text: Assessment of International Medical Graduates and Their Integration into Family Practice: The Clinician Assessment for Practice ProgramMaudsley, Robert F. MDAcademic Medicine: March 2008 - Volume 83 - Issue 3 - p 309-315 doi: 10.1097/ACM.0b013e318163710f International Medical Graduates Abstract Author Information Article Outline The Clinician Assessment for Practice Program (CAPP), a program of the College of Physicians and Surgeons of Nova Scotia (CPSNS), assesses the readiness for family practice of international medical graduates (IMGs) who have trained and practiced abroad with no formal Canadian residency training. CAPP has three parts. Part A, a therapeutics exam and an objective structured clinical examination, assesses practice readiness. Part B is a 12-month mentorship in which the CAPP physician is in active practice under a defined license and is mentored by an established family physician. The mentor provides teaching, supervision, guidance, and regular performance assessment. Each CAPP physician negotiates an individualized continuing medical education plan. An on-site assessment of each CAPP physician's practice is conducted by an external assessor who provides feedback to the CAPP physician and his or her mentor. Multisource feedback is administered at 10 months, using questionnaires from patients and colleagues. After 12 months, all assessment data are reviewed by the CPSNS to determine whether to continue the defined license. Part C, run by the registration department (not CAPP), may last three additional years until full licensure is obtained. To date, 148 IMGs have been assessed, 35 have been deemed eligible for a defined license, and 27 have entered family practice, virtually all in small or medium-sized communities in Nova Scotia. The program has been well received by participants and their communities. The mentorship, particularly valuable in assisting IMGs to integrate into their communities, has proven to be the defining feature of CAPP. Dr. Maudsley is executive director, Clinician Assessment for Practice Program, College of Physicians and Surgeons of Nova Scotia, Halifax, Nova Scotia, Canada. Correspondence should be addressed to Dr. Maudsley, College of Physicians and Surgeons of Nova Scotia, Suite 200, 1559 Brunswick St., Halifax, NS B3J 2G1,Canada; telephone: (902) 482-2915; fax: (902) 422-7476; e-mail: (email@example.com) or (firstname.lastname@example.com). Abstract Program Model The Three-Part CAPP Program Part A: Initial assessment Part B: Defined licensure Sponsors and mentors. Continuing medical education. First-year assessments. Part C: Obtaining full licensure and certification Program Funding Program Outcomes The 2005, 2006, and 2007 cohorts Future funding Changes to CAPP Resources for CAPP candidates and physicians. English competency. Clinical skills. Improved incorporation of CME. Program research and evaluation. Assessing specialists. The value of the mentorship. CAPP and the wider community. Summing up. Acknowledgments References Some developed and many developing countries do not produce and retain a sufficient number of physicians to meet their medical care needs. Canada relies on international medical graduates (IMGs) to contribute to the physician workforce; currently, 23% of Canadian physicians obtained their medical degrees from outside Canada.1 In the United States, 25% of the physician workforce are IMGs.2 In the United Kingdom and Australia, IMGs represent 28% and 26.5%, respectively, of the physician workforce. Lower-income countries supply between 40% and 75% of the IMGs to these four countries, with India, the Philippines, and Pakistan being the leading sources.3 In 2003, the College of Physicians and Surgeons of Nova Scotia (CPSNS) investigated the feasibility of establishing a program to assess IMGs wishing to enter family practice in Nova Scotia. During the previous decade, the CPSNS had referred IMGs to the University of Manitoba assessment program. After 2004, the University of Manitoba program was no longer available to IMGs in Nova Scotia because of increased demand (the Manitoba program was used to assess the IMGs of its own province as well as those of Saskatchewan). The establishment of a new program offered an opportunity for addressing some of the issues that had concerned Nova Scotia IMGs and physicians when they used the Manitoba program. During the years when the CPSNS still had access to the Manitoba program, IMGs were required to identify an established, willing physician sponsor in Nova Scotia before being assessed. Many of these established physicians were reluctant to commit to being a sponsor until they knew the IMG was licensable. Also, the quality of sponsorship varied considerably. Some sponsors were especially attentive to the learning needs of their IMGs, whereas other sponsors spent little time in the supervision or guidance of theirs. The establishment of a new program offered an opportunity to address some of these concerns. Therefore, the designers of the Nova Scotia program convened two focus groups: one of previous sponsors, and the other of IMGs who had been successfully sponsored by a physician, assessed by the Manitoba program, and were now in active family practice in Nova Scotia. From the focus groups, it was evident that a more formalized process of support, supervision, and evaluation was necessary to strengthen and regularize defined licensure. Thus, we developed a mentorship model in which the mentor plays a more active role during the first year of defined licensure. Across Canada, there are several other provincial IMG assessment programs for family physicians and specialists; however, according to a popular Internet site, all of these are focused on determining IMG suitability for Canadian residency training.4 In contrast, the Nova Scotia program has been initially limited to determining practice readiness for two reasons: first, there were virtually no residency positions available to IMGs in Nova Scotia; and, second, we believed that some IMGs are indeed ready for clinical practice but still require initial support and guidance to adapt to family practice specifically in Canada. This article describes the program developed in Nova Scotia to assess and integrate IMGs into family practice, and the experience of the program to date. Back to Top | Article Outline Program Model We developed a model that could be readily adapted to assessing international graduates of other health care professions as well as IMG physicians and that could be made widely available to professional licensing authorities. Although the initial focus was on the assessment of family physicians, we maintained the concept of a more broadly applicable model with emphasis on practice readiness—hence the name, the Clinician Assessment for Practice Program (CAPP). A three-part CAPP model evolved (see Figure 1). Part A is a stand-alone assessment component for IMG referrals who have applied to any medical licensing authority. For those IMGs who are granted a defined license to practice family medicine in Nova Scotia, this assessment becomes an integral part of their overall program along with parts B and C, which are both based on the premise that although newly licensed IMGs are considered practice ready, they lack formal Canadian residency training and experience. To compensate, Part B is a 12-month program of continuing professional development, with ongoing support, guidance, and evaluation by a physician–mentor as well as assessment at 6 and 10 months. Part C, which may extend up to three years beyond Part B, is essentially managed by the registration department of the CPSNS, rather than CAPP. Figure 1 CAPP accepts referrals from medical regulatory authorities of IMGs who are citizens or permanent residents of Canada, who have graduated, trained and practiced abroad (for at least three years, including both training and practice), and who have successfully completed both the Medical Council of Canada Evaluating Examination (MCCEE), a screening examination for IMGs, and the Medical Council of Canada Qualifying Examination Part I (MCCQE I), an assessment of competence for entry into supervised clinical practice with respect to knowledge, clinical skills, and attitudes. Some CAPP candidates have also completed the MCCQE II (an OSCE assessing competence for medical licensure in Canada). (The other candidates must also eventually complete this examination to earn full licensure; they can attempt to do so during their first year of practice.) A formal test of English is not required. Provincial medical regulatory authorities may require other prerequisites before referring an IMG to CAPP; for example, Nova Scotia requires IMGs to have been in clinical practice within the last five years. Back to Top | Article Outline The Three-Part CAPP Program Part A: Initial assessment Part A has two components: a written therapeutics examination, and an Objective Structured Clinical Examination (OSCE). (All candidates' general medical knowledge has been assessed by the initial, required MCCEE and the MCCQE I.) The therapeutics examination, three hours in length, uses a 50-item short-answer format, with nearly all questions related to a brief clinical scenario. The test assesses domains of pharmacotherapy, adverse effects, disease prevention, and health promotion for people of all ages from infants to older adults. Also incorporated into the examination booklet are several blank prescription forms that candidates must complete on the basis of the clinical scenario. Candidates are assessed as to whether their prescriptions, as written, are appropriate and could be safely and efficiently filled by a pharmacist. The second component, the OSCE, is developed and conducted in close collaboration with the Learning Resource Centre (LRC) of the Dalhousie University Faculty of Medicine. It is designed to simulate a half-day experience in a typical family practice clinic, and it comprises 14 stations, which are each 10 minutes in duration. Some cases are taken from the LRC case bank (an archive of cases used to assess medical students and residents) and modified to assess practice readiness; other cases have been developed specifically for CAPP by family physicians. The LRC staff select and train standardized patients to follow detailed scripts. The OSCE examiners, family physicians in active practice throughout Nova Scotia, are trained in a mandatory half-day workshop. During the OSCE, the physician examiners assess various clinical skills, including clinical reasoning and decision making as well as English proficiency as it relates to the clinical encounter. Standardized patients provide a more detailed assessment of CAPP physicians' communication skills and spoken English. Because some candidates may have had little or no experience with an OSCE, a 10-minute video orientation of a CAPP OSCE is included on the CAPP Web site (www.capprogram.ca), and candidates attend an orientation session on the day preceding the examination, to become familiar with the exam setting and OSCE protocol. Results of the Part A assessments are reported to the candidate and the referring medical regulatory authority in a comprehensive, mainly narrative format, emphasizing strengths and areas requiring improvement. The report of candidates' OSCE performance does not provide exact numerical scores; rather, candidates are divided into quintiles based on performance, and the candidate's placement is included in the report. The OSCE report, prepared by the chief examiner, contains commentary on the CAPP candidate's skills in history taking, physical examination, diagnosis and problem definition, investigation and management, clinical reasoning and decision making, communication, spoken English, and professional/ethical behavior. The OSCE report also provides information on the candidate's knowledge of public health/medicolegal and safety issues. Finally, the report includes global ratings (an overall assessment by the physician examiner at each station) of the candidate. The report for each candidate, typically 7 to 10 pages in length, serves to assist candidates in their continuing professional development. For candidates who have applied for licensure in Nova Scotia, the Part A assessment, along with information about previous training and experience, is considered by the credentials committee of the CPSNS, which decides which candidates will be granted a defined license and move on to Part B. A defined license is granted to physicians not meeting all requirements for full licensure. (Requirements for full licensure [not an option available to candidates at this stage] are holding both the licentiate of the Medical Council of Canada and certification in family medicine or a specialty by a Canadian certifying body.) This defined license is subject to conditions or limitations and is reviewed annually by the CPSNS. Candidates not successful in obtaining defined licensure may request that their report be forwarded either to the Canadian Resident Matching Service in support of an application to a residency program or to other provincial medical regulatory authorities. Candidates unsuccessful in qualifying for defined licensure are not permitted to take the CAPP assessment again without evidence of some additional training/experience, such as six months in a supervised general practice setting, approved by the CPSNS. Back to Top | Article Outline Part B: Defined licensure Sponsors and mentors. Each CAPP physician (defined licensee) must have a sponsor and a mentor as a condition of the defined license. This mentorship provides an opportunity for CAPP physicians to learn and experience family practice in Nova Scotia, with the coaching and facilitation of an experienced family physician. It is designed to ensure that CAPP physicians are competent, have support when they establish practice, and are integrated into the local community. The CAPP physicians select potential practice opportunities in communities needing family physicians, as determined by the provincial department of health (DOH) and the nine provincial district health authorities (DHA). Before mentors are assigned, travel and accommodation arrangements are made by the DOH for CAPP physicians to visit selected communities and practice sites and to meet with potential mentors and local DHA officers. The roles of the both the sponsor and mentor are described in the CPSNS regulations.5 Sponsors are designated by DHAs and must have full registration with the CPSNS. Most are the medical directors/chiefs-of-staff of the DHA. The sponsor proposes to the CPSNS a mentor for the CAPP physician. Before the CAPP physician establishes a formal relationship with a mentor or sponsor, he or she works under the supervision and observation of the proposed mentor for two to four weeks to determine compatibility. If all parties are agreeable, the CPSNS is notified, and defined licensure is formalized. The approved mentor must have full CPSNS registration, be engaged in a scope of practice comparable to that of the CAPP physician, practice in the same DHA, report regularly on the CAPP physician's performance, and notify the CPSNS promptly if concerns about the CAPP physician's practice arise. Each sponsor and mentor is provided with his or her CAPP physician's Part A assessment; an outline of the physician's previous training and experience (self-reported); and a procedural skills inventory of office and minor surgical procedures, noting training, experience, and confidence in performing such skills as providing pap smears, suturing minor lacerations, taking arterial gas samples, and applying simple casts. Mentors receive a comprehensive manual when they attend a mandatory two- to three- hour workshop conducted by the mentorship coordinator. Initially, this one coordinator meets individually with each CAPP physician to discuss Part B of CAPP, including the mentor's role as well as assessments by the mentor and others. The coordinator is readily available by telephone to both the mentor and CAPP physician and also travels to the practice site to assist with difficult issues or problems, if necessary. All mentors receive a monthly stipend for 13 months, with the expectation that they will spend four to five hours per week in direct contact with their CAPP physicians. Back to Top | Article Outline Continuing medical education. All CAPP physicians are referred to Dalhousie University's continuing medical education (CME) office at the outset of Part B for development of an individualized educational plan (IEP) based on the Part A assessment, previous training and experience, and the context of the new practice. A CME faculty member, an active clinician, is available as a resource throughout the mentorship, serves as the CAPP CME coordinator, and develops, with each CAPP physician, his or her IEP. This IEP is shared with the mentor and the mentorship coordinator. The overall goal of the CME component is to assist the CAPP physician in a learner-centered approach to continuing professional development based on the model of the reflective practitioner. Back to Top | Article Outline First-year assessments. The mentor not only facilitates progress and learning, but also evaluates the physician's performance providing progress reports at months 1, 2, 4, 6, 8, 10, and 12 to the CAPP physician, his or her sponsor, and CAPP administration. The categories of the reports are generally parallel to the Part A assessment so that previously identified strengths and weaknesses are the focus of the evaluations. Commentary is also provided on areas such as consultation and referral, record keeping, time management, professionalism, willingness to learn and change, and working collaboratively. The mentor uses a five-point scale ranging from performance is "above" to performance is "significantly below" that of an established physician (one who is settled in the community; conducts an active medical practice; and has gained the confidence of patients, medical peers, and other, non-medical coworkers) to assess the CAPP physician. The mentor notes both the basis of the assessment, such as direct observation or chart review, and the confidence he or she has in the rating depending on the number and duration of the assessments. The CAPP physician completes both a brief self-assessment of perceived progress and an evaluation of the mentor relationship. The mentorship coordinator reviews all progress reports as received and follows up with mentors and physicians. An integral component of Part B is an on-site assessment of the physician's practice after four to six months. This timing allows the physician to develop a reasonable volume of patients, yet it is early enough to effect improvement of any identified deficiencies. A CAPP external assessor, an active family physician who has received instruction specifically for the role, evaluates the CAPP physician's practice. The assessor receives the Part A assessment, a summary of previous training and experience, the procedural skills inventory, and the CME plan before the scheduled visit. The assessor operates under the CPSNS regulations with respect to peer review, which provides authority to review patient files and to comment on the quality of care provided while maintaining confidentiality and receiving indemnification from legal action by the physician. Spending three to four hours on-site, the assessor reviews the operation of the practice and physical facilities, conducts an audit of 25 randomly selected charts and a chart-stimulated-recall interview, interviews office staff as appropriate, meets with the mentor to discuss the CAPP physician's progress, and provides initial feedback to the physician and mentor at the conclusion of the visit. The assessor submits a formal report to CAPP, following a standard template, which is shared with the physician, mentor, and sponsor. The various assessors are nominated by the DHAs and approved by the CPSNS. CAPP assigns assessors, both to distribute the workload and to avoid assessments within their own DHA. At 10 months, to assess the physician's performance, we conduct a multisource feedback using standardized questionnaires that were specifically developed by assessment bodies in two other Canadian provinces for IMGs holding defined licenses.6 CAPP receives questionnaires directly from 25 randomly chosen patients, eight medical colleagues, and eight other coworkers, who may be either other health care professionals such as nurses, pharmacists, social workers, physiotherapists, etc., or office, clerical, or administrative staff in the practice, local hospital, or community. The CAPP physician supplies the program with a list of references, from which the last 16 are chosen. A fourth questionnaire, a self-assessment, is obtained from the CAPP physician. The questionnaires are scored and analyzed independently of CAPP by research colleagues who originally developed the questionnaires at the University of Calgary, and reports are provided to the physician, mentor, sponsor, and CAPP. The number of questionnaires given to each group of people was determined in pilot projects to balance the feasibility of obtaining a reasonable sample size with the need for producing valid data while maintaining the confidentiality of all respondents. At the conclusion of Part B, the physician's performance, as evidenced by a summary of the mentor's progress reports, the external assessor's report, the multisource feedback report, CME activity, and the mentor's summary statement, is reviewed by the CPSNS Credentials Committee. This committee grants continuations of defined licensure, specifies any conditions attached to licensure, mandates any further follow-ups, and decides whether the formal mentorship needs to continue. When the mentorship period is over, the physician moves on to Part C. Back to Top | Article Outline Part C: Obtaining full licensure and certification During Part C, the CAPP physician, as a defined licensee, must continue to have a sponsor approved by the CPSNS; this sponsor, the same sponsor as before, provides CPSNS with semiannual reports during the first year of practice and an annual report thereafter. During Part C, the physician must obtain both the Licentiate of the Medical Council of Canada (LMCC) and certification by the College of Family Physicians of Canada. Currently, physicians with a defined license for family practice have a maximum of four years to complete the requirements for a full license. An IMG physician can earn LMCC licensure by successfully completing both parts of the council's qualifying examinations. A defined licensee can obtain certification by the College of Family Physicians of Canada through the practice-eligible route (in contrast to completion of a formal family medicine residency), which requires five years of active family practice, two of which must be in Canada. Thus, many CAPP physicians can attempt the certification examinations in the third year of their practice in Nova Scotia (having had at least three years of family practice abroad) and, if unsuccessful, again in their fourth year. If they fail to meet this deadline, their defined license may not be renewed. (No CAPP physician has reached this stage of the program; therefore, none has failed to receive full licensure, but one could anticipate a strong community reaction should a popular and "successful " physician be denied continuation of defined licensure.) Back to Top | Article Outline Program Funding Because start-up funding from provincial and federal governments was not forthcoming, the council of the CPSNS committed funds as a loan, anticipating that the program would become self-sufficient within 24 months. Candidates pay an examination fee for the Part A assessment. Some candidates have expressed concern about the amount of the fee charged: 5,500 Canadian dollars; however, the assessment must be conducted on a cost-recovery basis. The Nova Scotia DOH has provided funding in support of Part B, including mentor stipends and partial support for the mentorship coordinator, CME costs, and costs for the external assessment and multisource feedback. CAPP subsequently received a one-time Health Canada grant to assist with implementation of the program. Since then, Health Canada funding has been received for the orientation program and a planned mentors' focus group and workshop. In 2007, the DOH provided one year of funding to support the infrastructure of the program. The DOH issues formal contracts both to the CAPP physician and to the mentor. The CAPP physician signs a four-year contract with the DOH and the DHA. The first year's compensation is guaranteed with subsequent years' pay continuing as during the first year, changing to fee-for-service, or becoming a blend of both. Contract completion results in a bonus to the physician. Back to Top | Article Outline Program Outcomes The 2005, 2006, and 2007 cohorts CAPP was established in mid-2004 and offered its first assessment in June 2005. The outcomes of the first four cohorts are outlined in Table 1. Because of initial demand, two assessments were conducted in 2005; subsequently, one assessment per year has been offered. Table 1 The 148 applicants from 2005, 2006, and 2007 received their medical education in 26 countries—the majority in South Asia (50%), the Middle East (25%), and Eastern Europe and Russia (10%). Virtually all of these CAPP physicians graduated between 1970 and 2007—43% between 1981 and 1990. Fifty-three percent of these 148 applicants are female. Although the majority of candidates resided in Ontario (105), there have been candidates who lived in Nova Scotia (25), British Columbia (6), Quebec (4), Alberta (3), Manitoba (2), Newfoundland and Labrador (2), and New Brunswick (1). Even though CAPP is a Nova Scotia program, large numbers of candidates have lived in Ontario because the greatest concentration of IMGs in Canada is in southern Ontario near the greater Toronto area. Candidates who are granted a defined license relocate to Nova Scotia to practice and live there. Nova Scotia, with a population of one million, has about 1,000 family physicians. There is an insufficient number of IMGs living in Nova Scotia to sustain the CAPP program and provide the numbers needed to care adequately for the citizens of that province. Twenty-seven CAPP physicians from these first four assessments are now in family practice in Nova Scotia. Twenty-five are practicing in small and medium-sized communities. The reduction in the number of candidates (see Table 1) has been significant and may be associated with at least three factors: the relatively low success rate in obtaining licensure (see reason below), which discourages potential applicants; the increase in residency positions and expanded IMG programs in Canada; and, possibly, fewer eligible IMGs in Canada than previously estimated. There is no definitive, accurate count of the number of IMGs in Canada who are seeking to practice in Canada. Media reports may have overestimated the numbers seeking licensure and practice opportunities. Back to Top | Article Outline Future funding The June 2007 assessment had 20 candidates, which is near the lower limit necessary to sustain the program. There have been discussions to determine whether provincial funding will be cost-effective to continue CAPP. From previous experiences, five to seven new CAPP physicians can be anticipated from a cohort of 20 candidates. The CPSNS and its credentials committee set a relatively high standard for granting licensure because candidates need to be practice ready and to demonstrate their ability to start practice immediately without any Canadian residency training. The cost of sustaining CAPP with this output could probably be justified when compared with the costs of providing complete family medicine residencies for a comparable number of (five to seven) IMGs; however, the success rate for any cohort of candidates is not predetermined and can be quite variable. Once a decision is made to offer the initial assessment (Part A), there is an implied commitment to provide the 12-month (Part B) mentorship component, so any funding decisions need to be made only after a great deal of consideration and planning. Back to Top | Article Outline Changes to CAPP Resources for CAPP candidates and physicians. At the time of the first assessment (June 2005), a job information fair was organized by the DHAs, DOH, and Doctors Nova Scotia (the provincial medical society). The fair provided candidates an opportunity to discuss potential practice sites with DHA representatives and contract arrangements with the DOH. Although well attended and positively received by participants, the job fair was not repeated in its original format, because the number of successful candidates from the first cohort was relatively small, and the fair organizers thought their resources could be better focused on those who were successful and deemed eligible for licensure. A much reduced version (sponsored and organized primarily by the DOH) was held in December 2005, and none has been held since because eligible CAPP physicians began to focus more on practice opportunities and site visits. Early on, in 2004, CAPP established a Web site (www.capprogram.ca) to provide information, examples of examination questions, an orientation video of a CAPP OSCE, suggested study resources, and current information about previous assessments. In addition, a five-day orientation program was provided to the third cohort (2006) of CAPP physicians after they had earned eligibility for defined licensure but immediately preceding their site visits to selected communities. Presenters of each three-hour session covered the following topics: orientation to the Nova Scotia Health Care System, cultural diversity, patient-centered care/collaborative practice, ethical and legal issues of practice, prescribing and narcotic prescribing in Nova Scotia, and use of the Electronic Bookshelf. The orientation also included clinical instruction and experience with female breast and genital examinations as well as male genital examinations. Finally, the session covered an overview of the CAPP physician contract, site visits, and the mentorship component of Part B. Feedback from this cohort, after having been in practice in Nova Scotia for six months, indicated the orientation topics to be relevant to and very helpful in their practice. A similar orientation program was organized for the 2007 cohort. Back to Top | Article Outline English competency. IMGs contemplating a CAPP assessment are encouraged to have their English language skills assessed and strengthened as necessary before attempting the assessment. CAPP administration believes that the Part A OSCE, through which both physician examiners and standardized patients assess English proficiency for nearly three hours, is a reliable and relevant test of CAPP candidates' English proficiency. In the first two OSCEs, physician examiners and standardized patients performed identical, but independent assessments of candidates' communication skills. Analysis revealed a high correlation between the two assessments. To provide examiners with more time to assess candidates' clinical-reasoning and decision-making skills, physician examiners now provide only a global assessment of communication skills and spoken English (vocabulary, organization, rate of speaking, accent, use of jargon/idiomatic expressions). The correlation between the two groups of assessors with respect to global assessments of communication skills remains high. Few of the IMGs assessed demonstrated difficulties with English proficiency significant enough to impair their communication with patients. Those few who did were deemed ineligible for licensure. Several of the successful candidates were advised to improve their English proficiency during Part B, and the mentors' reports, external assessments, and multisource feedback monitored progress in this regard. All these physicians demonstrated improvement during the year. Back to Top | Article Outline Clinical skills. The 2005 OSCE was adapted for 2006 to incorporate enhanced assessment of clinical-reasoning and decision-making skills, using a key features approach.7 Examiners at 9 of the 14 (reduced from 15) stations use structured questions to probe for a differential diagnosis, the most likely diagnosis, the case features leading to those selections, initial key management steps, and the rationale for selecting these steps. To provide additional time for these new skills assessments, the OSCE stations were lengthened from 10 to 12 minutes. A content validity study of the clinical scenarios used on the first two therapeutic examinations, using 23 family physicians in Nova Scotia, found nearly all test items to be relevant to family practice in Nova Scotia. Back to Top | Article Outline Improved incorporation of CME. It became apparent with the first cohort that the CME plan was not particularly well incorporated into CAPP physicians' practices, especially with respect to the involvement of the mentors. Now, CAPP physicians teleconference with their mentors, the CME coordinator, and the mentorship coordinator eight weeks into their practice to discuss the CME plan and possible modifications in relation to early experiences in their practice. This approach seems to have improved the engagement of the mentor in the CME process. A second teleconference is held shortly after the external assessor's visit to review the CME plan developed by the physician and mentor in response to the feedback and recommendations identified in the external assessment report. Another strategy meant to increase CME incorporation is the requirement that during month 12, the physician is required to submit a summary of CME activities to be included in the documentation considered by the CPSNS Credentials Committee. Back to Top | Article Outline Program research and evaluation. An active program of CAPP research and program evaluation is ongoing, using mostly qualitative methods, including surveys of stakeholders, mentors, and physicians; integration of IMGs into communities; usefulness of assessment of spoken English; assessment of clinical reasoning and decision making in the OSCE, using the key features approach; and potential links of external assessment and multisource feedback to the initial assessment. Back to Top | Article Outline Assessing specialists. There has been significant discussion about using CAPP to assess IMG specialists. Plans are underway, contingent on DOH funding, to provide assessment in collaboration with Dalhousie Postgraduate Medical Education for selected major specialties (e.g., anesthesia, internal medicine, psychiatry, general surgery) needed for medium-sized communities. The concept of context-specific practice and assessment is in development. The DHA will identify the scope of specialty practice required for an identified community, compatible with available resources. The context-specific assessment, lasting three to six months, conducted under the direction of the relevant Dalhousie residency program director in a teaching hospital, will be based on the identified context of practice. After a successful assessment, the IMG specialist will be deemed eligible for practice in the identified community within the scope of practice. The mentor will be a certified specialist within the DHA, with, at a minimum, a similar scope of practice to the IMG specialist. Enhancement of the practice context will depend on the availability of community resources and the acquisition of new knowledge and skills through CME by the IMG specialist. This approach—that is, the CAPP model of rigorous assessment, a mentor, CME, and periodic assessments—will be used for practice-ready IMG specialists. Back to Top | Article Outline The value of the mentorship. Although the initial focus and efforts of CAPP were directed at establishing a credible initial assessment (Part A), it has become apparent that Part B, especially with respect to the mentorship component, along with the on-site assessment, multisource feedback, and the emphasis on an individualized CME plan, is the essential and defining element of CAPP. It is also clear from comments of mentors and CAPP physicians that Part B, especially the mentorship, is very important to the integration of CAPP physicians into their medical and broader communities. In one arrangement that worked particularly well, three physicians were located in one clinic with a single mentor who spent a significant amount of her time mentoring them. Mentors can opt (as a term of their contract) to discontinue their participation at any time. Without a mentor, a CAPP physician is not licensable. Therefore, it is most important that mentors' concerns and problems be addressed promptly, to avoid escalation and mentor withdrawal. One mentor was replaced on an interim basis because of illness, and another mentor had significant other commitments, which was a factor in reassigning his CAPP physician to another mentor and practice in an adjacent community. Also important is the mentor coordinator's qualities; in particular, our current mentorship coordinator has been a significant factor in the successful implementation of the mentorship component with her ready availability to both mentors and CAPP physicians in order to address problems. Back to Top | Article Outline CAPP and the wider community. CAPP has been considered a success by the licensing authority, the provincial DOH and DHAs, and the local IMG community. CPSNS and its credentials committee have been very satisfied with the rigor of the initial and ongoing assessments and the comprehensive nature of the CAPP reports. The DOH and DHAs are pleased with the cost-effectiveness of placing CAPP physicians into communities chronically short of physicians. The IMG community, especially in Nova Scotia, has welcomed the opportunity to access an assessment without the necessity of additional residency training, although some IMGs have been critical of the assessment cost and the relatively low success rate. Still, the program has permitted both the assessment of IMGs and their integration into family practice in communities, many of which have been underserved by physicians for years. For example, the community of Yarmouth has been historically short of family physicians, but now three of the 2005 and two of the 2007 CAPP physicians have located and set up practice there. In the smaller community of Weymouth, there had been a solo family physician for six years, but now a CAPP physician has established practice there, resulting in improved access to care and relief for the established physician. Back to Top | Article Outline Summing up. The CAPP physicians, with few exceptions, have found the mentorship year to be a valuable and rewarding experience. Candidates consider the examinations to be a rigorous but fair assessment of their competence. Many in the broader education, IMG, and licensing authority communities view CAPP as a comprehensive program incorporating several innovative features, especially the mentorship, CME, and on-site and multisource assessments. Because of its comprehensive nature, ongoing funding to support such a program may be an issue, especially if the number of candidates is at the margin of cost-effectiveness. Therefore, if Canada should move to a nationally administered IMG assessment, the licensing authority may wish to use only Part B, in whole or in part, to complement defined licensure for IMGs. With the continuing dependence on IMGs to meet physician workforce shortfalls, especially in smaller and rural communities, CAPP has developed and implemented a model that is proving to be effective in addressing medical care needs while maintaining an appropriate standard of physician performance. Back to Top | Article Outline Acknowledgments The following have contributed significantly to the development and implementation of the Clinician Assessment for Practice Program: Dr. Cameron Little, Gwen MacPherson, Sandra Taylor, Patricia Saunders, and Amanda Mombourquette of the College of Physicians and Surgeons of Nova Scotia; Bruce Holmes, Alexa Fotheringham, and Linda Mosher of the Learning Resource Centre, Faculty of Medicine, Dalhousie University; Dr. Mary-Lynn Watson and Dr. Douglas Sinclair, Continuing Medical Education, Dalhousie University; Dr. Kevin Bourke, chief examiner, CAPP; and Dr. Jean Gray, Dr. John Ruedy, and Dr. Brian Hennen, Therapeutics Examination consultants.Back to Top | Article Outline References1 The Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources. Report of the Canadian Task Force on Licensure of International Medical Graduates. Ottawa, Canada: Health Canada; 2004. Cited Here... 2 Cohen JJ. The role and contribution of IMGs: A U.S. perspective. Acad Med. 2006;81(12 suppl):S17–S21. Cited Here... 3 Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353:1810–1818. Cited Here... 4 Medical Council of Canada. Canadian Information Centre for International Medical Graduates. Available at: (http://www.img-canada.ca/en). Accessed November 15, 2007. Cited Here... 5 The Acts of 1995–96: College of Physicians and Surgeons Registration Regulations. Sections 14 and 15 as amended 2005. Available at: (http://www.gov.ns.ca/just/regulations/regs/medreg.htm). Accessed November 15, 2007. Cited Here... 6 Lockyer J, Blackmore D, Fidler H, et al. A study of a multisource feedback system for international medical graduates holding defined licences. Med Educ. 2006;40:340–347. Cited Here... 7 Page G, Bordage G, Allen T. Developing key feature problems and examinations to assess clinical decision-making skills. Acad Med. 1995;70:194–201. Cited Here... © 2008 Association of American Medical Colleges


text:
A very long game with a deep story that is also very
Much-improved training and spellcasting from the previous
Pooled disposable items.
Too much like it's predecessor.
Boring and sometimes very lengthy dialogue.
Training is still a necessity.
The island of Ovis has been under the rule of the Holy Lodis
Empire for the last 15 years, and it's inhabitants have been
forced to convert to Lodisism. As Alphonse, a member of the
Order of the Sacred Flame of Felis, you must find out who
is betraying who in this mysterious holy war.
Controls: As with most GBA games, controls are simple
enough. The "A" button is the main button, used for confirming
menu selections and scrolling messages. Tactics Ogre
is very menu-driven and there is a lot of dialogue. The "B"
button is used to cancel a command. The "R" button is your
menu button, the "L" button is used only slightly as a shortcut
function in battle, the "Start" button pauses, and the "Select"
button is the help button.
Graphics: The graphics are almost identical to the
Playstation version of Tactics Ogre, released in 1997.
While it's impressive that the same graphics can be achieved
on a GBA (although I donït think Tactics Ogre was pushing
the Playstationïs processor very hard), it's also a little
disappointing that Atlus would just rest on their laurels.
The character classes have the same exact models as the Playstation
version. There are new animations for spells and special abilities,
however, which are nice.
Gameplay: Tactics Ogre is a strategy RPG (some call
it simulation RPG), so battles are menu-driven. It is the
same type of gameplay as Final Fantasy
Tactics. Your goal is to approach each battle with a plan
that will outsmart the enemy. Alphonse and a team of characters
start in one area of the battlefield, and the enemy starts
in another, usually on the opposite side. Factors like environment,
encumbrance, character class, and movement type limit where
your characters can go on the battlefield. There are a wide
variety of ranged and melee attacks that characters can perform,
and knowing these attacks is a key element on how you fight.
Characters can also change classes as they level up, which
offers a wide variety of choices for the player. Enemy players
and monsters can also be hired or recruited on the battlefield,
so there are many different types of characters available
to you.
A typical turn in Tactics Ogre would go something
like this. There is an overhead world map with fixed locations
that Alphonse can travel to. Some locations have shops where
you can purchase weapons, armor, items, and spellbooks. You
can also hire characters or monsters into your party. You
can move to any of the fixed locations on the map. A random
encounter may occur in areas that you have already cleared.
In areas you haven't cleared, a battle or cutscene automatically
comes up. Get through the battle/cutscene, and you're back
to the map to move to the next location.
Audio: The sound in this game is nothing to write
home about. It also uses some of the same tracks from the
Playstation version. Sound is mostly just used for background
noise during battles, and doesn't play a big role in the game.
Elemental sound effects are done well, whether it's casting
a fireball or raining on the battlefield. Overall the sound
is okay, but nothing special.
What's different: If you've played and beaten the
Playstation version, what kind of changes can you expect from
this version? A few, but not enough in my opinion. Emblems
are new, and are gained through combat. There are 32 total
emblems, and their purpose is to unlock character classes
and upgrade abilities. For example, you need the right emblem
to be able to become a knight.
The environmental effects are improved somewhat. If it's
raining in a battle, the overall water level will rise if
the battle lasts long enough. This can be a factor for attack
strength if your character is suddenly standing in water instead
of dry land. The disposable items, like health and magic restorers,
no longer need to be equipped on each character before battle.
They are pooled together and can be used by anyone at anytime.
Saves a lot of prep time for battle, and allows one character
to use multiple items. You have the ability to pre-level your
characters when hiring them. For example, if you're 20 hours
into the game and need to hire a soldier, you can pay extra
to have the soldier start out at any level instead of just
level one. Saves a lot of time in the training field. There
is an option to auto-equip your characters when they change
classes. So if you have a Knight that you want to change into
a Cleric, you can set it so that the character's armor is
replaced with a robe, the sword is replaced with a staff,
etc. There is also an "Optimal" and "Power" auto-equip option
in the organize screen. Spells now upgrade their area of effect
as your characters level up. This is nice because you don't
have to buy different spells for the range you wish to cover.
Training is much improved, if only for one change - if you
set the controls to computer, your characters won't use up
any of your disposable items! So, you can safely set both
sides to computer controlled, leave for an hour, and come
back with leveled-up characters. Quest Mode is earned by finding
or obtaining special books in battle. Once you've found a
book, you can explore an area tied to that book and it's like
a mini-battle. Only 6 characters per team, and you can set
the number of rounds you have to defeat the leader in. The
shorter number of rounds you pick and succeed at, the better
the prize at the end. You do not gain experience points in
Quest Mode, however.
The bad: While I really enjoy the Ogre series and
enjoyed Tactics Ogre on the Playstation very much,
this feels like I'm just playing the Playstation version all
over again. There are differences, but it doesn't feel much
different when playing. The story is also very hard to keep
up with, as there are many different religions, groups, areas,
and names thrown at you in the dialogues. I know this is true
of any RPG, but the conversations tend to drone on and on
and make me want to fall asleep. I'm sure the story is very
compelling, but the way it's told needs some work. Maybe if
there was some graphical representations of what the characters
were talking about, instead of the characters just facing
each other in a large room for 5 minutes, it would hold my
interest better.
Tactics Ogre is a good game, but it fails to distinguish
itself enough from it's 1997 cousin. Same character models,
same environments, same battle engine, same items, same weapons,
same spells...there's something to be said for consistency,
but I feel Tactics Ogre needed to expand on the idea
a little more, not just carbon-copy it. Definitely check it
out if you've never played the Playstation version, or if
you did play the Playstation version and are looking for more
of the same. This is definitely a niche title, so if you weren't
a fan of Tactics Ogre or Final Fantasy Tactics,
stay away.
- bluezero

subset: commoncrawl


text:
Careers: Full Time Features Writer at CP-Africa
Job Description
CP-Africa is seeking a full time Features Writer to author feature articles and interview African personalities from a wide variety of sectors for the website. The ideal candidate has an analytical background and is insightful, motivated and passionate about African affairs.
The candidate will have the following job responsibilities:
- Write insightful and in-depth feature articles on interesting topics daily
- Interview African personalities shaping Africa's future across business, technology and culture
- Support the CP-Africa editorial team with engaging and topical African content
The ideal candidate should be:
- Young and vibrant
- Confident and well spoken
- Based anywhere in the world
- Can work virtually and still have a high work rate
Interested candidate should send in their CVs and a writing sample showcasing their analytical ability electronically as soon as possible to email@example.com before October 5th, 2012.
The e-mail should be titled: Features Writer at CP-Africa
Only shortlisted candidates will be contacted.
About CP-Africa
Celebrating Progress Africa (CP-Africa) is one of the fastest growing online media outlets covering business, technology and culture in Africa attracting hundreds of thousands of monthly unique visitors. It aims to provide an online inspiration hub for Africans around the world and to provide a platform for leading edge analysis on African trends.


text:
app performance
Twin Prime Lands $9.5M To Make Your App Just Work
You know when you're looking at your phone and you see five bars and you think you're golden. Then you try to do something and the app you're using is just hanging in spite of the bars. Twin Prime, a company that came out of stealth this week, and announced $9.5M in funding, wants to solve that problem. It's working with app developers to make sure that you don't… Read More
Crittercism Raises $30M More, Inks Mobile App Performance Deal With New Backer Accenture
Some big news today from Crittercism, a startup that operates a platform for companies to monitor their mobile app performance with customers including the likes of Netflix, LinkedIn, Yahoo, Pinterest, Home Depot, AT&T and a number of other Fortune 500 names. Read More
Apps Respond The Fastest In Canada And Japan, Finds New Report By Crittercism
Engaging design, marketing, and a solid user acquisition strategy are all key to making a successful app. But an app's reliability often depends on factors beyond its developers' control, according to a new report by Crittercism. The company, which makes an app performance management and error monitoring system, found that an app's performance, including how often it crashes… Read More
Crittercism Lands $12M From Google Ventures & More To Help Mobile Developers Monitor App, Network Performance
Crittercism, the San Francisco-based makers of a performance management and error monitoring system for app developers, announced today that it has raised $12 million in series B financing. The round was led by Google Ventures, with contributions from existing investors, Shasta Ventures and Opus Capital. As a result of the new financing, Google Ventures General Partner Wesley Chan will be… Read More
New Relic Now Tracks Fastest Apps & Industries, Lets You Compare Your Speed To The Competition
New Relic, one of a number of startups that have emerged in the last 5 years to address the costly, patchwork BS of old-school enterprise monitoring solutions, gives developers an easy, cloud-based way to keep tabs on their apps in realtime — without breaking the bank. Of course, while any old monitoring and analytics service might bring that measurable 5 to 10 percent performance… Read More
With $5.5M From Google Ventures, Opus, Crittercism Launches An App Performance Management Solution
Last summer, after graduating from AngelPad, San Francisco-based Crittercism announced that it had raised $1.2 million in seed funding from the likes of Google Ventures, Kleiner Perkins, Opus Capital, Shasta Ventures, and AOL Ventures. Today, the startup has received further validation for its diagnostic and management tools for mobile developers, as Opus Capital, Shasta Ventures and… Read More


text:
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Date Posted: 2018-02-22 04:17:38
Visitors have accessed this post : 8684 times.
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text:
This article was printed from mlb.com, originally published .
Read more news at: https://www.mlb.com/phillies/news
Phillies in unfamiliar position as Deadline approaches
This is not the greatest of times for the Phillies.
They just finished a road trip through Colorado and Los Angeles with a 4-2 record, which typically is enough for a fun flight home, except they lost Wednesday afternoon's series finale to the Dodgers in gut-wrenching fashion in 12 innings to fall to 41-52 and 9 1/2 games behind the National League Wild Card leaders.
Amaro finds himself in quite a quandary with the July 31 non-waiver Trade Deadline just 12 days away.
Buy? Sell?
Hold? Fold?
If the Phillies trade talents like Cole Hamels and Shane Victorino they will have a hard time making the playoffs for the sixth consecutive season, especially with eight teams ahead of them in the Wild Card standings. But if they keep them and still fall short and then those players sign elsewhere as free agents following the season, the Phillies will have wasted an excellent opportunity to retool for 2013 and beyond by not trading valuable commodities for young talent.
Make the right call and the Phillies continue their winning ways.
Make the wrong call and the Phillies could be hurt not only this season, but beyond.
It sounds like plenty of sleepless nights for the Phillies GM.
"I mean, it's just different," Amaro said. "This is like one of those fun and stressful times of the year, you know? The offseason, right when free agency opens and the July 31 date are the times when you really like your job. Number one, you get to bring in a lot of people in the process. You're talking about your players. You're talking about other players. You're evaluating short term and long term, and you're bringing all of your people together to discuss the plans for the present and the future. To me it's a fun time."
Fun is relative because there are fun times like Amaro's previous three Trade Deadlines, when he acquired Cliff Lee (2009), Roy Oswalt (2010) and Hunter Pence (2011) with the team on the brink of winning a World Series championship, and then there are times like this, when Amaro has to decide whether or not to trade Hamels, if they cannot sign him to a contract extension.
"You try to make the best decisions you can for the short term and the long term," Amaro said. "The job at hand for us is to try to improve. If we continue to improve, whether it's short term or long term, that's what we're trying to do. Every time we talk to another club or we talk internally, our job is to improve. Improve in one area, improve in another area, if we can do that then that's all we can hope."
The Phillies are trying to sign Hamels to an extension, but if they cannot reach an agreement and the team does not show enough improvement before the deadline the Phillies seem likely to trade him.
What is enough improvement in Amaro's mind? What does he need to see?
"There are going to be some determinants with wins and losses obviously," he said. "That will be part of it. But I think every day you continue to assess what's the best thing for our organization, short term and long term. As I've said before, this isn't a team that gets blown up at any time. If we don't feel like we're going to end up being contenders this year, which I still think we are, then we're going to do what we've got to do to be contenders in 2013 and 2014."
The Phillies started 4-2 after the All-Star break. If they continue that pace they would be 10-5 from the break to the deadline.
"It's improvement," Amaro said.
But it doesn't seem like enough, right? The Phillies would be only 47-55.
"It doesn't mean we can't rattle off more wins," Amaro said. "It all really depends on how I feel the team is playing. We're playing a little better baseball now. If we continue to play better baseball that's a good trend. That's a good sign. Hopefully we continue to do that."
Amaro said he will not come to any major decisions in a vacuum. He will be meeting with his top officials in the coming days, folks like David Montgomery, Pat Gillick, Dallas Green, Scott Proefrock, Benny Looper, Charley Kerfeld, Gordon Lakey, Joe Jordan, Mike Ondo and others.
"We have guys that have a lot of different viewpoints, different thoughts," Amaro said. "They've got a lot of different viewpoints and everybody has their own agenda, but my job is to try to do what's best for the organization. Hopefully we take all this information and make the right decision.
"Sometimes you go with your gut. Usually I'm a consensus kind of a guy, but sometimes we're split 50-50. I guess that's why I wear the hat."
Of course, the biggest decision is Hamels. The Philies have drafted and developed one of the best young pitchers in baseball. They recently signed Cliff Lee to a five-year, $120 million contract, which Hamels plans to exceed.
Amaro is asked if it's as simple as not being able to reach an agreement with Hamels and trading him.
"Again, we think that we're contending," he said. "We're going to contend probably better with Cole than without Cole. Nothing necessarily has to happen before the 31st."
And why does he think the Phillies will contend?
"Because we have talent," he said. "We have ability on the field."
And the fact they are 11 under .500?
"I don't think anybody is running away with any of the Wild Card spots right now," he said. "Right now it would be very difficult to overcome the deficit as far as Washington is concerned [in the National League East], but you never know."
Amaro said he hasn't crunched the numbers to see how the Phillies would need to finish for a good shot at the postseason. But even if the Phillies win two of every three games the rest of the season they would finish 87-75 (.537). The Braves currently hold the second Wild Card spot and are on pace for 88 wins. The Phillies would need to play at a remarkable pace the final two months of the season, hope the Wild Card leaders stumble and none of the other teams ahead of them in the Wild Card standings get hot.
"I stay away from that stuff," Amaro said of those projections.
"One game at a time, babe," he said.
The Phillies have nine games before the Trade Deadline. It should be fun.


text:
Fiji Time: 9:21 PM on Sunday 25 February
/ Front page / News
Mere Naleba
Friday, January 17, 2014
Update: 12:44PM The acting Australian High Commissioner to Fiji Glenn Miles last night hosted more than 30 Fijians who have graduated from various fields of study under the Australian government scholarship.
The graduates were able to share their stories with those in attendance in the cocktail at the Mr Miles residence.
The graduates were studying in various Universities in Australia and have attained qualifications from certificates to PhD levels in Architecture, agriculture, medicine, environmental science, business, human resources management, engineering and so many other areas of study.
Use the free Acrobat Reader to view.
FJD to VUVFJD to TOPFJD to SBDFJD to WSTFJD to PGKFJD to XPFFJD to CHFFJD to SEKFJD to LKRFJD to ZARFJD to PHPFJD to PKRFJD to NOKFJD to INRFJD to DKKFJD to CADFJD to HKDFJD to SGDFJD to JPYFJD to GBPFJD to EURFJD to CNYFJD to NZDFJD to AUDFJD to USD
VUV to FJDTOP to FJDSBD to FJDWST to FJDPGK to FJDXPF to FJDCHF to FJDSEK to FJDLKR to FJDZAR to FJDPHP to FJDPKR to FJDNOK to FJDINR to FJDDKK to FJDCAD to FJDHKD to FJDSGD to FJDJPY to FJDGBP to FJDEUR to FJDCNY to FJDNZD to FJDAUD to FJDUSD to FJD
Exchange Rate updated on 23rd, February, 2018
Copyright © 2014, Fiji Times Limited. All Rights Reserved.


text:
You can donate to NOLArize! by visiting our donations page, where you'll find futher instructions
NOLArize! c/o
Lang Center for Civic and Social Responsibility
Swarthmore College
500 College Avenue
Swarthmore, PA 19081
Please feel free to contact us for any reason. Questions, comments, and complaints are all accepted, and will be read and responded to as quickly as possible.


text:
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text:
There are a number of people who believe that stocking our rivers and streams with hatchery fish is the answer to our depleted fish populations, but the latest research doesn't appear to back this up. Using genetic marking, scientists discover that hatchery fish are passing on their genetic weaknesses to wild steelhead salmon.
First Broadcast: 1998
Producer: Jim Newman


text:
Asia-Pacific Region Opens Up Unprecedented Growth Opportunities For Airlines
Aviation in the Asia-Pacific region grew by 73.1 percent between 2001 and 2010, and overtook the US as the largest market in 2009. Last year, 99 million seats were scheduled in July alone – a six percent year-on-year rise and an 11% increase in flight numbers. This rapid growth continues. It's anticipated that by 2014, as much as 45% of air travel will fly to, from or within the Asia-Pacific region. Meanwhile other sources have suggested that over the next 20 years, almost half of the growth in air traffic will be driven by this market. Part of this growth is attributable to the region's rapidly growing middle class, who are choosing to travel domestically and internationally by air. However, India's market is also growing and signs point to the rapid emergence of other markets like Myanmar and Indonesia. This is great news for airlines of course. The increasing demand for seats is expected to pave the way for airlines operating elsewhere to enter the market, while those that already fly in, out and within the Asia-Pacific region can capitalise through expansion. Many airlines have already begun to make considerable aircraft investments to cope with the increased demand; a trend that is expected to continue. According to Boeing, over the next 20 years, airlines will need 12,030 new airplanes valued at $1.7 trillion. It's not just ticket sales that will soar for Asia-Pacific airlines, however; ancillary revenue – such as food, beverages and duty free goods – will also be a major area of growth. Another significant area for investment by airlines in this region is in-flight entertainment as more and more passengers will want to be entertained during their journey. Premium airlines operating long and medium-haul flights will likely continue to invest in the latest embedded IFE systems which will operate on the Android platform, whilst low cost and regional carriers will look to wireless and portable IFE solutions. The investment in WiFi enabled aircraft is set to continue at pace too. Air Asia's long-haul affiliate airline, AirAsia X, as well as Qantas are just two of the region's airlines that have announced plans to offer passengers the Samsung Galaxy Tablet packed full of movies, TV shows and other entertainment. Meanwhile, budget airline Scoot has recently chosen to provide passengers with iPads that are pre-loaded with IFE content. This has reduced the weight of the aircraft by seven percent, while increasing seating by 40 percent. Air travel is changing, for passengers and airlines alike, and no market in the world is contributing more to its evolution than Asia-Pacific. If airlines in the region get their proposition right, they can expect major success over the coming years.
An interesting article Kyle! Galaxy tablets and IPads for customers…..Nice!
Business as usual … Follow the money!,,
Wow, I had never thought about how much weight could be saved by removing or adjusting the in-flight entertainment. And 40% increased seating!? How have they not simply removed the entertainment before in the past?


text:
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Brown Dog Interactive owns and manages a vast portfolio of web properties, primarily in the automotive and personal finance verticals. We like to call ourselves a "boutique lead generation firm." Our online brands combine premium domain names, intelligent optimization, and first-rate content. The result? Category-leading websites in some of the most competitive online niches. That means highly-qualified prospects for our clients, and lots of them. Led by a team of bright developers and experienced experts, Brown Dog Interactive is the future of online lead generation.
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text:
My Trackers
my Nutrition
my Fitness
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Sweet and Spicy Muffins
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Secrets of Success
My Busy Life
Friday, April 20, 2012
Things have been very busy for me lately. Between the meetings, family Bible study, working, caring for the kids, excersizing and other responsibilities.... It seems like I have no time for anything these days!
This week I've worked every day except Thursday and on my day off I had to go to the doctors and run errands! The good news is my doctor gave me a new medicine for my anxiety that helps with my back pain too. But its a non-narcotic that's reeealy good! [I still have my other medicine but I rarely use it. I have it for the night time b/c the tend to make me sleepy.] The new medicine doesn't make me tired but it does make me itchy, lol. As with any medication I am cautious, but so far today [and yesterday] I noticed an great improvement in my mood! I had been a little anxious and stressed lately, probably b/c of all the added things going on, but I'm getting myself back in the grove of regular, vigorous exercise [something that I have found to be the most helpful over everything else- cept prayer of course.] So I'm trying to focus on cardio on the days that I feel down b/c I've found that it helps pull me out of the blues better than anything!
My youngest is going to be enrolled in school for next year! I can't believe she is already gettin ready to go to school- my baby!!! My older daughter is going into Middle school this year!!! Its crazy, I feel like time is flying by and I just need it t slow down.
Recently Spark People contacted me about getting before and after pictures because they said I was a perfect candidate for a pitch they were sending to Woman's Day [and other magazines.] Of course I was shocked a very happy. My hubby took some better "after" pictures of me in a white dress that we bought back in 2005 for me to wear on my honey moon but I turned out to be too heavy for it back then- NOW it looks so beautiful on me! Icing on the cake for this wonderful week. The pictures will always have a special place in my heart for those several reasons.
Even if nothing comes about of it, that's ok, I'm just happy that I've seen the changes I have in my life! And that's all that really matters. It cracks me up when certain people make comments about me being to skinny [which is obviously a statement made out of a lack of knowledge about the whole situation, b/c if they knew how much muscle I've been putting in my body, if they knew how wonderful it makes me feel to eat right and workout regularly, if they knew how many health problems I HAD that have gone AWAY from all these changes, if they knew how much all this has helped with my alcoholism and anxiety then I'm pretty sure they would see how ridiculous it sounds from my point of view... but I just laugh it off.] I'm sure they mean well, but that's why it meant so much to me that Spark People noticed and considers my story worth sharing. I know that Spark People understands me and there are a ton of people here that understand me too and are cheering me on, not trying to hold me back!
I invite any one reading this to go to my main page and read the highlight statement. It sums everything up pretty well. I'm not concerned about losing weight any more. I'm proud and happy to say I've reached my weight loss goals. But now my gears have shifted. Now I want to get stronger and put more muscle in my body, which I have already begun to do. No No No, I'm not trying to bulk up! LOL. I want to look feminine, but I believe its just as beautiful an feminine to have lean muscle on me. Its the "magic secret" to maintaining weightloss and the best way to make your life easier physically in this world!
Today I worked [10-4] then came home and did TF45 Class with my hand weights. It used to be so hard for me to make it through a Turbo Fire work out with weights on my hands, but now its like nothing! I continue to be amazed and inspired by the gift of fitness that Jehovah has blessed my life with. I'm making some healthier food choices too.
Ok, I gotta catch some zzz's for work tomorrow. Another busy day ahead of me. Hope all my sparkies are doing well. I haven't forgotten any of you! Life is just throwing alot at me right now. But its nice to know that my friends here understand that and never jump to negative conclusions about me just b/c I've been busy, lol. I really do miss chatting with many of you and wish I had more time. Maybe Sunday I will be able to catch up on some of my sparkin', hahaha!
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I can remember when our baby started school. That May 2 of our daughters graduated, one got married in June, had convention in July, He started kindergarten in August & another got married in September. Where did I get the time & energy? I certainly couldn't do it now.
2134 days ago
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Great all the way around! Good for you!!!
I know about the "baby" going to school. When my baby started kinder, my middle son was in middle school and my oldest was in high school. Now, My oldest graduated, my middle son will graduate this year and my baby will be in 4th grade next year. Time flies!
Congrats on your many successes!
2134 days ago
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I don't know how you manage your busy life! It seems like you have everything under control and are doing great. I'm glad the medicine is working for you. Keep up the good work.
2134 days ago
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How wonderful that you see yourself changing for the better! We can see it, too! Your life sounds busy, but that's a great thing. Living a good life is never boring. I wish you all the best for continued joy and success!
2135 days ago
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Hope you are getting some much deserved "down" time! Your new picture looks BEAUTIFUL! How exciting about the magazine possibility. You are awesome!
2135 days ago
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You have done a wonderful job! Do not let people who say negative things affect you. There are always gonna be those who want to find fault. (too fat, too skinny, too whatever) Be happy with your accomplishments and thank Jehovah every day for the good things in your life! I am learning those lessons myself. I basically have stopped talking to anyone around me (except your dad) about my hopes and the things I want to happen with my health and weight. Anytime I mention those things I get alot of critical feedback (not helpful feedback mind you), it is like the food nazis must have their say. Just last night I had someone tell me just to eat salad for dinner! I had to try and tell them that I have to eat protein or I will not lose weight! Just can't get some people to understand, losing weight is NOT about eating salad!!! LOL how foolish some people can be!
Anyway....YOU GO GIRL!!! You are looking and feeling great and that makes me very happy. Take good care of yourself and your family and remember your old mom once in awhile.
2135 days ago
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You are doing great! Stay healthy and get strong!
2135 days ago
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I love, love, love your photo! I was going to comment on it before even reading your blog. I'll check out your page next.
It sounds like life is busy and good. Getting stronger and more fit is only going to make things even better. There is no need to worry about not looking feminine. That won't mysteriously disappear by having great tone and some muscle. You will only radiate good health. So go for it!
I have been too busy to spend much time on Spark, too. But I've missed you. It was great to find your blog this morning.
2135 days ago
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|Reviews for Overmind
| Luke Dragneel chapter 1 . 11/23/2014
Oh I love this, especially since the Overmind could potentially use the Human Cylon technology to build a genetic engineering facility that could create new beings of flesh & blood and bark & sap. I can see it now " and thus the Zerg were born" (for info on the Zerg look up the game StarCraft, while they might be the bad guys in that three battle, it actually isn't their fault. Besides their biology is ever so interesting in terms of both inspiration and for how they base certain abilities against one another. They also have their own weaknesses to see to, such as being cold blooded in most cases and some being very explosive while fragile in nature.
| Phoenix4416 chapter 1 . 9/4/2012
would be interesting to see this expanded into a full story
| aznblackhowling chapter 1 . 4/2/2010
This would be interesting to see either a 3 way war or when the humans encounter the Overmind group after the destruction of the colonies.
I hope you will continue this story one day. Perhaps after your Empress story is completed.
| alienyouthct chapter 1 . 3/14/2010
It's more like the 2:30 'trailer' file iTunes gave me for buying the season pass for Caprica than a real story. You set up a story... and then the story never materializes. I'm not sure why, but whatever floats your boat I suppose.
| Queen Tigeress chapter 1 . 3/4/2010
it would indeed be interesting to see a war between the humans and two cylon factions, great idea! this fic was an interesting look at what else Zoe may have created with her genius.
| jojobevco chapter 1 . 2/19/2010
This is good
| senna chapter 1 . 2/17/2010
Ignore the two idiots who wrote before me your story is great like always.
| Cylon117 chapter 1 . 2/14/2010
If you changed overmind to Imperious Leader id like its not I dont.
| Doomsought chapter 1 . 2/13/2010
Why? Why? Why?
So many stories and we all know you will never have time for all of them. You could continue this, once you have finished the others.


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The next-generation version of Microsoft's Kinect peripheral that ships with the Xbox One in November 2013 won't work with PCs, a company spokesperson confirms in a statement issued to Ars Technica. The Kinect that ships inside the Xbox One box won't have an adapter that allows it to plug into a PC. The new and improved Kinect for Windows sensor plugs into a computer's standard USB 3.0 port.
The hardware revelation grew out of the news that Microsoft is now accepting applications from developers hoping to get their hands on the next-gen Kinect device that will eventually launch for Windows after it ships with the Xbox One this fall. The company revealed that the new Kinect for Windows will launch publicly in 2014, but developers may gain access to the upgraded sensor's software development kit as early as November 2013.
The next-gen Kinect for Windows SDK costs $399 and nabs developers a pre-release Kinect sensor (to later be upgraded with a consumer model when the Windows version launches), direct access to the Kinect for Windows engineering team via a private forum and exclusive webcasts, and access to the development kit alpha program and all Kinect APIs. Microsoft confirms that there's a limit on the number of spots in the program, but applications are being accepted until July 31 at 9am PT for those who are interested. Approved applicants will be notified in August.
The original Kinect launched for Windows more than a year after its Xbox 360 counterpart hit store shelves. It's been used for applications ranging from PC gaming to medicine. Unlike the second-gen Kinect, the original hardware was compatible with both the Xbox 360 and Windows PCs via a standard USB connection.


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Copper and Brass Shipments Fall in April
Red metal shipments declined sharply in April, though the year-to-date numbers remain well ahead of 2010, according to the latest data from the Copper and Brass Servicenter Association, Overland Park, Kan. Shipments of both copper and alloy products suffered double-digit percentage drops in April, compared to both March and April 2011.
Total copper shipments of 7.8 million pounds in April were off 12.7 percent compared to the previous month and down 14.5 percent compared to the same month of 2010. Total alloy shipments of 12.1 million pounds were down 11.4 percent compared to March and off 10.1 percent from March 2010.
Still, for the year to date, total copper shipments of 49.2 million pounds were up 37.1 percent compared to 2010. Alloy shipments of 65.6 million pounds were up 27.6 percent compared to the first four months of last year.
Service center executives surveyed by CBSA suggested weather issues in many states had an impact on shipments in April. Additionally, the automotive industry has slowed down and respondents expect production to remain at lower levels through the summer. In contrast, demand in the semiconductor market was reportedly strong, though the spike is expected to be short-lived.


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You are here
Charting a New Course
This article originally appeared in the Bentley Magazine.
Ninety miles south of – and in many ways, a world away from – the United States, Cuba has been largely a mystery to U.S. travelers for half a century. Last spring, a group of Bentley undergraduates got a rare firsthand look at the country, through a course led by Associate Professor of History Cyrus
During the embedded travel component of "Cuba: Past, Present, Future," students met Cuban economists, political scientists, architects and artists, as well as ordinary citizens, to glean insights across the island nation, which has been under a U.S. trade embargo since 1960.
"The relationship between Cuba and the United States is so special," says Veeser, who proposed the course shortly after the Obama administration loosened travel restrictions for American citizens, in January 2011. "I wanted students to get an idea of how interconnected Cuban history and U.S. history are."
The country's distinctive place on the world stage was another prompt for developing the course.
"In terms of being a remnant of the old socialist system, there's basically just Cuba," he observes. "It can be hard for students to understand that there was a certain appeal to communism, especially for people in less developed countries. Cuba is kind of an artifact of a previous era."
Wide-Ranging Research
A broad range of readings and class discussion readied students for the trip, which took place over spring break. The mix of business and arts and sciences majors also pursued research projects focused on tourism, health and medicine, culture and sports, democracy and development, or the economy.
During their weeklong stay, with help from local guides, the Bentley travelers spent daytime hours visiting noteworthy sites and meeting with government, academic and community leaders. Evenings offered time to talk more informally with locals in Havana and Cienfuegos, a smaller city southeast of the capital. Former Bentley professor Michael Eizenberg and his company, Educational Travel Alliance, handled arrangements for the group.
Course participant Morgan Diamant '12 was struck by "the optimism and resilience that the Cuban people showed, despite difficult and often suppressive conditions. Even though they lack many freedoms that Americans take for granted, I saw a sincere, refreshing enjoyment for life."
Whatever disaffection lingers between the countries' respective governments, the Bentley group found most Cubans were "happy to meet Americans, curious about the United States, and pleased that Americans are able to visit now," Veeser says.
"Cuba was by far the most interesting country I've ever been to, and likely will ever go to," says Diamant, an Economics–Finance and Liberal Studies major who studied abroad three times during his student days. "Very few Americans can say they visited Castro-led Cuba."
The course did not solve every mystery about the country, though.
"They were in a state of befuddlement about how this economic system could continue to function," Veeser says of the Bentley undergraduates. "They tried to figure out what makes it work. I'm not sure they ever succeeded – but I'm not sure Cubans really understand it, either."
President Larson, along with guest experts, joined Bloomberg's Carol Massar and Cory Johnson, to talk about how college and universities are preparing graduates to navigate diverse environments.


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Over 100 years ago, Trane made the decision to stand out from the crowd. To build a comfort system like no other, using uncompromising quality, innovation and reliability. Today their legacy is found in everything Trane makes, from our premium materials to industry leading technology to extensive product testing under the harshest conditions. No detail is overlooked in our...
Over 100 years ago, Trane made the decision to stand out from the crowd. To build a comfort system like no other, using uncompromising quality, innovation and reliability. Today their legacy is found in everything Trane makes, from our premium materials to industry leading technology to extensive product testing under the harshest conditions. No detail is overlooked in our quest for a system...
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We had Legetts out to install a new system for us. The guys that came out were great. They were nice, polite and they made sure they left the house the way it was when they arrived. I would highly recommend Leggetts.
We have used Leggett's for years and would never dream of using someone else! They are always nice and professional and fix all of our problems. They even do our routine checkout for us twice a year, without us having to remember to call them; they call me.
All of my neighbors and family use them also, would highly recommend!! Great job!
I had a problem w/ my heat & had another company out , but they were unable to fix it. A neighbor recommended Leggett's and in know time at all I finally had heat. Will definitly recommend. Sara
First, the guy got lost coming here, then he lost his tool- apparently he screwed the panel door closed after leaving it in the unit. Then, he left my disconnect switch unhooked and out IN THE RAIN for 8 HOURS before calling to say, oops he forgot it. It's electrical! It's not supposed to get wet! Then he didn't fix the problem but charged $200. When called back out to fix the problem (of no heat), it took 2 HOURS to hook up a thermostat which he swears was the only problem. It should only take 15 min max to do that. But he blows 5 fuses while doing so. So, OBVIOUSLY NOT the only problem. THEN he rips off all the labels of the wires that he didn't put on in the first place, so he had no right! He did that after we said to take off their $189 thermostat, if that truly is the only problem, we would buy one less expensive. I guess that made him mad. But the problem isn't fixed! We have no heat but he swears he did his job?! Um, WHAT? He says it's just the thermostat, but even though we've put on 2, they say it's just that ones from Home Depot are inferior or that we got a 'bad batch' of thermostats. Trust me, don't pay HIGH dollar ($400 for these 2 visits that didn't even solve anything!) for these people. I was attracted to the 'family owned business' but I am no longer impressed. Not to mention the thing that really blows my mind- he left about 7 EXPOSED, stripped wires. I'm no electrician, but should you strip wires and then leave them sticking out in a customer's unit? If you are looking for someone reputable, we found this company who solved a similar problem for our neighbors for $79. Comfort Air Tech 904-699-7139.
Great service today. Steven got the job done like a pro. The problem ended up being minor challenges in two separate areas. Easily identified by the pro that came to my home. I would refer the company to anyone. The customer service at the office was excellent also. Nice to know there is a local business doing some honest professional work. Semper Fi Steven. -Doc
I had trouble with my A/C wasn't Cooling so I called Leggett and the technician that came out was incompetent he told me I needed a new fan motor and they charge me $1,000 for that and then my AC cooling went out again the next day and they charge me for a relay and again my AC went out the next day they told me that I have to replace the thermostat wire that was no good they charge me again...
Leggett Heating & Air Conditioning, Inc. is located at 660 King St, Jacksonville, FL. This business specializes in Heating Ventilation & Air Conditioning and has 12 review(s) with a star rating of 3.5.
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Welcome To An Evolution In Chiropractic
Never before in the history of the chiropractic profession has the correction process been as effective and painless as it is today. New techniques generate progress faster and more effectively than ever before.
People once thought of chiropractors only when they had back or neck pain, but new research deems chiropractic care a profoundly effective means for creating a body in balance. When your body is relaxed and in balance, you function at a higher level.
You sleep better, look younger, and move freely through daily activities. This body balance greatly improves all other aspects of your well-being, including mood, mental acuity, and overall health. The positive connection of body, mind and soul/spirit becomes clear. People in balance do more and they do it happily and with more awareness.
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Call 425-444-4815 today and move towards a more balanced you. Or schedule an appointment now.
My Hero, Dr. MO
I have a history of running for over 30 years including many marathons starting at age 40 and not paying attention to managing pain or injuries. Over the years I have worked with other Chiropractors and other types of medical doctors, PT and more but never consistent care. I have found a miracle in a short period of time with Dr. MO!! My neck pain, sciatica and lower back feel much better. Together we are working on my overall body including knees, feet, and not just my sciatica area as in the past. He has given my "tips" for better results each time I see him that I didn't know about or never had anyone take the time to listen to me. I am encouraged about long lasting results and being able to continue my running, biking, and other activities according to my timeline – forever. I'm hooked!!!!!!!!
Thank you,
|8:00am – 7:00pm
|8:00am – 7:00pm


text: The Room 101 Namakubi Ecuador Ranfla is a perfecto made at the Tabacos Rancho Jamastran factory in Honduras with elements of the two previous Room 101 lines. Boasting the original filler blend of the Room 101 Namakubi cigar, the Ecuadorean wrapper and the Honduran binder are elements of the successful Room 101 OSOK line. The cigar is full bodied with notes of wood, dried cherry, and coffee.


text: >> "Martin" == Martin Bialasinski <email@example.com> wrote: Martin> Did you check the right spots for help? [...] Forgot about a thing for this part. - Check the Bug Tracking System Maybe the problem you encounter is a known bug? http://bugs.debian.org/<packagename> will show you all reported bugs for the package. Sometimes there is also a patch or workaround in the report, so it is worth a look. Also you may find a bugs or todo file in /usr/doc/<packagename>/, so check this as well. Maybe the thing you want to do is not possible.


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Robin Chase, SM '86, is a career innovator who has moved between articulating big ideas and implementing them.
Ray Wood—Head of Global Power at Bank of America Merrill Lynch—views renewable energy as a "competitive and compelling investment."
EDF's Climate Corps places graduate student fellows, including many from MIT, in organizations to help them increase energy efficiency.
MIT Sloan Action Learning students have worked with EMC Corporation on sustainability-related initiatives that include reducing and reducing reusing the company's outbound packaging.
A plan for sustainable palm oil is one outcome of Brazilian cosmetics maker Natura's growing relationship with MIT Sloan's Sustainability programs.
Phosphate giant OCP works with the full range of MIT Sloan Action Learning programs to advance its sustainability strategy.
Next Step Living analyzes home energy efficiency, helping home owners save money with little or no upfront cost.
Zairo Cheibub, on MIT Sloan introducing him to sustainability as a key driver of business competitiveness.
Mark Doughty, MBA 1999, on answering his customers' calls for thoughtful, sustainable building.
Nike has taken a position of leadership and innovation for sustainability. MIT Sloan has been part of that journey.
The Environmental Defense Fund and MIT Sloan work closely on a variety of issues, from climate change to sustainable fisheries.
Fishbanks is an interactive game that teaches the dynamics of renewable resources by challenging players to build a profitable fishing business.
Omar Mitchell parlayed a summer internship with the NHL into a fulltime job as the league's first-ever Director of Sustainability.
The Sustainability Initiative at MIT Sloan helps Drew Morales finds the answer to: If I want to make a career out of sustainability, how do I do it?
Shawn Basak decided on MIT Sloan because he "wanted to be at a place where ideas are invented, not just practiced."
At Cargill, Ed Fish works in the food and agriculture industry.
Alice Hartley, Manager of Sustainable Innovation at Gap, explains how her team is an incubator within the larger company.
MFS Investment Management's Sean Kenney believes "capital markets hold the key to effecting change in the way corporate sustainability programs are implemented."
Kathy Lin's internship at the Environmental Defense Fund taught her about climate change's impact on local fishing communities.
MIT Sloan's emphasis on hands-on learning helps Carolyn Mansfield DuPont clarify her career priorities.
Sarah Nolet helped Frontier Co-op—the Iowa-based wholesaler of natural and organic products—strengthen how it analyzes data on resource consumption.