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- © 2008 American Dental Education Association
Executive Summary
(Delivered at the Macy Study Convocation)
Revitalization of dental education in the United States is an imperative, but it depends mainly on the willingness of dental school faculty to make great changes. My remarks address a system of education of dental professionals in relation to other health professionals whose vision seems at times to have surpassed ours. I advocate for a revitalization of our profession in order to stand at the fore when it comes to ensuring the health and well-being of the public. Thanks to advances in molecular medicine, health care is being transformed from a system of treating disease to one that provides predictive, preemptive, and personalized care. This presentation makes recommendations for rethinking the current system of dental education in order to elevate dentistry to its rightful place as a vibrant health care leader. Dental education needs to be a source of new knowledge, discovery, and innovation to sustain its legacy as a learned profession. Graduates must be lifelong learners who can critically evaluate science and technology for the good of their patients.
Future dentists should be providers of primary care, yet data suggest that the organizational structure to support this vision is lacking. The accreditation system, interrelated with licensure and National Boards, needs to set a better floor. While independence is an admirable goal, I see too much variation in the accreditation system. We must overcome fears and politics to upgrade the profession as pharmacy did when it introduced the Pharm.D. degree. With that came a change in the entire system of pharmacy education and clinical practice and recognition of pharmacists as members of an interdisciplinary health care team.
Dentistry and dental education are doing a lot that is good, but we must and can do even better if the profession is to thrive as a respected member of the health professions delivering high-quality, evidence-based care to the public. Dental students, faculty, and practitioners must have command of new and coming scientific advances and technologies that will have a profound impact on the practice of dentistry. We must take the long view in educating our students so they will, as practitioners, be able to expertly evaluate and use new technologies throughout their careers. With regard to technologies, three examples may help clarify their future importance in dentistry: 1) oral fluids and tissues are natural tools for health surveillance; 2) within the next five to ten years, microarrays of all 700 bacterial species will be available for diagnostic purposes as will treatment tied to this diagnostic tool; and 3) biomarkers of inflammation will continue to develop into chair-side technologies with appropriate treatments. These three examples—along with spectacular advances in imaging, materials science, stem cell biology, and regenerative medicine—signal the need for rigorous change in dental education and practice.
If we desire twenty-first century clinicians, we are obligated to teach students to "learn how to learn." We must teach them to practice evidence-based dental medicine. We must teach them to operate as members of interdisciplinary, primary health care teams. Moreover, we must ensure that the face of the profession—its practitioners—reflects the rich diversity of the community. Attendees at the Macy convocation are in a position to provide leadership, to work with appropriate organizations, and to enable Pharm.D.-like consensus. It behooves us to agree on a unified vision for revitalizing dental education. The vision should be based on a set of principles, either those originally laid out by W.J. Gies in 1926 or ones that may be a better fit with this day and age. The following are several recommendations for transformative change in dental education. In my view, based on my experience as a dental professional and leader, and by looking beyond our educational boundaries to places like MIT, I believe that they may be the most promising: 1) think BIG!; 2) involve students in hands-on learning experiences from day one; and 3) provide students and the profession with the tools to tackle major biomedical, clinical care, and societal issues including access to care, cost of care, HIV, emerging infectious diseases, elder care, and many others.
In fact, I believe that we already know what to do to upgrade the dental profession. We need to make it happen. We need to act as catalysts for change. We understand that change is necessary but continue to struggle with implementing sustained curriculum reform and regulatory reform. Why? Partly because we have not convinced the dental profession and the education community that a crisis really exists. "Crisis" may sound to the uninformed like crying wolf, especially in a climate in which dentists in private practice are doing exceedingly well. Further, we have not provided a compelling vision for the future. Transformation will require a profound reexamination of what we are doing today and what is necessary for survival and sustained growth. We must keep pace with new knowledge and methods of teaching—unless, of course, we choose to subscribe to the facetious message of W. Edwards Deming, who is credited with rebuilding the Japanese economy after World War II: "It is not necessary to change. Survival is not mandatory."
This is the dawning of the most exciting time in the history of dentistry. Indeed, medicine and dental medicine are in the midst of transformation from a focus on treatment of disease to predictive, preemptive, and personalized medicine. Despite the predictable resistance to change, it appears as if there is an inexorable move from a surgical, insular profession to a more integrated health care system in which dentistry and dental health care professionals can assume leadership roles in primary care. Clearly, this movement will require a renewed emphasis on risk assessment, prevention, behavioral intervention, and medical management of oral diseases and disorders. The subsequent evidence-based practice will require the development of uncommon partnerships among many sectors to integrate and translate findings from scientific discovery to novel patient and consumer health care models of the future. In this context, the oral cavity and its environs represent a unique portal and passageway for the study of human health and disease. Thus, the dental health care professional can be in the enviable position of a significant gatekeeper to primary care.
Dental education should be at the hub of this transformation from surgical to medical management and to preemptive medicine. Dental education should be the singular place where change is embraced and where new models for education, clinical care, accelerated technology transfer, and lifelong learning are tested and validated. Although dental education does many things correctly, it has not been proven to produce graduates who readily embrace science-based findings and who look to dental education, the faculty, and the academic health centers or universities as the primary source of information regarding contemporary clinical practice. Unfortunately, the current model of dental education creates "schizophrenic adaptors" of change. On the one hand, there is sufficient evidence to demonstrate that practicing dentists readily embrace new technologies that provide increased practice income or that improve technical skills, business practice, and efficiency. On the other hand, practicing dentists, by and large, do not appear to adopt rapidly new diagnostics, preventives, and therapeutics based on advances in science and technology. Unlike medicine, dental practitioners do not have a prima facie link to the dental school.
Adoption of the rapidly advancing science breakthroughs and the realization of the promise of molecular medicine will require huge changes in mindset, educational structure, and leadership. The purpose of this article is to examine the "system" of dental education (Figure 1⇓) and to proffer some recommendations on rethinking the current system in order to move dentistry to its rightful place as a vibrant leader in the public's health and well-being and to ensure dental education is at the forefront as the trusted source of science, technology, and clinical information.
The Problem
Over the past dozen years, there have been multiple reports issued and groups conducting studies about the future of dental education, most notably the Institute of Medicine (IOM)'s Dental Education at the Crossroads,1 the U.S. surgeon general's report on oral health in America,2 the American Dental Association's (ADA) future of dentistry report,3 the Santa Fe Group's special salon on reform of dental education,4 and the American Dental Education Association's (ADEA) Commission on Change and Innovation in Dental Education5—all of these have articulated a compelling and powerful case for change in dental education. Simply stated, the status quo is not working. The current dental education model is based on the 1926 Gies report,6 which has not been advanced beyond the fifty-year-old model in many dental education institutions. The principles of the Gies report remain germane today, and it provides the basis for many of the values dental education has embraced. Perhaps inadvertently, the fundamental principles have been eroded today, so it is important to reevaluate the tenets of the Gies report with the notion of recommitting to its fundamental values and principles. Unfortunately, there is significant evidence that most dental schools continue to teach the traditional basic sciences in lockstep sequence with or without integration depending on the individual school.7 At the same time, dental education has not kept pace or been responsive to shifting patient demographics and, in particular, the following:
changing age and ethnic/culturally related population demographics,
patient/population desires, needs, and expectations,
changing health system expectations,
evolving interdisciplinary expertise and practice requirements,
new scientific discoveries, and
integration of emerging technologies.
Perhaps most importantly and as a consequence, dental education has not been aligned with the core values and central mission of the research-intensive universities where most of them are housed. ADEA's Commission on Change and Innovation in Dental Education (CCI)5 articulated a number of points that are relevant to the issue of revitalization of dental education, concluding that a curriculum change, thus reform and revitalization, is compelling for a number of reasons:
Financing of dental education at all levels remains a significant challenge.
Recruitment and retention of faculty in an era of diminishing resources are seriously problematic.
The curriculum in many dental schools is based on a model of education delivery that is at best fifty years old.
Emerging science, technology, and disease patterns promise to change oral health significantly.
Dental education and practice are facing an increasingly ethnically and racially diverse population.
There are questions and concerns about the ability to sustain a "learned" profession while contributing to new knowledge in the university or academic health center setting.
There is a chasm that exists between the principles of dental education and the core values that define the profession.
While complexity of diseases across all populations continues to grow, the profession is evolving towards promotion of high-end specialized dental services.
The role of dentistry in primary care is diminished and magnified at the same time sciences are uncovering oral-systemic health relationships.
Meeting these and other challenges facing dental education, including embracing the astonishing advances in genomics, proteomics, pharmacotherapy, and systems biology, will require not simply a change in curriculum, but a reform of the entire dental education process and system, including changes in prerequisites, admissions, credentialing, financing, and quality assurance.8
It has become increasingly clear that dentistry needs to be the primary source of new knowledge, discovery, and innovation to sustain our legacy as a learned profession and that graduates must be lifelong learners who can critically evaluate science and technology. At this point of our evolution, it is debatable at best as to whether or not dental education is meeting these critically important objectives. Perhaps the single hallmark that defines dental education at this point in its evolution is the "silo" approach to curriculum development, education, and evaluation.9 This has led to an isolated, insular approach to training future dentists rather than an educational system in which dentistry is embedded within a comprehensive, interdisciplinary health care and training system (see Figure 1⇑). Thus, dental schools have created a gap between new scientific and technical advances and incorporation of these advances into dental education and clinical practice. Perhaps the greatest challenge dentistry faces is keeping the curriculum as relevant as possible so that future applications of risk assessment, disease prevention, diagnosis, and treatment—which are almost certain to come from the biomedical sciences such as proteomics, cell biology, microbial and molecular genetics, biometrics, and pharmacogenomics—are allocated sufficient curriculum time to meet changing patient needs, demands, and expectations.10
Nearly a decade ago, the IOM report Dental Education at the Crossroads raised the alarm regarding dental education when it stated that
the problem in reforming dental education is not so much achieving consensus on directions for changes but difficulty in overcoming obstacles to change. Agreement on educational problems is widespread. The curriculum is crowded with redundant or marginally useful material and gives students too little time to consolidate concepts and to develop critical thinking skills. Comprehensive care is more an ideal than a reality in clinical education, and instruction focuses too heavily on procedures rather than on patient care. Linkages between dentistry and medicine are insufficient to prepare students for a growing volume of patients with more medically complex problems and an increase in medically oriented strategies for prevention, diagnosis, and treatment.1
Even though this alarm was raised more than ten years ago and there has been some movement in the direction of having a more integrated approach to dental education, it is clear that significant obstacles remain, including escalating educational costs, resistance to change, a graying faculty, insufficient funds to revitalize the physical plant, insufficient funding to invest in new faculty and new technology, insufficient commitment to advancing research into the fabric of dental education, and continuing difficulty of building bridges between the dental education institutions and other health care professionals as well as with the community of practitioners. All of these observations underscore the notion that the need for curriculum and dental education revitalization is necessary now and must be approached with the clear understanding that, while no one model will work for all dental schools, the outcomes of the educational process should be similar. As stated earlier, the status quo is no longer desirable or acceptable! Rather, closer integration with medical education and training is essential, collaboration among the health professions is more important than ever, and dentists should be leaders in the health care community. In fact, a new generation of leaders in dentistry needs to be developed, and mechanisms to overhaul the credentialing process—especially national and regional board examinations—must be adopted that result in a more relevant credentialing process that links the modern practice of dentistry to scientific and technological advances and to societal needs and expectations.4,10 This is a daunting challenge, which will require effective leadership and a shared vision of the outcomes of the education process that are embraced by dental education's stakeholders.
Drivers of Change
At this point, we are armed with a virtual consensus regarding the necessity for reform in dental education, but with no clear consensus on how to move the reform forward to achieve a transformation effect. Thus, it is important to understand the drivers of change, as well as the disconnects that must be overcome (see next section) to create a more significant and contemporary educational system. The primary drivers of change are demographics, the media, science and technology, economics, public policy, industry, consumerism, the regulatory environment (OSHA, FDA, accreditation, boards, licensure), and education.
It would be beyond the scope of this article to describe every one of those drivers and their impact on the dental education system in detail. However, here we will consider four critical drivers that are important to consider: education, science and technology, economics, and consumerism. It is important to keep in mind that all these drivers in one way or another are not isolates but are interdependent. That is, if one is tweaked, it could resonate with or impact other drivers.
Unfortunately, on the education front, dental education has more often than not reacted to change rather than initiated change. There are multiple examples in which outside influences including so-called hotel room continuing education courses have had a greater influence on technologies that have ultimately made their way into the dental curriculum than through the technologies derived from science in the education environment. Indeed, Tedesco in 1995 made the provocative comment that stands today that "the dental education community has responded to the winds of change with some growth and little change."11 The 1995 IOM report reached two important conclusions that must be considered on the education front.1 First, dental education should be closely integrated with medicine and other relevant health professions. Second, dental education should be immersed in the totality of the academic health center described recently by Bertolami as a tectonic interface between disciplines and professions, where the silos disappear and the result is an agglomeration of virtual schools.12 Intellectual capital drives the complex integration of the dental school within the health center and with the communities it serves (Figure 2⇓). Unfortunately, despite all these recommendations and observations, a survey of the current structure, recent innovations, and planned changes in dental education revealed that only 7 percent of schools (four schools) reported that their entire curriculum was organized around themes of interrelated topics, whereas the great majority of schools (forty-three schools) indicated that only a few courses with interrelated subjects were in the curriculum.7 Although there have been recent successes in breaking the silo paradigm and in developing more integrative, thought-provoking models of education, the traditional lockstep biomedical and dental disciplines remain entrenched in many schools. So, on the education front, it seems clear that education is not a significant driver of change for many schools. The lack of sustained reform begs the question "are we headed toward a two-tier system of dental education and clinical practice?"
Science and Technology
In terms of science and technology, the astonishing breakthroughs that are occurring on a weekly basis have the capacity, if adopted and embraced by dental education, to transform the profession to the medical model. The twenty-first-century health challenges cited by the National Institutes of Health (NIH)13 and others include a focus on the following:
acute to chronic diseases,
aging population,
health disparities,
emerging infectious diseases,
regenerative medicine and stem cell biology,
diagnostics tied to treatment,
personalized medicine—realizing the promise of the genome project and molecular medicine,
and more.
Although the scientific horizon is filled with great promise and expectations, Keusch14 pointed out, at an International Association for Dental Research (IADR) Plenary Session in 2004, that in addition to advancements in science and clinical care in the twentieth century, there have also been disappointments, which continue to this day. These disappointments include the following:
disparities in health increasing,
increasing disparities in health research,
knowledge does not directly lead to solutions,
more neglected disease (largely of the poor),
failure to effectively use technology, and
profit-based drug/medical device development—avoids diseases of the poor and creates major problems of access, availability, and affordability.
Thus, there is a need to transform health and medicine for the twenty-first century in a preemptive manner relative to twentieth-century medicine. Zerhouni recently articulated these transformative notions, shown in Table 1⇓.13
The movement toward predictive, personalized, preemptive, and participatory medicine will be fueled by the rapid advances in technology and the breakthroughs envisioned through proteomics, metabolomics, systems biology, bioengineering, stem cell biology, tissue engineering, and gene therapy, among others. Importantly, dentistry is on the cusp of these scientific advances as the ability and capacity to use oral fluids and tissues as diagnostics and even health surveillance tools and as the application of findings from the human genome project is translated into novel therapeutics, preventatives, and interventions. In addition, there is excitement in the oral sciences about inter- and cross-disciplinary efforts to "build a tooth"; to re-engineer the biofilm; to develop novel, genetically targeted approaches to preventing caries and early detection of oral cancer, among others. There is much more, but suffice it to say that the translation of genomic-based discoveries to prevention and clinical outcomes is key to both contemporary practice and contemporary educational preparation.
Science is producing unbelievable breakthroughs that can improve health, save lives, and reduce the cost of care. So, the question remains: what will it take for these breakthroughs to make their way into dental education and clinical practice? This is the reason for the need to attack dental education reform NOW, so that dentistry is on the cutting edge not the dull edge of science and technology. The entire science base of dental education needs considerable rethinking, and new models of an integrated science curriculum, coupled with new clinical practice paradigms, need to be proffered and tested. Baum has argued that dental students should be provided more biological sciences and medicine, which are necessary to sustain the learned profession and practice as more medically minded practitioners and scholars.15 Donoff and others have offered similar calls for significant changes to dental education's core science and medicine base.16 However, no matter what new material is added or integrated, if the students and faculty do not use the information in patient care, it will result in a return to the status quo or worse!17
Unfortunately, although the potential for science and technology to be a major change agent is palpable, there is little evidence that dental education feels the universal urgency to embrace twenty-first century science and inculcate it into the curriculum and thus to patient care. Other health professions, including physicians and nurse practitioners, could conceivably manage oral diseases and disorders, so if dental education does not change, it could run the danger of losing its place as the gatekeeper for oral health.
Consumerism and Industry
Consumers have the greatest capacity to drive change! Perhaps the best example is the now old story of the patient, Kimberly Begalis, who allegedly contracted AIDS from a dental office. Following exposure of the issue on both 60 Minutes and 20/20, the obvious question the consumer asked the dentist was "how come you're not wearing gloves?" Consumer demand for dental professional change was so powerful that in 1986, after one year, dentists wearing gloves went from 25 percent to 90 percent!18 This is an illustration of the power of consumer-driven demand. Similar observations could be made about aesthetic dentistry: consumers are demanding whiter teeth and more beautiful smiles. As a result, the dental profession and the dental industry are responding to their demands by introducing new products including teeth whiteners and invisible orthodontic procedures, among others.
Educators, scientists, and the dental industry must establish some novel and creative partnerships to create, market, and distribute contemporary technologies to the practicing dentist, the health professions education system, and the consumer. In this regard, industry is in a quandary regarding how to move from making products that are successful in today's environment to new products generated from contemporary discovery science without suffering economic loss and market share. There may be unprecedented opportunity to those industry leaders who are willing to partner with the science, education, and other appropriate communities of interest to both move dentistry to the forefront of the new health care system while establishing exciting new products, devices, and markets.
The recent movement by the insurance industry to pay for preventive and periodontal services is based on the emerging science linking oral infections to systemic health. Importantly, the insurance industry appears to acknowledge that its willingness to provide these consumer services to selected populations will not only address oral health issues but has the capacity to reduce the overall cost of medical care. If this continues, we may enter an era in which consumer demand for dental services will grow even faster as the demands for care will transcend cosmetics.19
In terms of economics, Bailit et al.,20,21 as well as Brown and Meskin,22 have described the high cost of dental education and the decline in revenue to state-related dental schools. At the same time, there is a flattening of NIH support and a clear need to upgrade substantially the investment in dental education and research infrastructure and, in particular, faculty recruitment and retraining. Dental education is on the precipice of a crisis in which costs are escalating, revenues are declining, student indebtedness is at an all time high, and tuition is climbing to unprecedented and, perhaps, unsustainable levels. The net result is that most schools are expanding fundraising efforts and increasing clinical income to cope with the changing economic picture.
Given the macro environment surrounding dental education, it is unlikely that future revenues will increase substantially, and thus the ability to maintain the quality of the educational offerings and the ability to meet the research mission of the university will be compromised. Bailit et al.21 conducted an extensive financial analysis of the models of dental education and concluded that clinical income could be substantially increased if there were a shift in philosophy to a patient-centered clinical care model in which teams of faculty, residents, and students provide care to patients. This model is similar to that employed by medicine in teaching hospitals. If these data prove to be accurate, dental schools could have a ready source of income that could be reinvested in infrastructure and faculty recruitment. The barriers to implementing this approach in dental education are considerable, but the model should be tested and validated. At the very least, this concept illustrates the powerful impact that finances could have as a driver of change in dental education.
Disconnects That Form Barriers to Change
In addition to these important drivers of change, it is important to understand that there are at least five crucial disconnects that are barriers to curriculum reform and revitalization of the dental education system that must be addressed. These are as follows:
The teaching of science and its use in the clinical setting form the first disconnect. It is not a matter of what should be taught in terms of incorporating new courses and content in the curriculum or whether there is a vertical or diagonal model; rather, the question is how can the dental education system be more effective so that students and faculty can work together to apply science to clinical care at every level.
National boards, licensure, and reimbursement remain a barrier to innovation and creativity. There is an overwhelming need for board and licensure reform to accompany educational reform. There needs to be flexibility in boards, licensure, accreditation, and reimbursement systems to enable new models of dental education to be tested and validated.
The promise of new technology is incredibly exciting, but there are very few drugs, devices, and products to apply to the clinical setting at this time, so what can we offer practicing dentists that would make them want to change their practice today? Indeed, the current linkage between diagnostics and therapeutics is weak.
The cottage industry mentality of the dental profession is another disconnect—in particular, the lack of an umbilicus to the health care system and to the dental school, which is the antithesis of the medical model. This disconnect contributes in a major way to the isolation of the dental office and is a significant barrier to implementing a truly integrated model of dental education and clinical practice. The advent of the Practice-Based Research Networks (PBRNs) can be helpful in this regard, but even they represent an important but insufficient method to ensure that practices are linked to advances in science and technology and that practitioners are contributors to both knowledge and improved patient health outcomes.
Diversity and sociodemographics represent a seriously problematic disconnect among dental education, the dental profession, and society. In spite of numerous initiatives to stimulate a more robust applicant pool from the underrepresented and underserved cohorts of the population, the enrollment of minorities in dental education remains abysmal. At the same time, the overall applicant pool is expanding rapidly, and the demographics of the nation's population are shifting dramatically towards a more ethnically and culturally diverse society. Without a continuous and serious commitment to expand the pool of practitioners so that it reflects the nation's changing population, the profession could be in danger of creating a lasting society/dental practice disconnect. If this trend is not reversed rapidly, access to care will continue to worsen, and the profession will march on to elitism.
The High Ground
The dilemma faced by dental education is to continue to graduate competent practitioners to meet the present needs of the population, while preparing students for a radically different kind of practice in the future—one that emphasizes predictive, personalized, and participatory medicine. As stated earlier, the great majority of schools continue to use the lockstep approach to basic and clinical science instruction with little integration of science underpinnings at the clinical level and with continuing metastatic, irregular additions to the curriculum. It continues to be easier to base a curriculum on what was necessary to teach in the past rather than what will be necessary to learn in the future. So, given these dilemmas and the complexity of both the problems dental education faces and the drivers of change and the disconnects that exist, what is the high ground? That is, what are the expectations of graduates for the future? The following4,5 are considered to be the expectations that the ideal dental education would provide for its graduates:
a relentless sense of curiosity and inquiry;
critical thinkers;
problem solvers;
lifelong learners;
individuals who have been taught how to learn;
students and graduates who know how to access information;
students and graduates who know how to distinguish fact from fiction and evaluate science;
students, graduates, and practitioners who can apply science-based evidence to clinical practice in a variety of clinical settings;
integration of science, behavioral, and population knowledge;
ability to function as a primary care provider in interdisciplinary settings;
graduates and practitioners who have the capacity to function as either an independent scientist or a member of a practice-based translational research team;
competent to assume new roles in prevention, risk assessment, and early detection of disease; and
men and women of science.
These high-ground expectations of graduates in the future are not new nor are they novel, but they represent the kind of practitioner for the twenty-first century that many in the academic community and in professional organizations like the American Dental Association, the American Dental Education Association, the American Association for Dental Research, the private sector, the National Institute of Dental and Craniofacial Research, and many of dentistry's stakeholders would like to be the result of dental education. So the question becomes: how do we move dental education from its relatively asynchronous and insular focus to one that is truly integrative across an entire system of health professions education?
Educational Commons and Thinking Big
Perhaps an interesting lesson could be learned from the Massachusetts Institute of Technology (MIT).23 In its recent extensive rethinking of an MIT education, the dean of the School of Science, Robert Sibley, wrote: "It is impossible for us in four years to give students everything they need for life—one of the fundamentals is that students should leave MIT with a passion for learning." This is the essence of what the dental education community needs to embrace. In order to move to the next level of dental education, it appears that we have two issues that must be addressed. One is that we need to create what can be termed a dental "educational commons," that is, a consensus amongst stakeholders that students in the system of dental education should be provided with a shared set of ideas, common concepts, values, skills, attitudes, competencies, and arguments whose merits they can debate.23 The underpinnings of this educational commons are a science core of a new or novel array of cross-disciplines whose objective is to get the students and the faculty to think bigger earlier in their education.23 In essence, the think-bigger approach could result from:
stressing the cross-disciplinary interactions needed to address all aspects of a particular problem, including the use of science, population, behavioral, social, and engineering concepts to address emerging society issues;
introducing students from the first moment they enter dental education to the day-to-day life of science, education, and clinical practice—the hands-on learning approach;
thinking big, which means looking well beyond the school and the university;
equipping students to tackle some of the big, pressing problems like health care disparities, access to care, quality of care, cost of care, and AIDS; and
equipping students with uncommon intensity, curiosity, and excitement.
The net result should be for dental education to provide a structure and sequence of offerings at every level that result in the nurturing of cosmopolitan, creative thinkers. Creating an educational commons whose objective ultimately is to graduate people who are bigger thinkers could result in the profession remaining relevant in an ever-changing world. In this regard and if we look once again at the MIT model, in recent years they have had two remarkable initiatives, which I believe can be translated to dental education. The first is the creation of a new department of biological engineering, which is made up of faculty from a wide range of disciplines spanning biological sciences, medicine, genetics, computational biology, engineering, and social sciences and where leaders are educated at the interface of this complex array of disciplines—in effect, creating a new discipline. The bottom line is to produce a graduate who represents a new discipline and who is unlike any one of the existing faculty in this new biological engineering program. This is a profound objective, which in essence is what dental education reform is all about—that is, to produce a new graduate and practitioner who is unlike any of us but who can function in the complex, exciting environment that the twenty-first century demands.
The second learning experience from MIT that is applicable to dental education lies in the open curriculum model, which MIT has fostered.24 That is, MIT has put online virtually every course they offer in every discipline, which is available to the public for free! Since that time, over 120 institutions have joined an open courseware consortium. Why not dental education? The information cannot be used to obtain a degree, but it speaks to the freedom of movement of content and it speaks to something that has been missing in dental education and that is the ability to access information from a variety of experts across the nation, if not the globe, who could provide contemporary knowledge to the dental education environment and which can be accessed online. The objective here would be for dental education to consider this open curriculum model, but extend it further by accessing expert content from disciplines derived from any university, industrial, or federal source. Thus, specific programs could be developed for which students would get credit and essentially create what amounts to a new system of dental education—that is, a virtual dental school in the context of the health professions education system. In essence, the creation of a virtual "World Dental School" is a notion that is synergistic with the need for educational reform and also ensures state of the science content and could decrease the cost of education. The obstacles to establishing a world school are considerable, but isn't this a model that dental education should advocate and test?
Dental education is at a momentous time in its evolution. Notwithstanding all of the problematic issues articulated earlier in this article, the applicant pool is at its highest peak in many years and the quality of the applicants is superb. Therefore, dental education has an obligation to provide a curriculum and clinical care model that stimulates this incredible student body to be motivated and not "de-motivated." This is the time to define what dentistry should be and what dental education can really achieve in the complex environment in which it exists. Essentially, dental education needs the leadership to advocate for a more systems-oriented approach to integrating biology, molecular medicine, dental medicine, and clinical care across an entire spectrum and continuum of dental and health professions disciplines.
Unifying Vision: The Continuum
The second major issue that must be addressed beyond the thinking-big education commons notion is that dental education must adopt a unifying vision for the future. In 2004,4 DePaola and Slavkin proffered the vision that dental education should be a continuum that leads from predoctoral science and clinical education, moving into professional training in the clinical, biomedical, and behavioral sciences, and extending into lifelong learning in dentistry. In amplifying this notion of a unifying vision, it has become clear that the continuum, which represents the dental education system, should extend from a primary and secondary education pipeline through undergraduate education to dental and health professions education to the possibility of offering joint degrees where new discipline interfaces can occur and to lifelong learning orchestrated through a variety of mechanisms including the PBRNs, continuing education, and virtual grand rounds, among others (Figure 3⇓). The latter has the potential to create linkages between the practicing community and the academic health center. This continuum also enables integration with other health professions so that dentistry functions as a part of a primary health care team. If nothing else is apparent, it is without question that the dental education system is complex, and if one part is tweaked or adjusted, it will have significant effects on other components (Figure 1⇑). Real reform can occur only when the system is understood. Finally, it is important to note that sustained future curriculum changes require a strategic partnership with all stakeholders, including all other health professionals. Most importantly, to move from the status quo to a new level of dental education will require risk-taking and provocative leadership that is effective and efficient and results in a shared vision!
How to Move Forward?
Why Are We Still Struggling with Dental Education Reform?
While there have been many publications and initiatives calling for change in dental education, there has been little sustained, universal success that can be documented. A number of reasons come to mind:
It may be too expensive and time-consuming to either acquire new resources or redeploy existing resources to change. In this regard, dental education works on a thin margin with little excess fiscal capacity. So without an infusion of additional resources, the status quo or tweaking of the status quo prevails. Some institutions and their leaders are comfortable with the current education system and have difficulty seeing how any real change will pay off. That is, where is the incentive to change? Are any new resources coming to the dental school from the university? Other than threats of closure, what is the real incentive for change? In addition, some may take comfort in a more vocational rather than academic direction to the education of students, given the resources and time it takes to add scholarship and research to the fabric of education.
It is quite difficult to change dentistry without changing medicine and other components of the health professions system. The system of health professions education is complex, so when one segment is changed, there is an impact on the entire system. An example is the problem with turning out dentists whose primary care function is directed to health promotion and disease prevention. Unfortunately, the reimbursement and licensure systems are still geared to procedure-based dentistry rather than preventive initiatives, threatening the livelihood of a different type of practitioner.
The politics associated with change are enormous and are a potential deterrent to change. For example, the exploration of a new practitioner model creates a firestorm of concern among organized dentistry.
Leadership must be effective in order to execute transformational change. Leadership in dental education must be able to work in an environment that enables the leader to lead. This has not always been the case in dental education.
Thinking big and thinking globally are requirements for transformational change and, in many ways, are the antithesis of the insular approach that characterizes many dental education institutions.
Perhaps we have been approaching change from the wrong direction. Rather than start with education, perhaps we should try to effect change in the standards (boards, licensure, accreditation) that have a powerful impact on dental education and could lead to systemic change. Certainly, when the pharmacy degree was changed to a Pharm.D. and there was recognition that pharmacists could become valuable members of an interdisciplinary health care team, the entire system of pharmacy education and clinical practice changed.
Perhaps there is too much inertia in the system to expect anything more than incremental change.
Most importantly, in order for transformative change to occur, two things must take place. First, dental education and the profession must acknowledge that a crisis exists. Second, dental education and the profession must embrace a new vision for the future. It is evident that we have failed to articulate the immediacy of the crisis facing dental education and have not put forth a compelling vision of the future.
Over the past decade or so, dental educators have used a variety of approaches to improving dental education, ranging from decompression of the curriculum to problem-based learning to developing the competency-based curriculum. The array of initiatives is truly mind-boggling as can be seen in Figure 4⇓. Unfortunately, as Kassebaum et al.7 pointed out in their survey of dental education, very few schools have taken on the task of organizing a curriculum around interrelated topics and, most likely, none have addressed the provocative issue of integrating their course offerings throughout one continuum of dental education, including clinical integration with the range of health professional schools. Donoff in 2006 made some provocative recommendations for reforming dental education.16 Some of Donoff's observations are synergistic with the following recommendations for revitalizing the dental education system:
Develop new models to finance dental education or to address costs of education. These models can include:
asynchronously distributed, web-based models of curriculum content,25
distance education models in which degrees and courses can be offered online,
faculty taking responsibility for patient care,21
part-time dental education coupled with a "residency" requirement, and
exploration of the adaptability of the "Arizona Model" to other institutions.
Commit to the acquisition and utilization of appropriate resources to reinvest in academic quality integrated with the parent university or academic health center. Ensure reinvestment in academic enrichment, technology, and research infrastructure, and, in concert with other schools within the health center, recruitment of the next generation of faculty and the retraining of existing faculty. In this context, it is important for dental education to recruit new research faculty from sources outside dentistry, thus avoiding a zero sum game.
Build new workforce models designed to increase access to care and reduce the cost of care:
create the pediatric oral health therapist,26
create the comparable physician assistant and nurse practitioner model for the dental profession,
develop fully the utilization of the nurse practitioner in leading oral health risk assessment, health promotion, and disease prevention in the multidisciplinary health care setting, and
explore and test the feasibility of a new practitioner working at the interface of medicine, dentistry, nursing, and pharmacy.
Taking the lead from the University of Washington, establish a vigorous program to educate other health care professionals about oral health. Create a web-based oral health and wellness program that can be utilized by other health professionals.
Invigorate a new approach to interdisciplinary research such that research is embedded in the fabric of the continuum of the dental education system. In concert with the National Institute of Dental and Craniofacial Research (NIDCR), other federal health institutes, and the private sector, test novel approaches to train Ph.D.-level scientists to translate science to clinical medicine. For example, provide training in medicine and dental medicine to selected Ph.D. students so that they are conversant about dentistry and medicine from the clinical perspective and, thus, can lead a new generation of translational science transcending the dental education system.27 Continue to fund the U24 Model of "jump starting" research at selected dental institutions. These current U24s appear to be having an impact on the energy to change and the infrastructure to change. In particular, they appear to be having an impact on the recruitment of faculty who can be integrated into clinical decision making.
Some schools, like Case School of Dental Medicine, are utilizing students early in the first year to provide a hands-on sealants experience to children in school-based settings. Can we push this envelope so that dental students are placed in multidisciplinary health care settings from day one? This notion has the capacity to fundamentally alter dental education, such that a seamless curriculum spanning basic sciences to clinical care is apparent. In this model, students can progress from observers to questioners to collecting data, to assisting in differential diagnosis, to developing research projects, to understanding how basic, translational, and clinical information is used and integrated in patient care. This model can also create a nurturing environment for all disciplines to gain respect for the patient and for other health care providers. A critical outcome is to engage a new faculty role model for students, one who is not simply a "checker" but one who is a true man or woman of science and one who inculcates in the student the evidence-based approach to clinical decision making and clinical care through the span of dental education. A critical component of this approach is to design a physical plant to facilitate the realization of a continuum of education, research, and clinical practice. In this regard, a core curriculum specifically designed to support interdisciplinary education and clinical practice must provide the framework for this model, which, in turn, can be evaluated regularly for program improvement.
Explore the basis for the success of nursing and pharmacy, which have developed courses of study in which students utilize the information derived from the "sciences" in clinical settings.
Taking a page from the novel New York University experience, develop a multidisciplinary wellness clinic focusing on primary care and an integrative approach to prevention, risk assessment, and therapy. This approach could provide the basis for evidence-based, multidisciplinary courses to train translational research faculty, who become role models for interfacing between patients and student-clinicians.
Integrate the education of predoctoral dental and dental hygiene students with postdoctoral trainees, similar to the Columbia University pathophysiology and physical diagnosis model. The novel twist would be to include medical residents, nursing students, and pharmacy students in the same environment, creating a side-by-side interdisciplinary model of primary care.
Create incentives for regional sharing and consolidation of student, faculty, and curricular resources to make dental education more efficient and financially sound.
There are many more initiatives that could be developed to transform dental education. In order for any of the above to succeed, as well as any others being tried in dental education today, a number of "drivers" must be in play. These include provocative and effective leadership; willingness to take calculated risks and even begin a creative revolution; funding to support innovations and creativity (either new funds or redeployment of funds); flexibility in credentialing and reimbursement systems so that current credentialing is not a barrier for transformation; willingness to engage other health professions schools and disciplines; willingness to engage the consumer; an absolute commitment to scientific discovery coupled with translating science and technology into clinical practice; continuous documentation of clinical skills, knowledge, and attitudes; commitment to critical thinking, problem solving, information management, leadership, and teamwork; lifelong learning using interdisciplinary and experiential settings; commitment to an evidence-based approach to clinical decision making; and an absolute commitment to Thinking Big.
We are on the brink of a remarkable transformation of dental education. The only question that remains is this: do we have the will and leadership necessary to tackle the obstacles and move dentistry and dental education to become an ever more respected member of the health care team? Clearly, dental education has had some successes, and there is an increasing array of best practices aimed at improving dental education. However, there is much more to do. Academic institutions, like dental education, have always stood at the gate between the past and the future, attempting to prepare the next generation of leaders for a world that is new technologically and culturally. Unfortunately, education institutions today are among the most conservative forces in our society, out of touch with society's needs to create learning communities.28 The transformation we are seeking will require a profound re-examination of what we are doing today and what is necessary to do in the future. We must accept the pace at which new knowledge is being generated. We must be a part of knowledge generation and must recognize that the current methods of mastering dental education are outmoded, but that learning how to learn represents today's essential knowledge. Perhaps the words attributed to W. Edwards Deming are important to remember: "It is not necessary to change. Survival is not mandatory."29
Dr. DePaola is President Emeritus of The Forsyth Institute in Boston. He has served on the faculty of Tufts University School of Dental Medicine, Medical College of Virginia/Virginia Commonwealth University, Fairleigh Dickinson University School of Dentistry, University of Texas Health Science Center at San Antonio, University of Medicine and Dentistry of New Jersey, Baylor College of Dentistry, and Harvard School of Dental Medicine/Harvard Medical School. He has also served as Dean of the Dental School, University of Texas Health Science Center at San Antonio, where he was also Acting Dean of the Graduate School of Biomedical Sciences; Dean of the University of Medicine and Dentistry of New Jersey-New Jersey Dental School; President and Dean of Baylor College of Dentistry; and President of The Texas A&M University System Baylor College of Dentistry. Dr. DePaola has received many awards for his leadership and scholarship and is widely regarded as an expert on nutrition as it relates to health promotion/disease prevention activities and to oral disease, diagnosis, etiology, and therapy. He is the only dentist who has an honorary membership in the American Dietetic Association and the only dentist elected President of both the American Association for Dental Research and the American Dental Education Association. The American Dental Education Association presented him with a Presidential Citation for outstanding contributions to the organization and the profession of dentistry in 2003 and a Distinguished Service Award in 2005. He received his D.D.S. degree from New York University and his Ph.D. degree in Nutritional Biochemistry and Metabolism from the Massachusetts Institute of Technology. Direct correspondence to him at 144 Coventry Place, Palm Beach Gardens, FL 33418; ddepaola{at}forsyth.org.
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subset: commoncrawl


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Carnelian Tumble
Focus / Energy / Protection / Luck
Carnelian is a part of chalcedony and a variety of quartz family. It can be used to help to centre the vitality energy in any life force. It provides positive strength so that one can action on their motivation and goals.
This stone also helps to protect the wearer from envy, jealousy and anger. It also works on clearing rage or stored anger.
Carnelian is said to promote fertility and ease lower backache.
Product Description:
You will get 1 piece of similar tumble as shown in picture.
Message from Crystal Tale:
I found out that one other amazing ability of this crystal. It also helps to energizing other crystals! And it does a good job in refilling them with positive energy.
The ideal size ratio for Carnelian to charge other crystal is 2:1, or at least 1.25:1, otherwise the Carnelian might get harder to recover. This size is good for placing with other crystals for energizing, or charging for pendants and rings. As for charging bracelets, you might consider the palm size Carnelian.
Your well-being is important to us. Therefore we take extra effort to make sure all our crystals are thoroughly cleansed before shipping out.
* Please click here for Crystal Maintenance.
Please note that healing crystal meanings and properties are not equivalent to medical advice or substitute of medical treatment, and all the information provided in our web is based on a collection of research and experiences. And also as crystals and stones are made by mother nature, it is normal to find small holes, formation crack lines and little minerals of another on or inside them.
All the measurements are taken by eye and might be slightly different than the actual.
Crystal Tale does as best as we can to ensure the colors shown in pictures are as close as to the actual products at the environment where photos are taken. However, colour of crystals might vary under different lighting and we cannot guarantee that your computer/mobile phone monitor's display of any color will be accurate.
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You are here< backHome / Magazine / Archives / Spring 2008 / Carmen Comes to Town
Carmen Comes to Town
Carmen Comes to Town
Bozeman's Intermountain Opera Association (IOA) is celebrating its 30th anniversary this spring with a lavish production of Bizet's Carmen. Approximately 3,000 area residents and visitors from around the Northern Rockies will thrill to magnificent voices and lavish costumes as the gypsy girl, Carmen, seduces a brave soldier and then abandons him for a bullfighter. As has happened on hundreds of stages around the world since Carmen first shocked in Paris in 1875, Escamillo will strut across the stage, belting out the beloved "Toreador Song."
But wait a minute! Isn't this Bozeman, outdoor-recreation capital of the known world? What are we doing with a professional opera company?
The fact that Bozeman possesses one of the most-respected small opera companies in the country is the result of a lucky combination of circumstances. But then, so is Bozeman's status as one of the best-loved places to live and recreate outdoors. If it weren't for a fortunate combination of geology, geography, and weather patterns, we could be living in Kansas.
The IOA's good luck began with a young MSU voice instructor who wanted to sing opera in Bozeman just when one of the reigning baritones at the Metropolitan Opera—Pablo Elvira, married to a Bozeman girl—decided to make his permanent home here. At the same time, Mrs. Robert W. Martin, Jr., a New York City opera fan and cultural philanthropist, moved to Bozeman.
And voila! In May of 1979, The Intermountain Opera Association presented Verdi's La Traviata to an amazed and entranced audience. Who knew that un-miked human voices could soar over a full orchestra to the back of the Willson Auditorium! Who knew that you could weep over a love story sung in a foreign language!
And so it began. Martin raised money, and Elvira persuaded his friends to come and sing at affordable prices. People who had never heard an opera discovered that they loved it and volunteered to sell tickets, fit costumes, create props, usher guests, and serve on the board of directors. The very best local musicians joined the orchestra and chorus. Bozeman audiences learned to expect remarkable performances every spring.
As is bound to happen in the course of thirty years, things change. When Elvira retired in 1997, local soprano Linda Curtis took over as artistic director. The IOA's beloved conductor, Rome-born Giampaolo Bracali, died in 2006, but the British conductor Julian Dawson agreed to take his place.
The current board of directors has embarked on a long-range planning effort to build new audiences, find new sources of funding, and ensure the IOA has a year-round presence. They'll launch season ticket sales this year with a second production—Johann Strauss' exuberant Die Fledermaus</> —scheduled for October.
Carmen will be at the Willson Auditorium May 14, 16, and 18. Ticket info is available at 587-2889 and operabozeman.org.
Marjorie Smith has been an opera fanatic since she saw the film Carmen Jones (Oscar Hammerstein's reworking of Bizet's opera) at the Ellen Theatre at the age of 12. She currently serves on the IOA board of directors.
The Culture Club: Spring's Off-Trail Events
Bozeman is budding with entertainment options this season; there's bound to be something that floats your boat.
The Emerson Cultural Center's three art galleries display local and regional talent (not to mention the 11 other galleries that are rented out); they also play host to the Bozeman Film Festival, which shows films once or twice a month. For details go to theemerson.org or call 587-9797.
If you're into theater, the Equinox Theatre Company has shows almost every weekend, with new performances every month. Not to mention Broad Comedy and Teen Theater. equinoxtheatre.com or call 587-0737.
In Livingston, the Firehouse 5 will be performing The Music Man in March and Godspell in May. Go to firehouse5.org or call 222-1420.
There's plenty of live music that doesn't involve costumes or orchestras. Some venues that are known to bring in good bands are the Filling Station, the Zebra, the Eagles, Whiskey Jack's in Big Sky, Highsides in Livingston, and Pine Creek Café in Paradise Valley. Keep 'em on your radar.
Quench your thirst at the Montana Beer Festival on April 11-12. "Celebrating the quality and diversity of beer styles that exist in Montana and the Northern Rockies," it promises to be enjoyable and educational. For more info check out porterhouseproductions.com.
For a different kind of educational experience, don't forget about the Bozeman Library, which has special events every month. March 17 is Celtic and folk music, while Chrysti the Wordsmith and the DupliKates pair up on April 21 for a unique, etymological exploration of musical history. Call 582-2426 or visit bozemanlibrary.org.
-Erin Strickland
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Ecosystem Functions, Goods, and Services (EFG&S)
All the ways that humans recognize value in ecosystems are collectively described as ecosystem functions, goods, and services.
Ecosystem Functions
A phenomena in an ecosystem that results from the interaction of the structures and processes of that ecosystem (e.g. an animal acquiring food, flood stage changing slowly, a beach remains cool on a sunny day).
Ecosystem Goods
Tangible products that are extracted from the ecosystem that have economic or cultural value to our societies (e.g. fish, seaweeds, shellfish).
Ecosystem Services
Ways that ecosystems provide amenities to our societies that are not in the form of an extractable product (e.g. the provision of animal habitats, clean water, recreational settings, psychological or cultural well-being, storm protection).
The relative historical potential of a site to provide ecosystem services based on historic size and complexity of a site.
A kind of change to ecosystem processes or structures where modification of the nearshore landscape reduces the quantity or diversity of historical EFG&S. The historical ecosystem thus, serves as a baseline for evaluating the current ecosystem condition. Degradation of the historical state is estimated by the presence and intensity of stressors and landform change.
Site conditions with the potential to compromise restoration efficiency or effectiveness.
Past and
Ongoing Threats
Many threats to the health of the Puget Sound nearshore result from past activities, such as diking of river deltas to create agricultural lands. While other threats such as shoreline armoring, continue to occur today.
Restoration and protection activities will help restore Puget Sound, but until we have other tools in place to limit or stop continued threats, we cannot be fully successful.
Strategic Needs Assessment: Analysis of Nearshore Ecosystem Process Degradation in Puget Sound
Historical Change and Impairment of Puget Sound Shorelines


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Piano Tiles 2™ - Piano Game 4+
Don't Tap The White Tile 2
Cheetah Technology Corporation Limited
- #9 in Music
- Free
- Offers In-App Purchases
More rhythmic music, more exciting gameplay, more challenging levels, etc.
Play the anniversary carnival of Piano Tiles 2™ with 1.1 billion players around the world!
Game feature:
1. Simple graphics, easy to play and everybody gets playing the piano!
2. Breath-taking rhythm will challenge your handspeed limit!
3. Top challenge mode gives you thrill and risk!
4. Update of numerous songs, original, classic, bangs and all the style to satisfy different taste.
5. Share your record with your friends, and compare with world-wide players on the ranking list!
6. Sound of high quality makes you feel like in a concert.
7. Save your progress via Facebook account and share the progress in different devices.
8. More challenge, more bonus and a better self.
Gaming mode: Don't tap the white tiles! Tap the black tiles according to the melody and don't miss any tile! Concentrate yourself and maximize your reaction!
Support: If you have any question, please send it to firstname.lastname@example.com, or you can go to the settings - help and support to contact us. We will solve your problem asap.
Business Corporation: Cheetah Games is willing to cooperate with all the top game developers world-wide to create games. We are looking forward to your excellent games.
Please contact us: email@example.com.
Privacy Policy: http://www.cmcm.com/protocol/site/privacy.html
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What's New
Version 3.9.1
Minor bug fixed.
Ratings and ReviewsSee All
I love the game. I usually don't like there times of games. But I love this one. My first +1 is because it helps me tipe faster. That's because it goes fast sometimes and I end up getting better at ripping fast. My second reson is because of something weird. Ok so I can't stay still. Like I need at the most 1 body part moving. If I'm not moving fast at all my brain hurts. Like really bad. It makes me mad. That's why I like this. It's challenging my fingers to go faster. I think that's how I got to #1 on the Christmas leaderboard thing with the galaxy coffee cup? Ya know the thing...? Well lol 😂 still I really like this game. I literally got #1 in like 1 min. It was crazy lol. Never knew there would be such a good game like this to challenge my fingers lol 😆 definitely recommend if your like me and can't stop moving lol idk if it's only me buttttttt.............................. yea. The only problem is the bait.... I mean. It says u can do the Alan walker songs but... YOU CANT! U can only do one halfway for free.... the rest you can't do! If you wanted to play those songs then don't get this game... I won't let you........... I know I know I'm as sad as you are lol 😂 but if you get passed that it's a good game!
Too Confusing
Why can't we just have a simple game where we do what this app was designed to: tap the piano to play a song without hitting the white keys. Instead, you have to worry about all the weekly and daily challenges and rewards while being bombarded with ads every 2 seconds. Here's how it basically goes.
When you first play, you get to play a simple song - Twinkle, Twinkle. When you finish, you get an ad. Then, make sure you play Alan Walker's song! After that song, you get an ad. Want to keep playing Alan Walker's song? It's only $2.99! Oh, and here's 40% on coins so you can play more songs! While you unwantedly browse the prices for the coins, here's an ad! Now, here's the song menu. You're only a beginner, so the next song is Happy Birthday. Let's play! When you click on it, you can get a SPECIAL BOOST that will let you speed through the song! But, it costs 200 coins, or an ad! Don't want to do either of them? It's alright, you can play the song. Oh no, messed up on the second one because you're a beginner and still practicing? It's okay, here's an ad to cheer you up! And now, we'll show you the weekly challenges. This week's challenge is to get the best score on a song you could never play, because guess what? You're a beginner, and mess up on the first try. But it's not your fault, you haven't had any practice because every time you try you get an ad. It's so stupid. No one cares! We just to play the game!
Skip to end of review for TLDR this is a long one
I recently took a break from the game and came back and oh boy was the game different but not for a good reason. This game used to be an amazing game that you could play anywhere without needing to worry about internet and not be flooded with micro transactions and now it's not. At first everything was fine except some new pop ups which I had already gotten used to form previous updates but after 1 game. Only 1, I got an ad. This was fine at first but as i played more and more I saw it was after every. Single. Game. It used to be your choice to watch ads like if you wanted a revive but now you're forced to watch an ad that you can thankfully skip. The medkit system is just flat out horrible. You can revive for free with an ad and yet they expect you to pay them so you can revive instead of paying them with ads with money that doesn't come out of your wallet. I've had a problem with pop ups since the first introduction of them but I didn't mind because it was only one but now it's like 6 just telling you to buy a song and spin the wheel and challenges and do the ranked pieces and other useless stuff. Its just horrible.
TLDR This game used to be an amazing game that you could play anywhere without needing to worry about internet and not be flooded with micro transactions now it's a horrible ad and popup mess.
- Seller
- cheetah technology corporation limited
- Size
- Category
- Games
- Compatibility
Requires iOS 9.0 or later. Compatible with iPhone, iPad, and iPod touch.
- Languages
English, Arabic, French, German, Indonesian, Italian, Japanese, Korean, Malay, Portuguese, Russian, Simplified Chinese, Spanish, Thai, Traditional Chinese, Turkish, Vietnamese
- Age Rating
- 4+
- Copyright
- © cheetah technology corporation limited
- Price
- Free
- In-App Purchases
- 110 Diamonds $9.99
Family Sharing
With Family Sharing set up, up to six family members can use this app.


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For this Spring Seasons Story, I made some flowering cherry blossom trees. There are three sizes, small and tall each have two types, one with an extra layer of dense flowers. There are 2 colours available separately, and a scripted uberpack with 4 shades of pink blossoms and 6 bark colours to choose from in the combination of your choice.
At Seasons Story this month!


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Comments & Responses on the
Environmental Assessment Report
Etowah River Park Trail Extension
Land and Water Conservation Grant Project
Prepared by
Hayes, James & Associates, Inc.
4145 Shackleford Road, Suite 300, Norcross, GA 30093
Contact: Christie Sims, RLA
August 1, 2018
Etowah River Park Trail Extension
Public Review Comments and City Responses
Best regards.
Isabel Nazzari
● The trail extension design calls for clearing the minimal amount of trees and other natural vegetation to install the trail amenities. The flatness of the land and the nature of trail footprints make it possible to wind the trail route as needed to avoid most trees.
Bill Neill
Canton, GA. resident
● We appreciate your enthusiasm and support for this project.


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"Emotional competence requires the capacity to feel our emotions, so that we are aware when we are experiencing stress." ~ Addiction Expert Gabor Maté, Ph.D
What comes up for you when you think about stress? If you're like me, I used to think
about stress as a game. A "survival of the fittest" competition. I used to think, stress is experienced by the weak - so you need to build intestinal fortitude to overcome the stresses in life. I used to think I get energized by stress, and without it, I wouldn't get anything done. I used to think people who want to de-stress are slackers, soft-willed and lack ambition.
How's that for honesty?
I've come to learn that the truth is, like most things in life, nuanced. But what is undeniable is that stress in the modern world isn't like stress experienced by our ancestors, or even 50 years ago. Our physiology hasn't evolved as quickly as our lifestyles and technology to make sense and protect us from harm. In fact, chronic stress, which is the type of stress that many of us experience in the modern world is not an inconvenience, it's lethal.
So, do I still feel the same about stress as I did the past? Well, yes and no. And I'm not saying that just as a former management consultant.
Let's crack that nut apart, shall we?
1. Stress is good for survival
YES: If we were in the wild, and came across a tiger, our reaction to that threat would impact how well we're able to flee, attack and/or hide. Or if we were living off the land, and we had to relocate, that stressor would impact how well we're able to stave off hunger, stay energized and motivated to seek out our next plot of land.
NO: Our body's automatic response to threat is to produce chemicals to help us deal with short term stress with an endpoint (ex. When we've escaped the tiger or when we've arrived at our destination). Prolonged stress isn't good for our body because we are not meant to bathe in the stress chemicals for long periods of time. Stress chemicals over-time break down muscles, brain tissues, bones and wreak havoc with our mental and physical health.
SO WHAT? When stress is experienced in the short-term, it can help us run faster, jump higher, dig deeper into our mental and physical energy reservoir. However, whenever stress is extended, especially one with no end in sight, it's a quick way to remove ourselves from the proverbial gene pool, because we will get sick. It's not a matter of if, but when. Modern day stressors are often ongoing, long-term, almost with no end in sight. We'll talk more about that later.
2. Stress is experienced by the weak
YES: If we're defining the "weak" by someone who is lacking in ability or resources, there is some truth in this. Stress is experienced when the demand exceeds our ability or resources (perceived or real). Say, if the mob extorted me for $100M by end of the week, For sure I will be highly stressed out because I currently do not have $100M or the ability to easily acquire this money. Now, say if Jeff Bezos was extorted the same amount, his level of stress compared to mine would differ greatly because both his resources and ability, in this context, would exceed mine (for now).
Similarly, if we're asked to solve a problem at work for which we are under-resourced, or present on a topic for which we know very little, or host a dinner party when we are not confident about our cooking, or perform on a test for which we are ill-prepared, we will experience stress. In all these examples, the person would experience less stress, if given more support and resources.
NO: However, it's not like the top dog doesn't experience stress. Stress is an equal opportunity, non-discriminatory experience. The playing field is leveled out by the protective mechanism of our brain and body. Even if we had all the resources and abilities in the world, we still have to grapple with our evolved brains which come with an interesting feature for survival, but not very helpful for happiness. This feature is called "negative bias."
Negative bias is our brain's tendency to focus on the negative. Our brain evolved to routinely trick us into making three mistakes: overestimating threats, underestimating opportunities, and underestimating resources (Hanson 2013). This likely served us in the past - to be vigilant of threats in the wild and fulfilling opportunities. It was more beneficial for our ancestors to regularly mistake a rock for a tiger, than to not spot the tiger in the event it's there, even if it caused some unnecessary anxiety. Fast forward to us, who have inherited these traits in the modern world. In the modern world, there are more than just tigers that can potentially harm us, and our brain is on overdrive scanning our environment for threats (virtual and IRL). You know exactly what they sound like.
So what exactly is scanning our environment? Well, there are our five senses of which we're consciously aware (ex., a honking horn, smell of smoke, a look disdain). We also have a hardworking system interpreting our environments for threats below our level of consciousness. This system is our Autonomic Nervous System (ANS) and it senses and monitors our environment 24/7 - even when we are sleeping. In fact, this why we tend to not sleep as well when we are in a new location because half of our mind is assessing if our new environment is safe (Tamaki et al. 2016).
Now, take into the context of our modern living where it is said that we consume more data in one day that a person from the 15th century consumes in a lifetime! Some of these norms are: hyper-accelerated pace of life, inability to fully disconnect from work, financial pressures, dating / relationship pressures, addictive mobile devices, negative emotions with social media usage, disrupted sleep due to late nights, blue lights and interruptions from technology on our circadian rhythm, lack of sun exposure, lack of access to nature, frequent flying and radiation exposure, lack of connection to community, exposure to pesticides, convenience of processed foods, trans fats, GMOs, and sugar at our fingertips… just to name a few.
When our ANS sends messages to our brain with potential threat to our wellness, our brain sends directives to our sympathetic nervous system (SNS). The SNS is responsible for preparing us for activity related to "fight/flight/freeze." When the SNS receives the message that we are under threat (perceived or real), it releases chemicals to help us get out of danger. The HPA axis which consists of the hypothalamus, pituitary gland and the adrenal glands, is the network responsible for releasing stress chemicals. As long as our brain is still receiving messages of threat, our HPA axis will keep its "foot on the gas pedal" (Seyle, 1950). Over time, this messes with our hormones and creates a downward spiral on our health. Unfortunately, in our modern world, most of our stressors are on-going because it's now our way of life.
If you're feeling your SNS responding to this section of the article, go ahead and take 3 deep breaths through your nose filling your belly with air, keeping your exhale a second longer than your inhale, and tell yourself you're safe and not in danger (this will activate your parasympathetic nervous system to chill; you're welcome).
SO WHAT? Everyone experiences stress; many will experience chronic stress especially in modern living. Some experience stress very consciously, but everyone is experiencing stress on a subconscious or unconscious level as well. If health and wellness is important to us, we must identify our contributors of stress, monitor our levels of stress throughout the day, and work on supporting our stress response system. We are most vulnerable to the ailments of stress when we think we are not impacted or don't take efforts to de-stress. A side note about sustaining stress - according to the Hans Selye, father of stress research, our bodies respond to stress in three stages 1) Alarm 2) Resistance 3) Exhaustion. When we are in stage two, our body is pushing down the "gas pedal" of our stress chemicals to maintain our ability to escape danger. Individuals vary on the length they can sustain stage two. During this period, we might not be feeling awesome, but we're getting things done, so we believe we're coping just fine. However, the gas will eventually run out and we'll dip into stage three, where we become susceptible to serious diseases. Unfortunately, many (including me) learn this lesson the hard way - when we wake up one day mentally and physically burnt out or learn that our health has been seriously compromised.
3. Stress is energizing and productive
YES: Our brain needs to be a little bit challenged and our interest piqued for us to access the creative area of our brain. Our prefrontal cortex (PFC) is the most evolved region of our brain responsible for things like decision making, expression, innovation and insight. A neuroscience perspective is that in order to access our PFC, we need to be in a sweet spot that generates eustress or "good stress" which is between being completely bored out of our minds and overwhelmed. Eustress is not determined by the type of stressor, but how one perceives the stressor, which means everyone's "sweet spot" is going to be different. When we are out of range of Eustress, we heavily rely on our basal ganglia which is the part of the brain responsible for our "working memory" - think frying an egg, driving or riding a bike, where we don't really have to think a whole lot (Fabritius, 2018).
This means some stress is good for us. we know we're experiencing eustress when the stress (Seyle, 1974):
NO: Bad stress or distress is unrewarding and with a lot of risks attached. When our body perceives unhealthy stress, we produce a chemical called cortisol. When cortisol is released, our PFC shuts down. When we are exposed to stress, we lose our prefrontal cognitive abilities. Why? Because when our life's threatened, the priority is to get us the heck out of danger rather than play with creative concepts. The PFC is the brain region that is most sensitive to the detrimental effects of stress. So much so that prolonged exposure to stress causes this part of your brain to shrink (Arnsten 2010).
Bad stress weakens prefrontal networks and higher cognition (Arnsten 2015). What does this mean? It means that stress can make us stupid. Stress shuts down the thinking part of the brain so that we can respond to threat instinctively and reflexively. This would have been the "smart" thing to do in the wild - when there's no time to sit and wax philosophical. However, our ancient protective mechanism doesn't help us out in the modern world when stress runs high. We are expected to think and refine and analyze and calculate and negotiate and present and produce creative, innovative, brilliant solutions to most modern-day problems.
SO WHAT? Some short-term good stress is good for us. We need to be aware of the eustress and distresses in our lives to keep check of the type of stress we are taking on. Too much stress is harmful to our cognitive ability. In fact, not only do our PFC shrink with stress, our amygdala, the part of our brain that detects danger and reacts with fear, anxiety, and aggression actually increases in size as it works overtime. So the more anxious and stressed out we are, the more anxious and stressed out we become! (Kaufer et al., 2014)
4. People who can't handle stress lack grit and ambition
YES: Our society definitely depicts people who can't handle stress as lacking in will or perseverance. We see this in movie characters and perhaps even some people through our lives. It begins with the child who can't resist and wait to eat the marshmallow and will eat it immediately upon being given one. Then the teenager who struggles with the test and gives up completing it only halfway. As adults, the person who lets "that's too difficult" become the driver their decision making. It is entirely possible that all of these individuals lack grit and ambition because they can't handle stress. But more likely, there's something else going on here.
NO: There are a few concepts that can easily get conflated with not being able to handle stress.
There are many reasons why people don't persevere, and many of them have nothing to do with the ability to cope with stress. In fact, when we have a clear vision and purpose, coupled with skills to boost our confidence, we will naturally prioritize to realize our goals.
It has been shown that when individuals are taught how to delay gratification for a more positive outcome, crystallize their vision and purpose, and increase their confidence with training or new tools, the same individuals will charge forward with new found energy and direction.
As mentioned previously, there are good stress and toxic stress. Good stress challenges us to grow, and if we do it well, we are rewarded to our satisfaction. Toxic stress is prolonged with an unclear "finish line," where the challenges and difficulties are mostly out of our control with lack of/uncertain rewards. When we identify the toxic stress in our lives, the choice becomes clearer in terms of how we want to respond. If we continue and do nothing about our toxic stress, it's a form of self-harm. So one can say people who opt-out, won't or "can't" handle stress (toxic stress) is practicing self-care.
SO WHAT? There are definite benefits to developing "intestinal fortitude," "thick skin" and other strategies such as social support and presence/mindfulness techniques and other skills to make us more resilient to life's ups and downs. However, most of us will experience at some point in our lives where inevitably stress will impacts our wellbeing. We need to take care of ourselves so that we can offer our best to the world because that's what will make us happy. We need to recognize when we are enduring something toxic without replenishing ourselves and stop the self-abuse. High-performance athletes will spend millions of dollars on self-care and performance recovery annually. Why the investment? Because they know that when they practice self-care by reducing/removing toxicity from their lives and replenish with nourishing elements for their minds and bodies, they will thrive and outperform themselves in the long run. Just ask LeBron James!
Ok, I'm stressed out. What's the big deal?
According to stress experts such as Dr. Hans Selyes ("Father" of Stress Research), Dr. Robert M. Sapolsky (Professor of biology and neurology at Stanford University), Dr. Bessel Van Der Kolk (PTSD and Neuroscience Researcher) and others, here are some physiological impacts of chronic stress on our bodies:
A part of me wished I'd known more about the causes and impacts of stress on personal wellness in past years. I might have reprioritized and changed many life's decisions. But then, on the other hand, I wouldn't be in the position to share my experience today and hopefully help out someone else.
Passing on my experience with you so that you may make a more informed decision about how you want to live your life.
Do you have an experience with stress you'd like to share? Do you have an idea for a future article? Drop me a note, I'd love to hear about it!
Leave a Reply.
January 2020


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Friday, March 7, 2014
Day Before Snow
I thought spring was coming, but the day after I took these pictures we received about 8 inches of lovely fluffy cold stuff!
Life has been pretty slow lately. I rearranged my "studio" (the room that I use as my closet/sewing space/ knitting area! Pictures to come soon. Or, perhaps a video reveal? ).
My husband is talking about buying a shed for our backyard so he can turn our storage room into a "perfect man cave" (since I took over half his man cave with womanly things.) I know not every couple is blessed to have their own space, but I know both of us having different places to go has drastically helped our marriage when we need time apart. I have a running joke with Mr. Adventure over the fact that we have two bathrooms--because I'm sure this tiny fact has saved our marriage more then once.
Other then that, I've read a few books. Mr. Adventure and I had a silly spiff and made up over drinks at Logan's Roadhouse. We also successfully attended the gym every other day last week. Also, all that swimming has given me an ear ache. Poor ear.
Life is pretty slow right now, and I'm
enjoying it. Here's to spring--and a hopeful look towards turning Mr. Adventure's man cave into a nursery. Maybe.
How are you?
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