum developed for medical students to introduce milestones prior to entering the residency stage. This study took place at a medical school with a robust ultrasound curriculum that showed success in early integration and longitudinal development of ultrasound skills throughout medical school ( 7- 8). We sought to determine the effects that a pre-clinical Emergency Medicine Interest Group (EMIG) Milestones Elective would have on preparing students interested in EM as a specialty to meet the level 1 milestones prior to graduating medical school. The EMIG Milestones Elective’s objective was to prepare the students who complete the elective to meet 19 of the 23 level 1 milestones (4 were omitted, as they are better suited for MS3 and MS4 years in a clinical setting). As a result of the study, we sought to determine the effect, if any, that the elective had on 1) preparing students to meet milestone expectations, and 2) impacting the level of interest expressed by the student in pursuing Emergency Medicine as a specialty. Additionally, the results of the survey would allow us to identify parts of the curriculum to improve for future years. Here, we report significant increases in self-reported preparedness for meeting the majority of the level 1 milestones included in the study. This study was reviewed by the Institutional Review Board and classified as exempt with a waived requirement for signed informed consent. A Study Information Sheet was provided to students via email and on the first page of the electronic survey with response buttons to indicate consent. Students were allowed to participate in the elective regardless of participation in our study without penalty. There were 23 sub-competencies outlined by the ACGME. Four of the 23 were omitted in designing the curriculum because they were better suited for third- and fourth-year training. The four omitted sub-competencies were PC8 multi-tasking, SBP1 patient safety, SBP3 technology, and PROF2 accountability as these are better taught in a clinical setting during the third- and fourth-year medical school training. The decision to omit these sub-competencies was made by the elective coordinator with guidance from the faculty advisor who was also associate residency program director at the time and well-versed in milestone requirements and residency education. The remaining 19 sub-competencies were more broadly categorized into 6 competencies based on ACGME guidelines: patient care, medical knowledge, system-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. The 19 level 1 milestones are outlined in Table 1. Data regarding competencies 5 and 6 were combined in our analysis due to the similarity in competency features. |Competency||Sub-competency||Level 1 Milestone| |1: Patient Care||PC1: Emergency stabilization||Recognizes abnormal vital signs.| |PC2: Performance of focused H&P||Performs and communicates a reliable, comprehensive history and physical exam.| |PC3: Diagnostic studies||Determines the necessity of diagnostic studies.| |PC4: Diagnosis||Constructs a list of potential diagnoses based on chief complaint and initial assessment.| |PC5: Pharmacotherapy||Knows the different classifications of pharmacologic agents and their mechanism of action. Consistently asks patients for drug allergies.| |PC6: Observation and reassessment||Recognizes the need for patient re-evaluation.| |PC7: Disposition||Describes basic resources available for care of the emergency department patient.| |PC8: Multi-tasking||Manages a single patient amidst distractionsa| |PC9: General approach to procedures||Identifies pertinent anatomy and physiology for a specific procedure.| |Uses appropriate Universal Precautions.| |PC10: Airway management||Describes upper airway anatomy.| |Performs basic airway maneuvers or adjuncts (jaw thrust/chin lift/oral airway/nasopharyngeal airway) and ventilates/oxygenates patient using BVM.| |PC11: Anesthesia and acute pain management||Discusses with the patient indications, contraindications and possible complications of local anesthesia.| |Performs local anesthesia using appropriate doses of local anesthetic and appropriate technique to provide skin to sub-dermal anesthesia for procedures.| |PC12: Other diagnostic and therapeutic procedures: Goal-directed Focused Ultrasound||Describes the indications for emergency ultrasound.| |PC13: Other diagnostics and therapeutic procedures: Wound management||Prepares a simple wound for suturing (identify appropriate suture material, anesthetize wound and irrigate).| |Demonstrates sterile technique Places a simple interrupted suture.| |PC14: Other diagnostics and therapeutic procedures: Vascular access||Performs a venipuncture.| |Places a peripheral intravenous line Performs an arterial puncture.| |2: Medical Knowledge||MK: Medical knowledge||Passes initial national licensing examinations (e.g., USMLE Step 1 and Step 2 or COMLEX Level 1 and Level 2).| |3: System Based Practice||SBP1: Patient safety||Adheres to standards for maintenance of a safe working environment Describes medical errors and adverse eventsa.| |SBP2: Systems based management||Describes members of ED team (e.g., nurses, technicians, and security).| |SBP3: Technology||Uses the Electronic Health Record (EHR) to order tests, medications and document notes, and respond to alerts Reviews medications for patientsa.| |4: Practice Based Learning and Improvement||PBLI: Practice-based performance improvement||Describes basic principles of evidence-based medicine.| |5: Professionalism||PROF1: Professional values||Demonstrates behavior that conveys caring, honesty, genuine interest and tolerance when interacting with a diverse population of patients and families.| |PROF2: Accountability||Demonstrates basic professional responsibilities such as timely reporting for duty, appropriate dress/grooming, rested and ready to work, delivery of patient care as a functional physician.| |Maintains patient confidentially.| |Uses social media ethically and responsibly Adheres to professional responsibilities, such as conference attendance, timely chart completion, duty hour reporting, and procedure reportinga.| |6: Interpersonal and Communication Skills||ICS1: Patient centered communication||Establishes rapport with and demonstrate empathy toward patients and their families.| |Listens effectively to patients and their families.| |ICS2: Team management||Participates as a member of a patient care team.| |EMIG: Emergency Medicine Interest Group; ACGME: Accreditation Council for Graduate Medical Education| Convenience sampling was used to gather our data. Participants were first- and second-year medical students enrolled in the milestones elective. A survey assessing the level of interest in EM, overall preparedness for an intern year in EM, and readiness for meeting the Level 1 skills for each of the 19 included milestones was designed in Qualtrics Survey Software. The responses were scored based on a Likert scale (i.e. not prepared at all, somewhat prepared, neutral, very prepared, and extremely prepared). A repeated measures design was used, in which the same variables were measured on the same sample before and after the curriculum. The survey was first administered at the beginning of the academic year prior to any elective events (pre-curriculum survey). Respondents taking the pre-curriculum survey were de-identified and assigned an anonymous, random 6-digit identifier used to track the survey results at the end of the year (post-curriculum survey). The post-curriculum survey contained the same questions and answer choices as the pre-curriculum survey. Due to the novelty and specific focus of our study design, the questions used in our survey have not been validated. There were 15 events throughout the year: Wilderness Medicine, Intro to EM Talk, Procedures Workshop, five Talk Shops with EM attendings, Research Opportunities dinner, Shadowing, Jeopardy, Matching into EM Panel, Disaster Medicine, Cadaver Workshop, and Post-Match Panel. Sub-competencies were assigned to events based on the event type (Table 2). These assignments were also discussed with the faculty member overseeing the elective. This advisor was also well-versed in what each event entailed. Students earned credit for sub-competencies assigned to a particular event by attending. Credit for the elective was earned by attending the combination of events to satisfy all 19 sub-competencies and at least eight events. After all events were held, the post-curriculum survey was administered using the 6-digit identifier for longitudinal tracking. |Wilderness Medicine||Camping weekend and educational conference in the San Bernardino Mountains instructed by EM physicians.||PC1, PC5, PC6, PC7, PC9, PC10, PC13, PC14, MK, ICS1, ICS2| |Intro to EM Talk||EM attendings introduce the field and dynamic flow in the emergency department.||PC3, PC5, PC6, MK, PROF1, ICS1| |Procedures Workshop||Four rotating stations of suturing, ultrasound-guided IV insertion, IV access, intubation.||PC1, PC2, PC3, PC4, PC5, PC6, PC7, PC9, PC10, PC11, PC12, PC13, PC14, PBLI| |Talk Shops with EM Attendings||Five dinners held throughout the year at ED attendings’ houses.||PC7, SBP2, PROF1, ICS1, ICS2| |Research Opportunities Dinner||Dinner with ED attendings where ongoing research projects are introduced.||MK, SBP2, PBLI| |Shadowing||ED shadowing scheduled by students based on availability.||Varied. Students were allowed to choose up to 7 milestones per day of shadowing for credit with a brief description of cases seen that satisfy the milestones chosen.| |Jeopardy||Test-your-knowledge of EM related topics.||PC1, PC2, PC3, PC4, PC5, PC6, PC7, PC10, PC11, PC12, PC13, PC14, MK, PBLI, ICS1, ICS2| |Matching into EM Panel||Attendings describe the path to matching into EM.||SBP2, PROF1, ICS1, ICS2| |Disaster Medicine Talk||Lunch talk with EM physician describing the role of disaster medicine.||PC1, PC4, PC9, PC13, ICS2| |Cadaver Workshop||Procedures demonstrated on fresh tissue from cadaveric donors.||PC1, PC2, PC4, PC9, PC10, PC11, PC12, MK, PBLI| |Post-Match Panel||Graduating MS4s discuss their path to matching into EM.||SBP2, PROF1| The elective was graded based on completion for transcript notation and without penalty if a student did not complete the elective. No letter grades were assigned, and participation in the survey was voluntary and anonymous. Forty-six first- and second-year medical students signed up for the elective, and 22 of the 46 completed the elective for credit. Twenty-two students agreed to participate in the study and took the pre-curriculum survey. Thirteen out of those 22 students who completed the initial survey also completed the post-curriculum survey. Students who did not complete the elective were not included in our study due to an incomplete data set. We used these 13 sets of data for our analysis. The responses were re-coded into 1 (not prepared/interested at all) to 5 (extremely prepared/interested). Distribution of milestones are presented as median and interquartile range (quartile 1 to quartile 3). In case of competencies 1 and 6, the median and interquartile range (IQR) of all milestones that comprised those competencies were calculated. The statistical significance of any difference between pre- and post- curriculum was calculated by using Wilcoxon Signed Ranks Test. The Wilcoxon Signed Ranks Test was used because the survey design repeated measurements before and after the curriculum on the same sample, as the surveys administered asked identical questions to the same respondents. We used IBM SPSS statistics 26 for data analysis. Some of the members involved in the creation of this study were faculty who worked directly with the study participants in other aspects of training. Participation in the study was optional and participants could withdraw at any time without penalty or academic repercussions. The data collected was not traceable to individual respondents due to the use of anonymous, randomly-assigned identifiers. The survey questions assessed self-identified level of interest/preparedness in the field of emergency medicine in general and not specific to our academic institution. There was no reference to our institution's faculty or affiliates, so participants could answer survey questions honestly without any impact on transcript grades. There were 13 sets of data included for analysis. The median (IQR) for overall preparedness for an intern year in an EM residency was 1 (1 to 2) before the curriculum and 2 (2 to 3) after the curriculum (Figure 1, p=0.027). The median level of interest in EM was 4 (3 to 5) before the curriculum. The median level of interest in EM remained 4 (3 to 5) after the curriculum (Figure 1, p=0.317). In assessing perceived preparedness for each of the 19 level 1 milestones grouped by competency, there were significant increases in competencies 1-4 (Figure 2). The categories and their corresponding statistical p-values are displayed in Table 3. For competency 1 (patient care, sub-competencies PC1-PC14), the median score was 2 (1 to 3) prior to the elective and increased to 3 (2 to 4) after elective (p=0.004) (Table 3). |Measure||Intervention||N||Mean||Median||Min||Max||1st quartile||3rd quartile||Statistical test| |Overall preparedness for intern year in EM residency||Pre||13||1.5||1||1||4||1||2||-2.209||0.027| |Level of Interest in EM||Pre||13||3.8||4||2||5||3||5||-1.000||0.317| |Competency 1 (Patient Care)||Pre||13||1.8||2||1||3||1||3||-2.889||0.004| |Competency 2 (Medical Knowledge)||Pre||13||1.3||1||1||3||1||1||-3.134||0.002| |Competency 3 (Systems-Based Management)||Pre||13||2.4||2||1||5||1||4||-2.081||0.037| |Competency 4 (Practice-Based Performance Improvement)||Pre||13||1.9||2||1||4||1||3||-2.889||0.004| |Competency 5 (Professionalism)||Pre||13||3.2||3||1||5||3||4||-1.867||0.062| |Competency 6 (Interpersonal Skills)||Pre||13||3.3||3||2||5||3||4||-1.308||0.191| |Competencies 5-6 (Professionalism and Interpersonal skills)||Pre||13||3.4||4||1||4||3||4||-1.190||0.234| |N: Count, Min: Minimum, Max: Maximum| The median score for preparedness in competency 2 (medical knowledge, MK) was 1 prior to the elective; median level of preparedness increased to 3 (2 to 4) after the elective (p=0.002) (Figure 2). Competency 3 (system-based practice, SBP2) showed a median increase from 2 to 3 (p=0.037), and competency 4 (practice-based learning and improvement, PBLI) also showed a median increase from 2 to 3, (p=0.004) (Figure 2). Competencies 5 and 6 (professionalism and interpersonal and communication skills, PROF1 and ICS1-ICS2) did not show a significant increase from the post-curriculum survey. For these milestones, the medians for pre- and post-curriculum were 4 (p=0.234) (Figure 2). Significant increases in the students’ perceived preparedness were seen in 16 out of the 19 level 1 milestones included in the elective as well as overall. The competency that showed the most significant increase was medical knowledge (sub-competency MK). Within the elective, PC1 and MK (medical knowledge) had the highest number of events that qualified for milestone credit, which may have played a proportional role in preparing students to feel they could meet the level 1 milestones for those sub-competencies. As an elective geared towards first- and second-year students, it is also expected that initial medical knowledge may naturally increase with more time and exposure to medicine, not only in the field of EM, but generalizable to the time spent in the medical school environment. The next competencies to show the highest significance in increased preparedness were patient care (sub-competencies PC1-PC14) and practice-based learning and improvement (sub-competency PBLI). Patient care encompasses the greatest number of sub-competencies, and 11 out of the 15 events covered at least one sub-competency in this broader competency. Therefore, an increased frequency of events that incorporate patient care may positively influence preparedness in those level 1 milestones. Additionally, several of these 11 events contained hands-on skills training, so this finding could also indicate that students show better response to an active learning setting, allowing them to feel more confident in these categories. Lamba et al. previously studied the effects on self-reported confidence after hosting a procedures workshop on intubation, thoracostomy, and central venous catheterization, which fall under the competency of patient care ( 8). The previous study was similar to ours in having a small sample size surveyed before and after an intervention workshop; however, the study was performed on EM-bound senior medical students rather than first- or second-year students. Our study showed similar results in that there was a significant increase in self-reported preparedness for patient care after the elective. Practice-based performance improvement is a theme seen throughout events in the elective as this study took place in an academic institution with several areas of ongoing research and emphasis on research-based improvement practices. This environment may have played a role in increasing preparedness in this competency. System-based practice also showed significant increases in perceived preparedness. The level 1 milestone for this sub-competency SBP2 is that a student is able to describe members of the ED team and their roles (e.g., nurses, techs, security). This skill is best taught through interactions with attendings or students in their third or fourth years and through shadowing. Though skills acquired through shadowing were left open for students to select which ones they would receive credit for, the other events that covered SBP2 involved direct interactions with attendings and/or fourth-year medical students. The remaining competencies of professionalism and interpersonal and communication skills (PROF1, ICS1, ICS2) require consistent training and are not readily addressed in the types of events offered through the elective that are more geared towards procedural skills and talk shops. The post-match panel was notable for being moved to a virtual setting this year due to COVID-19 pandemic restrictions, which may have resulted in less engagement with the panelists than has been observed in similar events in previous years. Overall, this may point to the notion that professionalism and interpersonal communications skills are not easily taught or improved upon by a short elective course. In a survey conducted by Stehman et al. regarding assessment of the competency of professionalism, non-technical skills were most commonly assessed by faculty evaluation and only 11.2% of the survey respondents felt that this method of assessment of professionalism was very effective ( 9, 10). In our study, there was no significant increase in perceived preparedness in the non-technical competencies; taken together with the previous study, our results suggest that it may be difficult to objectively assess these skills. There was no significant increase in interest in EM after the curriculum, though the baseline median level of interest was already the highest of all the survey categories at “very interested.” Students who were already interested in EM may have been more likely to take the elective initially, and those whose interest was consistent throughout the year may have been more likely to complete the elective, resulting in the insignificant change at the end. Students who lost interest in emergency medicine might have dropped the elective and, therefore, potentially biased the sample by not completing research surveys. One of the limitations of our study is its sample size. Although 22 students completed the elective, we only received 13 complete pre- and post-curriculum sets of data. It is likely that the respondents who were lost to follow-up were those who did not complete the elective. Within the 13 complete data sets, it is also impossible to track which event each of the respondents attended due to the de-identified format of the survey. This absence of tracking is important because it is possible to achieve all the milestones through a number of combinations of events, so the learning environments for each of the 13 students may not have been identical. Additionally, there may be volunteer bias due to our use of convenience sampling. The students participating in the surveys were those already enrolled in the elective at the beginning of the academic year and completed it by the end of the year. The students who completed the elective may have been more likely to report increased preparedness due to higher interest in EM-related topics at baseline. Another limitation of our study was the fact that our surveys were not previously validated. Due to the novel design and focus of our study, there were no previously validated surveys that addressed the main hypothesis of this study. In our study design, students self-reported their perceived level of preparedness in achieving level 1 milestones, rather than having a standardized method of measuring preparedness in the form of a post-curriculum assessment. For addressing this limitation, future elective courses could have third- or fourth-year medical students or EM residents evaluate the first- and second-year students before and after the elective in a practical skills session or through written exam. Quinn et al. report a method of evaluating students rotating through EM based on milestone achievement through the use of faculty evaluations and quizzes ( 9). Future studies using our elective could develop a more formal assessment of skills in a similar way. Another limitation was accommodating for COVID-19 social distancing restrictions and implementation of remote learning so that our final event (Post-Match Panel) was held over video conferencing and may have limited the interaction that normally would be facilitated in a live event. Lastly, it is important to acknowledge the possibility of confounding, as this elective ran concurrently with the MS1 and MS2 medical school curricula. It is possible that increases in perceived preparedness observed in the survey data could be influenced by reinforcement of material in mandatory courses. Implementing a milestones-based curriculum during the pre-clinical years may better prepare the students interested in pursuing EM for meeting level 1 milestones prior to residency stage. This elective can be readily recreated in other programs by creating events that broadly encompass many aspects of EM. Examples include case studies, skills workshops, and interactions with attendings (e.g., lunch/dinner talks). To capture more abstract skills such as professionalism and interpersonal communication, events targeting these skills should be offered. Further investigation in the form of pre- and post-curriculum testing specific to each emergency medicine milestone is warranted to validate these results and better assess the true extent of achieving level 1 milestones. - Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system – rationale and benefits. N Engl J Med. 2012; 366:1051-6. - Desy JR, Reed DA, Wolanskyj AP. Milestones and millennials: a perfect pairing - competency-based medical education and the learning preferences of generation Y. Mayo Clin Proc. 2017; 92(2):243-50. - Santen SA, Rademacher N, Heron SL, Khandelwal S, Hauff S, Hopson L. How competent are emergency medicine interns for level 1 milestones: who is responsible?. Acad Emerg Med. 2013; 20(7):736-9. - Hauff SR, Hopson LR, Losman E, Perry MA, Lypson ML, Fischer J, et al. Programmatic assessment of level 1 milestones in incoming interns. Acad Emerg Med. 2014; 21(6):694-8. - Hawkins RE, Welcher CM, Holmboe ES, Kirk LM, Norcini JJ, Simons KB, et al. Implementation of competency-based medical education: are we addressing the concerns and challenges?. Med Educ. 2015; 49(11):1086-102. - Fox JC, Schlang JR, Maldonado G, Lotfipour S, Clayman RV. Proactive medicine: the “UCI 30,” an ultrasound-based clinical initiative from the University of California, Irvine. Acad Med. 2014; 89(7):984-9. - Fox JC, Chiem AT, Rooney KP, Maldonado G. Web-based lectures, peer instruction and ultrasound-integrated medical education. Med Educ. 2012; 46(11):1109-10. - Lamba S, Wilson B, Natal B, Nagurka R, Anana M, Sule H. A suggested emergency medicine boot camp curriculum for medical students based on the mapping of Core Entrustable Professional Activities to Emergency Medicine Level 1 milestones. Adv Med Educ Pract. 2016; 7:115-24. - Quinn SM, Worrilow CC, Jayant DA, Bailey B, Eustice E, Kohlhepp J, et al. Using Milestones as Evaluation Metrics During an Emergency Medicine Clerkship. J Emerg Med. 2016; 51(4):426-31. - Stehman CR, Hochman S, Fernández-Frackelton M, Volz EG, Domingues R, Love JN, et al. Professionalism milestones assessments used by emergency medicine residency programs: a cross-sectional survey. West J Emerg Med. 2019; 21(1):152-9.

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I have been chatting with colleagues about students and attendance in courses. What do we do to get students in the classroom? Better yet–wanting to come to class and ready to participate might actually offer the correct comment or want by faculty. I have incorporated attendance and participation into the way that I evaluate the students, but I have also not assessed their attendance and participation. What have I found? It’s a pain to take roll, yes, but I find that I learn the students’ names faster, when I take roll. Students can come to class and not really be there-not want to be there and might be doing their math homework for all I know. I find that for early morning courses, I really have to peppy and be prepared to perform more. I have to wake them up and I have to make the class “worth” it for them to wake up early and come to campus. I also find that when participation is used to evaluate them, they are more apt to come to class. There is no easy way to answer this question. Why? Some terms this is not a point of concern, as the stars will align and you don’t even have to worry about it. I find that attendance also varies between the type of class–large lecture, small lecture, seminar and the year of the student. Then, add to this the type of student: keener, good, enthusiastic, year of the student, major, minor, etc. There are so many factors outside of an instructor’s control. Thinking of my undergraduate career, I know that I attended class all the time. I was a keener and would always make sure that my work schedule never conflicted with my school schedule. I also looked at my attendance at university as a privilege (first generation college student). I would look around the room at all these “new” people during the mid-term and wondered why they never came to class. Before anyone comments that students today are working–been there, done that. I was often working two jobs and volunteering at the radio station, paper, or student club(s). When I am wearing my professorial hat, I also know that there is a correlation between good attendance and good marks. But, I can talk about this until I am red in the face and only some students will listen to this point or “get” it. I do feel bad for the students who are phoning it in and really don’t seem like they want to be in class or at university. But, that is probably another blog post!

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I previously blogged about an Anti-Bullying held on March 31st, 2012 that I attended in San Diego. The workshop was sponsored by Voices of Women and was for the local Somali community. The latter half of the panel included a community member and the local Police. The first presenter was Ramla Sahid, community organizer. Yes, I smiled when I heard this descriptor and after hearing her presentation I was so impressed. Did I share that she’s also a SDSU alum?! Yes, she is. This young woman is working for social change. “We are accountable to one another.” Hearing her say this was important. She was reminding the mothers and daughters in attendance. Yes, the audience was predominantly sex segregated and I will speak to this later. She also gave a polite yet scathing commentary on how the tough on crime legislation and policies in California were counter-productive. The other speakers were two police officers: one Lieutenant and one Detective. I am not using their names–both of them work in the community and I will leave it at that. The two really spoke to the intricacies of the laws regarding bullying and harassment. There were a few moments when I wondered if the presentation was right for this audience, but nonetheless their presentation was good. I also was at times fascinated by their guns. The guns looked out of place–I know that they were on duty, but after years in Canada I am not as used to seeing lots of guns around. (Humor). The officers noted that if bullying begins in primary school it only worsens in junior high and high school, so it’s important that we respond. “Respect is universal.” Lots of head nodded when the Lieutenant made this statement. Farah noted that we need to get the men involved and that they need men only workshops. I am not sure if I agree, but then again I am not taking into the cultural considerations. Perhaps he is on to something and these male only workshops can also speak to the importance of fatherhood. More workshops is definitely something work thinking of given the proliferation of bullying and need to curb it in schools. When the question and answer period took place Agin Shaheed noted that we must get the fathers involved. There were only mothers in attendance. He also noted that across the US 87% of teachers are women. (Is this why we keep on hearing the press and experts pick on teachers? Is there bullying against teachers because this is still viewed as women’s work? Maybe that is another post).

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