text: Outcomes of Different Clerkship Models: Longitudinal Integrated, Hybrid, and BlockTeherani, Arianne PhD; Irby, David M. PhD; Loeser, Helen MD, MScAcademic Medicine: January 2013 - Volume 88 - Issue 1 - p 35–43 doi: 10.1097/ACM.0b013e318276ca9b Clinical Education Abstract Author Information Article Outline Purpose To examine student perceptions and learning outcomes of three different third-year clerkship models: a yearlong, longitudinal, integrated clerkship (LIC); six-month clerkships with continuity (hybrid); and traditional, discipline-specific block clerkships (BCs). Method The authors compared the perceptions regarding the clerkship year and the hidden curriculum, as well as the pre- and postclerkship academic performance, of third-year medical students participating in LIC, hybrid, and BC models between 2006 and 2010. Results Generally, LIC students rated the following clerkship experiences higher than did the hybrid and BC students: faculty teaching, faculty observation of clinical skills, feedback, and the clerkship overall. Students in the LIC observed more positive role-modeling behaviors and had more patient-centered experiences than BC students. All students preferred to see patients more than once, work within a consistent site or system, and work with a stable group of peers and faculty mentors over time. Whereas students in both the LIC and the hybrid models outperformed their BC counterparts in clinical skills, student performance on the U.S. Medical Licensing Exam Step 2 (clinical knowledge) was equivalent across models. Conclusions Key differences in student experiences and outcomes between the continuity clerkship models (LIC and hybrid) and BCs reinforce the literature and the educational framework for continuity in clinical learning. The benefits to student outcomes seem to increase with greater opportunities for continuity. Dr. Teherani is associate professor, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Dr. Irby is professor, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Dr. Loeser is professor, Department of Pediatrics, University of California, San Francisco, School of Medicine, San Francisco, California. Correspondence should be addressed to Dr. Teherani, University of California, San Francisco, School of Medicine, Office of Medical Education, 185 Berry St., Suite 5350, Box 3202, San Francisco, CA 94107-1751; telephone: (415) 509-4988; e-mail: email@example.com. Abstract Method Participants and setting Clerkship models at UCSF Measures Overall perceptions. Perceptions of the hidden curriculum. Academic performance. Data analysis Results Overall perceptions Perceptions of hidden curriculum Academic performance Discussion and Conclusions References Advocates for continuity in clinical learning environments assert that longitudinal relationships with patients and faculty members provide substantial opportunities to sequence and advance learners' competence, to actively involve learners in physician-like roles, to support patient-centered values, and to reduce the observer role that students often take as they are shuffled from one specialty rotation to another.1,2 Clinical education is a social learning process that, when optimally designed to facilitate longitudinal relationships, allows learners to gradually become substantial participants in a community of practice.3,4 In these communities of practice, patient care occurs through continuous, collective activity; the relationships among physicians, their patients, and their colleagues are key to learning and, ultimately, to quality patient care.3 As such, students should train in an environment where educational methods resemble and reinforce these collective and continuous relationships. Yet, such relationships are difficult to establish and maintain in the fragmented and discontinuous work environment of traditional, discipline-specific block clerkships (BCs).2 Continuity in clinical education includes longitudinal experiences, such as following patients from diagnosis through treatment, from inpatient to outpatient care; learning through a curriculum that comprises sequenced experiences with appropriately increasing difficulty and interdisciplinary integration; and building ongoing relationships with supervising clinical teachers over an extended period of time.1 Internationally, many medical schools have developed clerkships that incorporate varying models of continuity.5–9 These models vary in structure from 6- to 12-month, fully integrated, continuity clerkships, referred to as "longitudinal integrated clerkships" (LICs); to half- or full-year clerkships in a single site that offer differing levels of integration, which we refer to as "hybrid" clerkship models.1,10,11 LICs are defined as clerkships in which students participate in the care of patients over time, develop learning relationships with the clinicians who care for these patients, and do so by participating in the clinical disciplines simultaneously.6 Hybrid clerkships include varied features of LICs (e.g., students participate in the care of patients and build learning relationships with the clinicians who care for those patients but within three distinct clerkships that may not occur simultaneously). Both these clerkship models with continuity (LIC, hybrid) are in contrast to the traditional BCs in which students complete each of their clerkships sequentially and do not receive a deliberate role in patient care or structured learning relationships with clinicians. Research suggests that students who participate in clerkship models with continuity (LIC or hybrid) perform better than or equivalent to their BC peers in clinical skills and knowledge acquisition.5,8–10 Students who participate in these clerkship models with continuity also experience progressively higher levels of patient care responsibilities,7,9,12 demonstrate greater flexibility in addressing their own educational needs,9 and have a positive view of educational continuity.7,8 In addition, students who participate in LICs sustain higher patient-centered attitudes, receive more feedback from faculty, and report more satisfaction with the curriculum than students in BCs.5,8 Given these positive findings, questions remain about how much continuity is required to achieve the desired outcomes. Our institution provides an ideal environment for examining this question because we have run three different clerkship models in parallel: (1) a yearlong LIC, (2) two 6-month clerkships with continuity (hybrid), and (3) traditional, time-limited, discipline-specific rotation BCs. For the three clerkship models in this study, we compared the student outcomes that investigators have examined in prior studies5,8,10,13,14 of clerkship models with continuity: students' perceptions of their clerkships, students' descriptions of their clerkship experiences, students' perceptions of the hidden curriculum and of patient-centered experiences, and measures of students' pre- and postclerkship academic performance. Back to Top | Article Outline Method Participants and setting Between 2006 and 2010, 612 third-year medical students completed their clerkships at the University of California, San Francisco (UCSF). We employed a case–control posttest evaluation study design to assess differences among LIC, hybrid, and BC models. The UCSF institutional review board approved the research protocol. Back to Top | Article Outline Clerkship models at UCSF At our institution, the seven required clerkships (in family and community medicine, internal medicine, neurology, obstetrics–gynecology, pediatrics, psychiatry, and surgery) occur during the third year of medical school. The curricular oversight body guiding the development of our clerkship models with continuity (LIC, hybrid) has required that each of these clerkship models include both of the following educational principles: Continuity of site, curriculum, faculty, and peer cohort; and Continuity in patient care with increasing responsibility as competence develops. The clerkship models with continuity employed similar means of addressing each principle, as described below. The LIC is based at the UCSF Medical Center (San Francisco, California) and integrates all seven core clerkships over a full year. Clinical settings are largely ambulatory, with six weeks of interspersed inpatient training throughout the year (during weeks when students do not have a scheduled preceptorship). Students work with a preceptor in each discipline, have an assigned advisor to guide them through the year, experience a stable peer cohort across the year, and participate in a curriculum that emphasizes patient-centered and student-driven learning.13 The LIC currently accommodates approximately 10% of students in the third year. Both hybrid clerkships are six months in length, occur at different major urban teaching hospitals, and include a stable peer cohort, an assigned faculty advisor who oversees each student's clinical learning progression, and a core weekly curriculum similar in content to material covered during the various disciplines in the BC model (described in greater detail below). Clinical experiences are divided between inpatient and outpatient settings. The first hybrid clerkship, which occurs at the San Francisco General Hospital (city and county hospital; San Francisco, California), integrates two clerkships (internal medicine and family medicine) followed or preceded by a third clerkship of choice (surgery, obstetrics–gynecology, or pediatrics). This hybrid clerkship entails a curriculum that emphasizes caring for the underserved. The second hybrid clerkship occurs at the San Francisco Veteran's Affairs Medical Center (San Francisco, California), comprises four consecutive BCs (in internal medicine, neurology, psychiatry, and surgery) in varying order, and includes a curriculum that emphasizes communications, clinical skills, and professional identity development.10 Together, the two hybrid clerkships currently accommodate approximately 30% of students in the third year. In all three clerkship models with continuity (LIC and the two hybrid), enabling structures and processes support students in acquiring a panel of patients to follow in continuity. The structures and processes for acquiring patient panels for each clerkship model with continuity are developed based on optimal methods for continuity at the site and in each discipline. The BCs take place at numerous sites including all three major medical centers mentioned above. They range in length from four to eight weeks, provide clinical experiences in outpatient but predominantly inpatient settings, and include a longitudinal (the preceptor remains constant) ambulatory preceptorship of 22 half-day sessions integrated throughout the year in a clinical field of interest to the student. The BC currently accommodates approximately 60% of students in the third year. Late in their second year, students enter a lottery system and rank all four available clerkship choices (LIC, two hybrid, BC). During this study, all students who requested the LIC or BC received their first choice. With rare exceptions, students interested in hybrid clerkships received their first or second choice. The most frequent second choice for students interested in the hybrid clerkships was the BC. Back to Top | Article Outline Measures In this study, we assessed four cohorts who participated in the hybrid and BC models (academic years 2006–2007 through 2009–2010), and we assessed three cohorts of students who participated in the LIC (academic years 2007–2008 through 2009–2010). Because the LIC is the newest of the three models, it provided one year's fewer data to include in the analysis. Back to Top | Article Outline Overall perceptions. We used two measures to assess the students' perceptions of their third year: their survey-based evaluations of the clerkships and comments garnered from student focus groups. Students evaluated their clerkship experiences on a standardized course evaluation form, choosing ratings from poor (1) to excellent (5). We compared LIC, hybrid, and BC student responses to four sentinel items measuring (1) the quality of faculty teaching, (2) the adequacy of faculty members' direct observation of students' clinical skills, (3) feedback on students' performance, and (4) the overall quality of the clerkship. These items constitute a set of institutional benchmarks for clerkship quality; the middle two consistently receive the lowest ratings at UCSF and are the most difficult to improve. Completion of clerkship evaluations is required by all students and linked to their ability to view their assessments. We examined only the evaluation scores for those clerkships included in a given model program (i.e., if a model did not include surgery, then we did not include the surgery clerkship evaluation scores in the analysis for that model). We invited all students who participated in a clerkship model with continuity (39 LIC and 136 hybrid) to participate in focus groups at the end of the clerkship model. We also invited 15 randomly selected students from the BC model to participate in focus groups at the end of the third year. Participation in all focus groups was voluntary, and the groups consisted of only those students who had received invitations and agreed to participate. We provided the participants with lunch (as is the usual custom for curricular focus groups at UCSF), and we deidentified data from all the focus group participants. The team conducted 12 focus groups in total (3 cohorts of LIC students, 3 cohorts each of students from each hybrid model, and 3 cohorts of BC students). We asked students in the focus groups to Reflect on their overall experiences in the clerkship model or year; Discuss their experiences engaging in patient care and, if relevant, continuity of care; Discuss their experiences over time within a given site or system or across multiple assigned sites; Discuss interactions with peers either in their cohort (clerkship models with continuity) or generally (BC); and Describe mentorship during the clerkship year. A research assistant recorded notes during the focus group sessions. Back to Top | Article Outline Perceptions of the hidden curriculum. To compare students' perceptions of the hidden curriculum across the different clerkship models, we administered the Communication, Curriculum, and Culture (C3) instrument to all students at the end of their third year.15 Participation in the C3 survey was voluntary, and we did not offer incentives to complete it. The instrument comprises 29 items in three content areas: role modeling, students' experiences, and support for students' actions. For the role modeling items, students indicated how often they observed clinical teachers model certain behaviors with patients, from never (1) to always (7). For example, one item asked students to indicate how often they observed residents communicating concern for and interest in patients as unique people. For the items on student experiences, students indicated how often they experienced positive "learning relationships," how often they had received information or teaching on conveying "bad news to patients," and how often they had observed patients being treated as "objects," from very often (1) to never (5). For example, students were asked to indicate how often they heard other students telling stories about patients that tended to portray the patients as diagnoses rather than as unique human beings. We reverse-scored the four items addressing learning relationships" (e.g., "During your third or fourth year of medical school, an attending or house officer observes you while you interview a patient and provides you with feedback on your bedside manner"). Finally, for items covering the support of students' actions, the students indicated how encouraging their instructors were when the students themselves engaged in patient-centered behaviors, from discouraged (1) to strongly encouraged (5). For example, students rated the extent to which instructors encouraged them when they tried to develop rapport with patients. We averaged the item scores in each content area to calculate three overall content scores for the instrument. Higher scores indicated more positive perceptions of the hidden curriculum. Back to Top | Article Outline Academic performance. We measured academic performance with both pre- and postclerkship variables. Because students were allowed to rank and were almost always assigned to their preferred clerkship models, we compared preclerkship academic performance variables for LIC, hybrid, and BC students to determine whether differences existed prior to beginning clerkships. Preclerkship variables comprised first-time scores on the Medical College Admission Test (MCAT) Physical Science section, Biological Sciences section, and Verbal Reasoning section—as well as first-attempt scores on the United States Medical Licensing Examination (USMLE) Step 1, which students must take before commencing their clerkships. Grading at the end of the clerkships is norm-based on a three-point scale: honors, pass, or fail. Students' clerkship grades are based on observational ratings by clinical supervisors and clerkship-specific examination scores. We measured honors received by totaling the number of honors received in the seven core clerkships. Postclerkship clinical skills are assessed at the end of the third year using an eight-station clinical performance examination (CPX). All eight medical schools in the California Consortium for the Assessment of Clinical Competence develop and use this examination, which covers a range of clinical scenarios including acute, chronic, behavioral, and ill-defined problems. Standardized patients use checklists and global ratings to assess students' performance at individual stations. The score for this exam is based on two skills areas: data gathering (history taking and physical examination) and communication skills. Scores for each skill range from 0% to 100% correct. Finally, we assessed postclerkship knowledge using students' first-attempt USMLE Step 2 Clinical Knowledge score. We did not use the USMLE Step 2 Clinical Skills score because it is simply pass/fail, and, with rare exception, all of our students pass. Back to Top | Article Outline Data analysis We used descriptive statistics to present student demographics. We examined the relationships between clerkship model (LIC, hybrid, or BC) and overall clerkship perceptions and between clerkship model and academic performance variables using one-way analysis of variance. We adjusted comparisons of postclerkship academic performance for baseline differences in preclerkship academic performance variables. To determine the effect of clerkship model on students' perceptions of the hidden curriculum, we used a multivariate analysis of variance (MANOVA). We further analyzed significant findings through post hoc univariate analyses using Scheffe tests to account for unequal group size. The study had 90% power to detect a minimum of 0.3 absolute difference in the C3 results as derived from the literature describing the reliability and validity of the C3.15 We used SPSS (version 19; Chicago, Illinois) for the analyses. One of the investigators (A.T.) and a research assistant conducted the analysis of the qualitative focus groups data using open coding methods.16 To ensure that we accounted for students' experiences across clerkship models, we reported on themes that arose in at least two of the three clerkship models (LIC, hybrid, BC) and presented the variations on those themes by clerkship model in the results. Back to Top | Article Outline Results The study included clerkship evaluation and academic performance data from 563 of 612 third-year students (92%) who completed clerkships between 2006 and 2010. Across three years, 39 (7%) completed the LIC; across four years, 136 (24%) completed the hybrid models, and 388 (69%) completed the BC. Across all models, distribution by gender and by age of student was consistent with the class overall. Because of the voluntary nature of student participation in focus groups and the C3 survey, student response rates varied and are reported in the results section of each measure. Back to Top | Article Outline Overall perceptions Students in the LIC rated all four clerkship benchmarks (faculty teaching, adequacy of observation of clinical skills, feedback on performance, and overall clerkship) significantly higher than the BC students, with the exception of the internal medicine clerkship, which all students rated uniformly highly (Table 1). LIC students also rated the clerkship benchmarks significantly higher than the students in the hybrid clerkships did in the majority of cases. In the surgery clerkship, the BC students rated the faculty teaching, direct observation, and feedback benchmarks significantly higher than hybrid model students did, but both the BC and LIC groups rated the "clerkship overall" similarly. Table 1 We conducted focus groups with 135 students. For the LIC focus groups, 37 (95%) of the 39 invited students actually participated. For the hybrid clerkship focus groups, 71 (52%) of 136 invited students participated. Finally, for the BC, 27 of the 45 (60%) invited students participated. Table 2 displays the number of students who participated in the focus groups, key themes raised (whether through positive, negative, or neutral comments), the number of groups in which each theme was discussed, and the number of students discussing each theme (we did not record the sessions verbatim, so we do not include quotations here). The greatest distinctions in themes discussed were between students in the clerkship models with continuity (LIC, hybrid) and the BC. Table 2 Students in the clerkship models with continuity (LIC, hybrid) perceived their third-year education positively and felt that the strengths of the clerkship year outweighed any challenges. These students expressed sadness that the program had ended and described the experience as "amazing." Students in the LIC realized the significant benefits of their experience close to the end of the year as the extent of their professional development became evident. In contrast, BC students did not discuss their overall satisfaction with the clinical year (Table 2). In the clerkship models with continuity and BC focus groups, students highlighted the educational value of seeing the same patients more than once. Students, including those in the BC group, reported that when continuity with patients occurred, it contributed to their learning and to patient care. Students reported on two forms of continuity with patients: deliberate and fortuitous. Deliberate continuity occurred with the panel patients whom students followed throughout their clerkship models with continuity. Students reported that, in these cases, they themselves were able to make a positive impact on their panel patients' care and that they often became their patients' advocates. Opportunities for deliberate continuity were more limited in the hybrid clerkships; for example, a patient's follow-up appointment might be scheduled past the end of the model's six-month duration. Opportunities for fortuitous continuity with patients arose occasionally in all clerkships and contributed to students' understanding of patient care. Examples included students who completed more than one BC at the same site and saw a patient again, scheduled or unplanned, on a different service. Students reported that working within a single site or system for an extended period was beneficial to their learning. Most BC students thought that changing sites made the third-year experience more challenging, requiring time to become acquainted with new systems and cultures. Hybrid model students appreciated that not having to relearn systems allowed them to focus on learning and patient care. Moreover, being at the same site gave students opportunities to develop ongoing relationships with faculty members and to feel like team members. LIC students focused less on their site and more on the academic health care system. These students described challenges of working in multiple clinics and hospitals within a given system, and they offered suggestions for how to maximize their time and opportunities to learn about patient care. Students who participated in clerkship models with continuity, and those in BCs who had the opportunity to work with a peer cohort, valued this aspect of learning. Students in the clerkship models with continuity reported that the peers in their cohort allowed them to support, learn from, and help one another; they shared and discussed patient cases which enhanced their learning. These students often identified patient types lacking in their peers' panels and provided suggestions for managing difficult patient interactions. The ability to share experiences with peers provided a support network that made the clerkship experience less overwhelming. Finally, regular cohort meetings or weekly seminars solidified peer relationships. Students reported varying experiences with mentorship in the third year. BC students wished for more mentoring, and some wished for a formal mentoring program. Overall, students in the clerkship models with continuity appreciated having assigned mentors, although they stated that the mentors were only sometimes effective because of time constraints. Because of familiarity and long-term presence at a site, continuity model students with unsuccessful assigned mentors were readily able to find other faculty for mentorship. Students in clerkship models with continuity emphasized that the nonevaluative nature of mentoring was critical to its success. Back to Top | Article Outline Perceptions of hidden curriculum The C3 survey was completed by 17 (44%) of the LIC, 49 (36%) of the hybrid, and 88 (23%) of the BC students. The MANOVA indicated significant differences for students who participated in the different clerkship models (F = 2.6, df = 6, P < .02). Post hoc analyses revealed that students in the LIC perceived more positive role-modeling behaviors in their teachers and more patient-centered experiences (e.g., fewer instances of patients' being treated as objects) than did BC students (Table 3). There were no significant differences between clerkship model participation and students' perceptions of support for their own patient-centered behaviors. Table 3 Back to Top | Article Outline Academic performance Students who participated in clerkship models with continuity (LIC, hybrid) did not differ significantly in their preclerkship academic achievement from their BC peers, except that LIC students had slightly higher MCAT verbal scores than BC students (Table 4). We adjusted postclerkship analyses for baseline differences in MCAT verbal scores. On postclerkship performance, students in clerkship models with continuity performed significantly better on the data-gathering portion of the CPX than BC students. Students in clerkship models with continuity demonstrated a trend toward higher scores on USMLE Step 2 (Clinical Knowledge), although there were no statistically significant differences across clerkship models. We detected no differences either in CPX communication skills scores earned by, or in the number of honors received by, students across clerkship models. Table 4 Back to Top | Article Outline Discussion and Conclusions This study examined differences in students' reported experiences and in their academic outcomes across three different clerkship models: LIC, hybrid, and BC. We found that students, regardless of the clerkship model they chose, preferred continuity during their clinical education—that is, opportunities to see patients and to work with a stable group of peers and faculty mentors over time. Figure 1 summarizes the results and benefits of the three clerkship models. When the three models in this study are placed on a continuum of educational continuity, the BC affords the least, the hybrid models an intermediate amount, and the LIC the most continuity with patients, peers, curriculum, faculty, and a site/system. Students performed similarly on knowledge acquisition outcomes, regardless of point on the continuity continuum. As opportunities for educational continuity increased in the hybrid and then the LIC models, performance on clinical skills improved and student perceptions of the clinical year became more positive. LIC students who experienced the greatest amount of continuity rated their teaching faculty, the faculty's observation of their clinical skills, the feedback they received, and the clerkship overall higher in almost all clerkship disciplines than did students who experienced the BC and hybrid models. In addition, LIC students also rated their experiences with patient-centered behaviors and positive role modeling higher than did the hybrid and BC students. Overall, as continuity increased, so did the benefits to student outcomes. Figure 1 Our findings, like those of others, reveal that continuity is a powerful force in the clerkship experience.5,8,9 Students reported valuing the extended time and facilitated opportunities to care for patients, interact with faculty, and work closely with peers. Such continuity enables central engagement in the community of practice.4 Others report that this type of engagement facilitates the formation of the learner's identity as a physician-in-training and increases his or her sense of belonging to such a community.3,4 We found that engagement increased with more continuity in that students realized the educational value of seeing the same patients over time, being at the same site, and learning from peers. Further, we found that some reasonable amount of time in the same site/system facilitated other aspects of continuity; for example, students reported that working within a consistent site or health system over an extended period of time promoted learning opportunities because they did not have to keep learning a new culture or system. However, others have created LICs absent of continuity of site or/system and have reported positive outcomes.6,9 Our data demonstrate that, for maximal benefit to students' clinical learning experience, continuity within a site or system must be accompanied by formally facilitated opportunities for continuity with patients, peers, and faculty. We found that continuity with patients contributed to student learning about patient care, as demonstrated by the higher CPX scores of the students who participated in the clerkship models with continuity and by the students' own descriptions of how continuity relationships with patients both allowed them to serve as patient advocates and facilitated patient–preceptor relationships. Others have found that students in clerkship models with continuity report a different view of the hidden curriculum and patient-centeredness than BC students.8,14 Our study confirms these findings; our students in the LIC model reported experiencing significantly fewer adverse effects of the hidden curriculum than did our BC students. Our study also aligns with previous findings that students in clerkship models with continuity assume more responsibility for patient care over time.12 Faculty have greater knowledge of and confidence in their students' abilities and, thus, bestow on them increased levels of responsibility and autonomy for patient care.12 Similarly, students in clerkship models with continuity may experience more patient-centered care because they know their preceptors better and observe them in action in a broader array of circumstances. We found that facilitated opportunities for continuity with peers (e.g., cohort meetings, weekly seminars) during the clerkship year provide a much-needed support network and enhanced learning. Research has shown that the social system of peers supports both personal and professional growth at a crucial transition period of elevated anxiety.10,17,18 Our findings show that such a support system also challenges students to learn more about their own and their peers' patients. Delivering effective and high-quality health care today requires teams of health care providers and depends on how well team members communicate, coordinate care, and provide care for patients.19 We found that students in clerkship models with continuity lauded their peers whose presence provided opportunities for communication, discussion about patients and learning, and work as it occurs in contemporary health care systems. Although all of the clerkship models in this study involved multiple, interdependent components, our study was not designed to determine the relative contribution of each component: continuity with a peer group, mentor, or patients; longitudinal integrated experiences; or ambulatory versus inpatient clinical experiences. Each of these components, individually or together, may provide "affordances" (i.e., opportunities to engage in work and retrieve the support needed to learn) that contribute to the continuity effect.20 Further research is needed to identify the distinctive and essential success factors that each of these models promotes. We believe that the clerkship models with continuity that we describe are the beginning of much-needed reform of clinical education at both the undergraduate and graduate medical education levels.21 Companion innovations that require further inquiry include developmentally sequenced mentoring and assessment, competency- and entrustment-based advancement instead of time-based advancement, and education and workplace system redesign. The study has limitations worth noting. Students were from a single medical school which may limit the generalizability of this study to other locales, but we collected data from multiple years on three distinct clerkship models, which allowed numbers adequate for detecting differences across models. Further, students chose their own clerkship models rather than receiving a random assignment. Allowing students to choose might have positively affected their perceptions of the clerkships as they selected the model that they felt best fit their needs; however, because most students received their first choice, student enthusiasm was equalized across models. In fact, the opportunity for students to individualize their clinical experience by choosing a model that fits their needs might be particularly important for successful clinical learning in the third year as students transition from the classroom to clinical settings, a time of high levels of stress and anxiety.17,18 Finally, because we studied these models for three or more years, we moved beyond the characteristic pioneer enthusiasm, which inflates ratings of new programs, to a steady state of operation. In conclusion, the benefits to student experience and learning seem to increase with greater duration and quality of educational continuity. Longitudinal relationships with patients, teachers, and peers seem to strengthen students' patient-centered values, clinical skills, personal and professional development, and support networks—all of which are essential for a successful clinical experience. This research supports the call for increased continuity in clinical education. Acknowledgments: The authors wish to thank Victoria Ruddick for her editorial assistance, J. Christian Burke for his expertise in graphics, and Karen E. Hauer, MD, Bridget O'Brien, PhD, and Patricia O'Sullivan, EdD, for their thoughtful critical review of the manuscript. Funding/Support: None. Other disclosures: None. Ethical approval: The University of California, San Francisco, committee for human research institutional review board approved the research protocol.Back to Top | Article Outline References1. Hirsh DA, Ogur B, Thibault GE, Cox M. "Continuity" as an organizing principle for clinical education reform. N Engl J Med. 2007;356:858–866 Cited Here... 2. Christakis DA, Feudtner C. Temporary matters. The ethical consequences of transient social relationships in medical training. JAMA. 1997;278:739–743 Cited Here... 3. Egan T, Jaye C. Communities of clinical practice: The social organization of clinical learning. Health (London). 2009;13:107–125 Cited Here... 4. Wenger E Communities of Practice: Learning, Meaning, and Identity. 1998 New York, NY Cambridge University Press Cited Here... 5. Hirsh D, Gaufberg E, Ogur B, et al. Educational outcomes of the Harvard Medical School–Cambridge integrated clerkship: A way forward for medical education. Acad Med. 2012;87:643–650 Cited Here... 6. Norris TE, Schaad DC, DeWitt D, Ogur B, Hunt DDConsortium of Longitudinal Integrated Clerkships.. Longitudinal integrated clerkships for medical students: An innovation adopted by medical schools in Australia, Canada, South Africa, and the United States. Acad Med. 2009;84:902–907 Cited Here... 7. Mihalynuk T, Bates J, Page G, Fraser J. Student learning experiences in a longitudinal clerkship programme. Med Educ. 2008;42:729–732 Cited Here... 8. Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School–Cambridge integrated clerkship: An innovative model of clinical education. Acad Med. 2007;82:397–404 Cited Here... 9. Worley P, Prideaux D, Strasser R, Magarey A, March R. Empirical evidence for symbiotic medical education: A comparative analysis of community and tertiary-based programmes. Med Educ. 2006;40:109–116 Cited Here... 10. Chou CL, Johnston CB, Singh B, et al. A "safe space" for learning and reflection: One school's design for continuity with a peer group across clinical clerkships. Acad Med. 2011;86:1560–1565 Cited Here... 11. Schwartzstein RM, Huang GC, Coughlin CM. Development and implementation of a comprehensive strategic plan for medical education at an academic medical center. Acad Med. 2008;83:550–559 Cited Here... 12. Teherani A, O'Brien BC, Masters DE, Poncelet AN, Robertson PA, Hauer KE. Burden, responsibility, and reward: Preceptor experiences with the continuity of teaching in a longitudinal integrated clerkship. Acad Med. 2009;84(10 suppl):S50–S53 Cited Here... 13. Poncelet A, Bokser S, Calton B, et al. Development of a longitudinal integrated clerkship at an academic medical center. Med Educ Online. April 4, 2011;16 doi:10.3402/meo.v16i0.5939 Cited Here... 14. Krupat E, Pelletier S, Alexander EK, Hirsh D, Ogur B, Schwartzstein R. Can changes in the principal clinical year prevent the erosion of students' patient-centered beliefs? Acad Med. 2009;84:582–586 Cited Here... 15. Haidet P, Kelly PA, Chou CCommunication, Curriculum, and Culture Study Group.. Characterizing the patient-centeredness of hidden curricula in medical schools: Development and validation of a new measure. Acad Med. 2005;80:44–50 Cited Here... 16. Strauss A, Corbin J Basics of Qualitative Research: Grounded Theory Procedures and Techniques.. 1990 Newbury Park, Calif Sage Publications Cited Here... 17. Chittenden EH, Henry D, Saxena V, Loeser H, O'Sullivan PS. Transitional clerkship: An experiential course based on workplace learning theory. Acad Med. 2009;84:872–876 Cited Here... 18. O'Brien B, Cooke M, Irby DM. Perceptions and attributions of third-year student struggles in clerkships: Do students and clerkship directors agree? Acad Med. 2007;82:970–978 Cited Here... 19. Doran DMHall L. Teamwork—Nursing and the multidisciplinary team. Quality Work Environments: Nurse and Patient Safety.. 2005 Sudbury, Mass Jones and Bartlett Cited Here... 20. Billett S. Learning through work: Workplace affordances and individual engagement. J Workplace Learning. 2001;13:209–214 Cited Here... 21. Cooke M, Irby DM, O'Brien BC Educating Physicians: A Call for Reform of Medical School and Residency.. 2010 San Francisco, Calif Jossey Bass Cited Here... © 2013 Association of American Medical Colleges


text:
Sir Elton John has become famous for his talent whilst many reality TV stars have become famous for... well, something else.
The "Candle in the Wind" singer made an appearance on BBC World satellite radio and decided to share his opinion on reality TV shows with the world.
John said, "With reality television, you get all these nightmare people who want to be successful, when you really want them to be assassinated."
This is not the first time the singer has voiced his criticism of people he believes are hungry for fame, in fact he even has an album dedicated to this issue titled The Diving Board.
When asked about his new album, the musical legend revealed, "It's about someone who's attracted to fame no matter what."
"They want fame whatever the consequences, and they'll do anything to get there."
We can think of more than one example right now, but we will let John do the talking for us! The "Circle of Life" singer pinpointed actress Lindsay Lohan, who had been thrust into the limelight at such a young age, and battled substance abuse issues before getting on the path to recovery.
John said, "Lindsay Lohan, unfortunately, who had a great career as an actress and as a recording artist, she had a hit album..."
"Suddenly, everything has fallen to bits because of the drugs. Her parents were a nightmare. She has become a victim of success and she wants success, no matter how much (it costs)."
This is not the first time that John has made a comment on celebrity culture as he previously revealed to CNN, "We focus so much on celebrity in our culture and we don't focus on the right things."
"And I'm so sick of seeing celebrities on covers of magazines and on — tweeting, and on Facebook and reality shows... it's disgusting."
And you'll see personalized content just for you whenever you click the My Feed .
SheKnows is making some changes!
b e h e a r d !
Welcome to the new SheKnows Community,
where you can share your stories, ideas
and CONNECT with millions of women.Get Started

subset: commoncrawl


text:
All-Conference Nominations Pfeiffer, Marble, Quam lead 'Cats into Postseason
Western Nevada College proved during the regular season, it could beat any softball team in the Scenic West Athletic Conference.
Now, the sixth-seeded Wildcats are out to earn some additional respect in the Region XVIII Tournament May 10-12 in Taylorville, Utah.
The Wildcats (21-39 overall) open the double-elimination tournament against Snow (32-18) at 11 a.m. (PST) on May 10.
WNC has more than doubled its win total from the program's previous three years of existence. In the process, WNC surprised Salt Lake, the nation's top-ranked team, 6-5 on Feb. 11. The Wildcats also knocked off second-seeded College of Southern Idaho 6-3 last weekend in a hotly contested series.
WNC defeated the other five teams in the SWAC at least once during the conference season.
"To tell you the truth, we're really looking forward to coming out this weekend and showing these teams. I don't think a lot of these teams have respect for us," said WNC Interim Coach Rosie Contri.
To earn some additional respect, the Wildcats must first get by Snow, which has won seven of eight games against WNC this season. Six of those contests, however, were decided by five runs or less, including 2-1 and 7-6 defeats on April 20.
Many of the Wildcats might recall that Snow eliminated them last year's regional tournament, 2-1.
Now in the fourth year of the program, the Wildcats are pursuing more than their first-ever postseason victory.
"We're definitely going to come out, just like in basketball for March Madness, this is May Madness, where anyone can win as long as you show up," Contri said. "I have confidence these girls will actually show up."
The Wildcats are led by three players who have been nominated for postseason honors: sophomores Melanie Pfeiffer and Taleas Marble, and freshman Jennifer Quam.
Marble has hit a team-high 16 home runs in 169 at-bats, as well as 11 doubles and three triples. She also led the Wildcats with a .391 average, 49 RBIs, .775 slugging average and 131 total bases.
Pfeiffer, a shortstop, provided the Wildcats with a steady middle infield presence and hit .301. She tied Marble for the team lead with three triples, scored 34 runs and knocked in 20.
Quam has developed into a dangerous leadoff threat for the Wildcats. In addition to leading the Wildcats with 67 hits, Quam has become one of the nation's top base stealers, swiping 55 bases in 59 attempts. Her .345 batting average was second to Marble and 49 runs topped the Wildcats.
|For additional information, please contact:
|WNC Information and Marketing Services
2201 W. College Parkway
Carson City, NV 89703
|Phone: 775-445-3234
Fax: 775-445-3198
E-mail: firstname.lastname@example.com


text:
One of the most important parts of your computer is the Antivirus, a lethal bug can not only wipe out your entire data but even render your hardware useless. Each antivirus software will claim some groundbreaking technology that defeats viruses but it's not long before a virus comes out that circumvents that. The only way to combat that is have an antivirus software that is consistently improving and updating to keep up with the new viruses and worms. Here are a few antivirus softwares which will hopefully keep your computer alive.
The first two are almost symbiotic in their existence. AVG Anti Virus Free and Avast free are the two of the most downloaded software on CNET, there is a very good reason for that. Both being good and dependable free ant viruses. If you are going to chose one of these you need to also get an anti malware software. These two are definitely entirely free but they also have paid versions which are naturally better in every single way. If your someone who uses your computer casually, doesn't download many files of the web and mostly goes to trusted sites, this might be good for you. To anyone who uses the web a lot and these are not the best security for you, a lot of important features are left out and also the fact that the paid versions have bigger database for virus recognition. Another annoying part of the free deal is that updates for the database occur later for the free versions. These are recommended for anyone you know who might be a light pc user. If you are above the average pc user and want something free, these are the two best but don't forget to get an anti malware software along with it, something such as Malwarebytes.
There is two other great antivirus software, both are paid but very much worth the price. First there is ESET Smart Security's, which is a giant killer of viruses. Unlike many antivirus softwares of the old, the interface is slick and easy to use even for non IT folk. It has an amazing sandbox feature, which will run all registered files in a sandbox to see if they contain malevolent code. This is done when you chose to with suspicious files, it also doesn't take hours to scan the files like some other software's would do. The price might seem a bit step but it does carry the value of it. The other is Bitdefender, since its creation Bitdefender has consistently been considered the best by many, an amazing feat for an antivirus software, which seem to come and go. It's threat to alert speed is second to none and it also has a much more reasonable price than ESET Smart Security. Another thing to worry with these big fully featured antivirus is how much do they affect the performance of everything else. Some users have had slower response rates with ESET running at full security while with Bitdefender that has rarely been reported. Both are amazing antiviruses and definitely two of the best right now. It doesn't matter which one of these you get since both will protect you well.
The days of a virus being behind every file, every possible web page are gone but the threat still remains alive therefore antivirus software are still an essential tool.
Recommended links: http://free.avg.com, http://www.avast.com, http://www.eset.com/, http://www.bitdefender.com


text:
Located in the City of Los Angeles Watts community, Dolores McCoy Villa is a new affordable, 64 unit apartment complex with a full range of supportive services for homeless families.
The complex features extensive common areas, a laundry room, community room, athletic center, outdoor courtyard, bbq area and a playspce for children.
Newly completed in 2010, McCoy Villa provides a variety of two and three-bedroom apartments at affordable rents for families.
The property participates in the Housing Authority of the City of Los Angeles Permanent Supportive Housing Program. Each unit receives a Section 8 rental subsidy that enables residents to pay 30% of their actual household income for rent.


text:
Hugh Laurie on The Simpsons: First LookMatt Richenthal at . Comments
Daniel Radcliffe isn't the only big name set to appear on the November 7 episode of The Simpsons.
House star Hugh Laurie will also voice a character on that Halloween-based installment, as the actor will portray a character named Roger, a shady castaway who interrupts Marge and Homer's vacation.
"I've loved the show since it started; this is one of the central pillars of modern culture," Laurie told TV Guide, spoiling his character's fate by adding: "I die in the end, and I don't think I've ever died on microphone. That's a first."
Matt Richenthal is the Editor in Chief of TV Fanatic. Follow him on Twitter and on Google+.


text:
Book of Joshua
Teaching Series by R.C. Sproul
The book of Joshua stands at a transition point in the Old Testament, linking the Five Books of Moses to the Historical Books. The book of Genesis reveals God's promise of the land to Abraham. In the book of Joshua, … Learn MoreCD $31.00 $27.90 Add to Cart
Also available in one other format


text:
tag:blogger.com,1999:blog-2272431515083873489.post5632409610622749373..comments2015-12-16T14:50:32.304+00:00Comments on Blogtor Who: REVIEW: Evacuation EarthCameron email@example.com:blogger.com,1999:blog-2272431515083873489.post-64120118535833634832010-11-15T20:26:12.429+00:002010-11-15T20:26:12.429+00:00I ain't a 'hardcore gamer' (I love gam...I ain't a 'hardcore gamer' (I love games like Uncharted but I hate first person shooters cos I find them so outdated, limited and samey) but is this really the best a DS can do? A bunch of drawn stills with a voice track over the top? Shame they can't get Smith and Gillan to use the motion capture techniques of the aforementioned Uncharted games to really bring the characters to life and have Smith and Gillan actually performing the character animations. Part of the reason I enjoy watching those actors is in their visual performance (particularly Smith's quirks) and it's what I felt was one of the big things lacking from the Adventure Games. Or is it just too costly for a company to risk on a Doctor Who game and so we just get usual shovelware email@example.com:blogger.com,1999:blog-2272431515083873489.post-8349580696412673712010-11-15T06:05:26.207+00:002010-11-15T06:05:26.207+00:00I'm a long time gamer as well and I must say t...I'm a long time gamer as well and I must say that it's a little harsh of you to assume all gamers only like to blow stuff up. I'm an adventure game lover from way back and this little gem looks to hark back to the dayso f classic, hand drawn point-and-click adventures suck as Broken Sword. I'll be getting this for sure!Joehttps://email@example.com:blogger.com,1999:blog-2272431515083873489.post-76703592633195708332010-11-13T21:03:51.711+00:002010-11-13T21:03:51.711+00:00I'm a "proper" gamer, a longtime gam...I'm a "proper" gamer, a longtime gamer. And this sounds absolutely lovely to me.

Actually, I think that's probably "hardcore" gamer you're looking for. Those are the ones complaining when a game doesn't have enough "realism" (i.e. blood & guts) and looking down at more casual players for not being as crazily obsessive about playing games as them. As you can tell, I don't much like the type. :)

I wonder, though, how the story of this game relates to the Wii one, if at all. The summaries made it sound rather like they were connected in some way...SpiritMusehttps://firstname.lastname@example.com:blogger.com,1999:blog-2272431515083873489.post-30185094404047003572010-11-13T00:07:22.263+00:002010-11-13T00:07:22.263+00:00Just one more reason for me to get a DS for Christ...Just one more reason for me to get a DS for Christmas, then.kesomonhttp://email@example.com


text: On Friday 7th September 2012, about 7:35pm, officers attached to the Marigot police station responded to a report of a vehicular accident which occurred at La Croix Maingot. Reports indicate 26-year-old Jeff Rene of La Croix Maingot was driving a Kawaski motorcycle along the said road when he lost control of his vehicle and ran off the road. As a result of the impact, Rene sustained serious injuries and was transported to the Victoria Hospital. He was treated and admitted in a critical condition. On Saturday 8th September 2012 at about 8:20pm, Rene succumbed to his injuries. A post mortem is scheduled for a later date. Investigations are continuing.


text:
I love how the bottom two use store bought (probably thrifted) large frames and don't worry about custom building one to fit the TV perfectly. I think I will go with that option and switch my frame and frame color up with the season or holiday! Like a orange one for Halloween time and a red one for Christmas. Have fun with it!
Next time your looking to compare a lot of items in one place, check out Wayfair. I've ordered from them several times (they used to be CSN stores) and have always been very happy with my experience!


text:
Stress. Lack of sleep. Having to make a bunch of seemingly small decisions. Veering from your usual routine. Trying to eat a healthy diet. What do these things have in common?
They all deplete your willpower.
According to the authors of Willpower: Rediscovering the Greatest Human Strength, everyone has a finite amount of willpower, and you use it up on all sorts of tasks you don't necessarily associate with requiring willpower. In this fascinating review of science, psychology, and common sense you'll find out what depletes willpower, what restores it, and what that means for your attempt to set and achieve your goals.
The whole book was interesting, but a couple of points I found most intriguing were the discussions of the importance of habits and the contradiction between the suggestions for kicking addictions versus keeping to a diet.
Habit formation is something I've read a lot about in literature about Charlotte Mason's philosophy of education, and it's always instructive to see how the concept of good habits is validated in research. In the context of willpower, habits help you to make a good choice without depleting your limited reserves. So, to use a simplistic example, if you make it a habit to eat at a salad place every day for lunch, you spare yourself the daily willpower depletion of debating whether to eat salad or a burger and fries. The habit/willpower connection extends to more subtle areas of behavior and lifestyle as well.
The authors also (perhaps unwittingly) touched on a fascinating contrast I first saw articulated on Gretchen Rubin's blog – the question of whether you are an abstainer or a moderator. The willpower book suggests that the best way to quit a habit like smoking or the like is to make yourself a bright line policy. That is, to say "I will not ever have another cigarette." The bright line policy helps to reduce the amount of time you have to spend dithering over whether this is a good time or a bad time for a smoke, or if you have smoked too much that day, or if you should cut down more, etc. On the other hand, the authors take more of a moderator approach to diet and suggest that it's more effective to tell yourself you can have small amounts of everything than to say you'll never eat sugar again. For a moderator, that would work well. For an abstainer, it's a recipe for disaster (Jen Fox, I put that in just for you!) because you'll spend so much time and energy and willpower debating about when it's all right to eat the cookie. For me, since I'm an abstainer, it's much, much easier to say "I don't eat cookies." Because once I fall off the wagon, I'm off in a big way.
Whatever you think about the moderator versus abstainer distinction (and I'd love to know what you think of it!) and whether or not you are interested in diet or just all around interested in goal setting and getting things done, I'd really recommend Willpower.
In the book, the authors talk about how being depleted in one area, such as having decision fatigue or not getting enough sleep, can make it harder to have willpower in other areas such as being pleasant to your family or eating healthy foods. They argue that the state of depletion makes all of your emotions heightened and cravings stronger. Do you find this is true?
Disclosure: This post contains affiliate links.


text:
What does Paralympics mean?
Definitions for Paralympics
Here are all the possible meanings and translations of the word Paralympics.
The Paralympic Games, a counterpart of the Olympic Games, nowadays at the same venue, designed for handicapped athletes
Chaldean Numerology
The numerical value of Paralympics in Chaldean Numerology is: 8
Pythagorean Numerology
The numerical value of Paralympics in Pythagorean Numerology is: 7
Sample Sentences & Example Usage
[They're] really starting to come out of the woodwork, the sport of sled hockey will be huge by the next Paralympics.
To be a candidate for the Olympics and Paralympics is too important a subject to be driven by enthusiasm and impatience.
People think that the Paralympics is a more benign version of the Olympic Games and that it is not as pointed, as targeted and as fierce, that is such a wrong misconception.
The profile of Paralympics sports has increased and that carries with it an intrinsic risk that people will try to stretch boundaries, by means of technology, by means of unauthorized substances and whatever is humanly possible.
Images & Illustrations of Paralympics
Translations for Paralympics
From our Multilingual Translation Dictionary
Get even more translations for Paralympics »
Find a translation for the Paralympics definition in other languages:
Select another language:
Discuss these Paralympics definitions with the community:
Word of the Day
Would you like us to send you a FREE new word definition delivered to your inbox daily?
Use the citation below to add this definition to your bibliography:
"Paralympics." Definitions.net. STANDS4 LLC, 2018. Web. 24 Feb. 2018. <https://www.definitions.net/definition/Paralympics>.


text:
Arbroath's RNLI all-weather and inshore lifeboats responded to a plea for help from the town's cliffs in the early hours of last Sunday.
The lifeboats were launched shortly after the call for assistance at 2.40 a.m., joining an operation involving HM Coastguard and Police Scotland.
Aberdeen Maritime Rescue Coordination Centre also paged teams from Carnoustie, Montrose and Stonehaven to reports of a man falling from the cliffs.
The RNLI crew made their way ashore and first line casualty care was given by the volunteer crew, assisted by paramedics from the Scottish Ambulance Service, to a man who had sustained injuries.
Due to the difficult terrain at the scene RAF rescue helicopter 131 was scrambled from RAF Bulmar in Northumberland.
The helicopter casualty was then airlifted to Ninewells Hospital, Dundee, to receive further treatment.
The man's identity and nature of the his injuries are not yet known.
Police and ambulance crews were evacuated by Arbroath's RNLI lifeboats back to the lifeboat station due to rising tides. All teams and crews were stood down after the rescue at 5 a.m.
We have now uploaded a video which we have been given permission of the RNLI to use.


text:
When Connecticut utility regulators approved a license for Positive Energy to sell electricity to residential and commercial customers last year, they were apparently unaware that the real head of the company had recently been fined for making false statements in a mortgage application.
The state banking department in 2008 had issued a finding saying Ventura had made the statements with the intent of defrauding the mortgage lender.
Documents found by CtWatchdog disclose that when Positive Energy applied for permission to be an electric aggregator in Connecticut on Feb. 5 2009, Elena Cahill of Orange was listed as the head of the firm.
But by the time regulators approved the application on April 8, 2009, Joseph Ventura had already taken over as president of the company, records obtained from the Ct Secretary of State's office show.
Ventura was ordered to pay a $100,000 fine the previous year by the state Banking Department for lying on his mortgage application at a time when he was a mortgage loan officer. The banking commissioner also sought to have criminal charges filed against Ventura, but the statute of limitations had run out.
Ventura, records show, signed a document for the Secretary of State's office stating that on March 4, 2009 he became the president of the company while the the firm's application was pending before the utility regulators.
However, according to a spokesman for the state Department of Public Utility Commission, Positive Energy as of Friday had not formally informed the department that Ventura is the head of the company.
DPUC Spokesman Philip Dukes said he did not know if the commissioners would or would not have approved Positive Energy's application if they had known of Ventura's involvement with the firm or of his civil conviction. At this point since Positive Energy is licensed Dukes did not believe that the license would be revoked based on the information I told him.
He said the department did eventually learn – though not by a formal notice of change of ownership – of Ventura's involvement with the company.
Dukes said that a few weeks ago that Ventura was called to DPUC headquarters where he was warned to dial back his company's aggressive sales approach. He said Positive Energy had 10 complaints with the DPUC, not an unusual number compared to the dozen or so other electric sellers.
Ventura, who became a sponsor at CtWatchdog last month, refused to comment Friday and threatened a libel suit if I printed anything false about him or his company. He said his lawyer would respond next week to my questions.
The light started shining on Ventura's checkered past after I wrote a column announcing that his company had signed a contract to be one of our sponsors. I explained that I was interested in having the firm associated with my site because I believed in electric competition and was intrigued by the fact that former television consumer advocate Mike Boguslawski was hired to be the spokesman for the company.
A reader – perhaps associated with a competing electrical seller – suggested that I check out his history with the state Banking Department. I did. The summation of the accusations can be found here.
Department spokesman James Heckman – responding to my request for details – said that two years ago his agency ordered Ventura, who runs the Middlebury-based company, to pay a civil fine of $100,000. Positive Energy claims to have about 40,000 residential and commercial customers in Connecticut.
"In August 2008, the department made a criminal referral to the Chief States Attorney's office, but was advised the closing took place in 2003 and was now outside the one year statute of limitations," Heckman wrote me.
In November 2008 his department referred the fine to the state Attorney General's office for collection.
"The only tangible asset was an automobile that would have cost more to confiscate and sell than it was worth," he wrote me. "In March 2009 the agency wrote off the fine."
Ventura declined to discuss the allegations, but claimed that it is on ongoing issue that he is appealing.
"This is an ongoing, unsettled matter. Allegations are not defined as guilt. The only thing I will say on this matter is that I am fighting this matter. Per my Attorney, I have been advised to not make any further comment until this matter is resolved," Ventura wrote me.
Following one of our former president's policy of "trust, but verify" I asked the banking department whether that was true.
Nope. There is no record of Ventura filing any appeal or making any attempt to pay his fine.
I attempted to question Ventura about why he lied to me, but he refused to respond. However, another official of the company suggested that the sponsorship at my site should end.
Meanwhile, following my hunch that if Ventura lied to my readers, he may have also deceived state public utility regulators.
To me the issue is not that Ventura has a checkered past – if everyone who lied on a bank application was arrested there would be few people left OUTSIDE of prison.
The problem I have is that Ventura then lied about it and appears to have pulled the rug over the eyes of state regulators.
Positive Energy customers won't be harmed because if anything happen they can simply switch to an alternate supplier or go back to CL&P or UI without penalty.
But just like I can no longer support having Richard Blumenthal – who clearly lied and deceived the public – as the Attorney General, I can't support a company as a sponsor whose CEO lied about a serious matter.
Similar Posts:
- Positive Energy Electric President Fined $100,000 For Bank Fraud
- Positive Energy CEO Has No Assets To Pay $100,000 Bank Fraud Fine
- Positive Energy CEO Sued By State To Collect $100,000 Bank Fraud Fine
- Conn Officials Preparing Legal Action To Force Positive Energy CEO To Pay $100,000 Bank Fraud Fine
- Ct Regulators Freeze New Applications For Electric Aggregators
- Positive Energy Electric Ordered To Give Rebates To 3,200 Customers


text:
The Hurricane Swim Club coached by Butch Babin competed at the Maine Winter Championships at Bowdoin College this past weekend. Many swimmers had best times while Alexis LaBree, Carson Prouty, Colby Prouty IV and Cooper Sever all qualified for the Eastern Zones Meet in New York.
Hurricaine Swim Club
Community Author:
Post Date:


text:
In the Limelight - MOSC at Wagner-Noel Performing Arts Center
Published 6:00 am, Tuesday, November 15, 2011
The first Masterworks concert at the Wagner-Noel Performing Arts Center has been a long time coming. Indeed, the Midland-Odessa Symphony's move to this new performing space had been announced constantly for the last few years. A question crossed my mind as we walked into the Center last Saturday night — would we be like Dudley Moore in "10" — could reality ever live up to the hype? Mostly — yes. Yet it is the artists' vision and depth that make music, not necessarily a space. But as Gary Lewis stated eloquently at the beginning of the concert, "a concert hall is the instrument of the orchestra" — and by this measure the Midland-Odessa Symphony and Chorale have just about the best tool that architecture can offer.
First, the MOSC must be congratulated on the evening's smooth organization. No first-night nerves or chaos, no — to stretch our Dudley Moore analogy — braids banging into our faces at unfortunate times. It was as if the Symphony had been performing there for years. The pre-concert speeches were perhaps a little long, and I am not entirely sure why we should applaud illustrious audience members for their mere presence among us, but all was pleasant enough.
The evening's theme was a strident one — "Fighting for Freedom" — and the orchestra started in suitably forceful manner with Beethoven's "Leonore" Overture. The master's only opera, "Fidelio," was first performed as Napoleon was marching into Vienna, and Lewis accentuated the dramatic mixture of struggle against an apparently overwhelming power. As the minutes flowed past, the sheer acoustic clarity and loveliness of the Center surrounded us. An instrumental solo could be heard as if you were only a few feet away, while lush layers of sound cascaded when the whole orchestra was playing.
Classical music has perhaps the greatest dynamic range of any musical form, and this hall is an ideal vehicle for communicating the emotions rendered by that range. So in the Leonore Overture the pristine sweetness of the flute's conversation with the violins was accentuated in a manner that would not have been possible in the Mid Cities Church — for all its alluring charms.
The second piece was an interesting choice. Eric Baker's trumpet was particularly haunting and stirring in the slower section of Arutunian's Trumpet Concerto in a-Major. Just as his co-principal had given an unforgettable moment in his offstage trumpet call in the "Leonore," so the haunting, almost fragile cadences of a muted trumpet were gorgeous. This concerto is not perhaps the most spectacular written for this instrument, but it provided a fine platform for Baker's talents.
The leisurely intermission opened new vistas of enjoyment offered by the Center. Wandering up and down the promenades and stairs that elegantly surround the hall was a relaxing, meditative experience. Small, perfectly dressed children found the wide open spaces irresistible and ran for the sheer delight of doing so. Couples sat on the modernist but surprisingly comfortable stone surfaces that look out into the night.
And then to Shostakovich's Symphony No. 5. Sitting on the third level for the second half of the concert was a great experience. Seeing the whole orchestra rather than just the usual suspects was enlightening. Lewis gave a simple interpretation of Soviet 20th century history - Stalin was undoubtedly a murderous monster, but the Tsars that men like him replaced were hardly a bed of roses. However, the conductor is on firmer ground in his musical interpretations. The first movement was brash, bold and yet contained the touch of irony that the composer constantly refers to in his attempt at living up to Stalin's programmatic demands of music.
The second movement was full of sarcastic tones, particularly in the humorous phrasing of the bassoon as it conversed with the pizzicato violins. The beauty of the third movement accentuated Caryn Crutchfield's lyrical oboe — surely we should enjoy a solo concerto from her soon — Mozart's perhaps? The final movement's martial celebration, which was perhaps subtly mocking toward Stalin's dreams of the permanence of the system he was creating, was just the right mixture of triumphant celebration and hyperbole. Shostakovich was wryly asking — what are we really celebrating here? The Stalinist system, or the fact that one day it will be replaced?
So a rousing first Masterworks in the Symphony's new home. Upcoming concerts include the Holiday Pops on Dec. 3rd, and what should be an electrifying concert from the young pianist Kyle Orth early in the new year. Very early in his career Orth has made the leap from the technical musical expertise that many possess to a unique sound that few ever achieve. He should not be missed.
For details on all their concerts contact the MOSC at 563-0921 or go to www.mosc.org.
Graham Dixon, Ph.D.


text:
Alternative Fueling Station Locator
Find alternative fueling stations near an address or ZIP code or along a route in the United States. Enter a state to see a station count or see stations data by state.
Find stations on your mobile device or download the iPhone app or Android app.
close ×
More Search Options
- Biodiesel
- Electric
- Ethanol
- Hydrogen
- Propane
All locations are approximate
Stone's Education Superstore
210 Hampton Woods Ln
Raleigh, NC 27607
Raleigh, NC 27607
- Access:
- Public
- Hours:
- Store business hours; see front desk for access
Fuel Available
Electric Vehicle Charging
- Level 2 outlets:
- 2
- Connector types:
The station locator does not support your current browser. To use this application:
- Upgrade your browser to a new version.


text:
Some highlights of this building include a doorman, concierge, laundry room, dry cleaning, bike room, basketball court, children's play room, fitness center, lounge, and rooftop deck.
The Financial District, contrary to its name, is not all business. In addition to the short walk to work and numerous transportation choices, residents that live in the converted office buildings enjoy a multitude of cultural and recreational options in this neighborhood. Some of the interesting sites include the Westfield World Trade Center, Brookfield Place, New York Stock Exchange, Battery Park, Bowling Green, World Trade Center Transportation Hub, Fulton Center, Trinity Church, City Hall, 9/11 Memorial Museum, and One World Trade Center. With stunning views of the Brooklyn Bridge, nearby South Street Seaport offers a large variety of shopping, dining, and entertainment choices as well.
Note: Some photos may be representative of similar units in the building to illustrate typical finish quality, fixture types, and amenities.
Subway options include:
Wall St
Broad St
Fulton St
Whitehall St-South Ferry
Claim your apartment now. Email me immediately to schedule a viewing for this and other similar apartments.


text:
EasierLiving.com, LLC
297 High Street
Dedham, MA 02026
EasierLiving knows how much we all value our right to privacy. Any personal information will only be used to make a better website. Your information will not be passed along or sold to any other organization.
Except where specifically noted, no information or images within the EasierLiving Web site may be copied, duplicated, stored in a retrieval system or reproduced in any form without the express written consent of EasierLiving. If you have any questions regarding our policies, please contact us.
EasierLiving assumes no responsibility for errors or omissions. The information and images described herein are subject to change without notice. EasierLiving is a trademark of EasierLiving.com, LLC. All other trademarks and service marks are property of their respective owners.
Copyright © 2017 EasierLiving.com, LLC. All Rights Reserved.
EasierLiving.com, LLC has provided the information on this web site for your convenience. Please note that we will update this web site periodically.EasierLiving.com, LLC makes no representations or warranties, either express or implied by or with respect to anything in this document, and shall not be liable for any content herein.
For immediate assistance, call toll-free at 1-855-493-9856
For all other inquiries, please email us:


text:
In our previous Intro to Linguistics posts, we've covered phonetics (the study of speech sounds) and phonology (the study of how sounds are combined to create meaning). Today, we'll be looking at another field of linguistics, morphology.
Morphology is the study of the structure of words and how they are formed. To give you an idea of what morphology is all about, we'll start out with a list of key terms.
morpheme - The smallest unit of linguistic meaning or function. Words can be made up of one or many morphemes. Depending on how they attach to each other, morphemes can be either free or bound.
|A happy cat awaiting some attention.
bound morpheme - These morphemes are always bound to words and cannot be words by themselves.
affix - Affixes are bound morphemes attached to a stem or root. They have different names based on where they're attached to another morpheme. Prefixes attach to the beginning, suffixes attach to the end, infixes are found in the middle of a morpheme, and circumfixes attach both before and after.
This is just the tip of the iceberg in terms of morphology. The morpheme that remains when all affixes are removed is called a root. For example, happy is the root of the word happily.
Morphemes that create a new stem or word are referred to as derivational morphemes. They often change the grammatical category of a word. In the word happily, the suffix -ly converts happy from an adjective into an adverb.
Inflectional morphemes, on the other hand, add grammatical information such as case, number, person, gender and tense to the word. In the word cats, the suffix -s indicates number, while in played, the suffix -ed indicates the past tense. Not too tricky, right? There's much more to morphology, but we'll keep it short and simple for today.


text:
Manage Mary…
"Setting up systems so I don't panic."
"Haven't developed a system to capture leads and upsell clients."
"Where to start … figure out what goes first, last, or in the middle."
Where you are right now…
As a Manage Mary, you're a solopreneur who may have one or two foundational systems in place, but overall there are significant gaps in your business foundations. You're lacking the step-by-step plan on what to do first, what to do second, third etc. to build your business. You are disorganized, and you're not working efficiently.
You absolutely love what you do, and are passionate and clear on your expertise, but you have no idea of the sequential order of creating a business.
The challenges you're currently facing…
As a Manage Mary you're very concerned with cash flow right now – you would love to be able to generate consistent income, and increase cash flow more quickly, without having to rely on family funds or 0% lines of credit. The clients aren't coming in as quickly as you'd like, and you need to have a system in place so that you can follow-up and nurture client relationships. This in turn would convert potential clients into paying clients, and so build your client base and generate the consistent cash flow that you are desperate for.
You are working long hours but are not seeing any results, and this is causing you stress and sleepless nights.
What your best next steps are…
Given these challenges, your primary focus needs to be on building the foundations for your business. And this means putting in place the RIGHT systems in the RIGHT order to create your solid foundation. Even though marketing your business is critical for your success, at this stage your marketing won't be successful unless you first have your business foundations in place.
This means creating a Strategic Business Plan that provides you with a clear Big Picture Vision and Ideal Client Profile, and then working your plan consistently over a 90-day period so that you can begin to build your client base and so generate a consistent cash flow.
A Manage Mary is all about creating specific goals and then creating a plan to move towards your goals, along with the accountability you need to move your business forward quickly.
The Business Success Strategies products that will be perfect to take you to the next level…
- Is Your Business Set Up To Fail? Free Quiz
- Your Systems For Success Six-Week Challenge
- School for Online Business Success: Monthly Membership Training


text:
Aries Decan 3 are ruled by Venus in the Chaldean system and Jupiter by triplicity (Sagittarius). The Sun trail blazes through the constellations of the Sea Monster, River, Goldfish, King, Fishes and Princess from April 9 – 19. Although we are in a fire sign you can see we have quite a nautical battle on our hands as Venus was the goddess of love and war in ancient times. So what we end up with is a raging sea and a tsunami of flaming emotions. Aries decan 3 needs to make love not war, but if it can't make love then the war can get very monstrous indeed.
Despite the decan being ruled by two benefics in separate systems, nearly all of the stars in Aries decan 3 are given the attributes of Saturn, or Jupiter/Saturn. Everything with these rams is played at epic proportions. It is also very sexual, since we know Jupiter was the biggest nymph chaser of them all. Of course this decan will have quite Sagittarius attributes too , so here we get judgemental folk who sometimes take the law into their own hands. We can also find pirate types and vigilantes here.
Bounty Hunters & Black Gold
Of course very ardent lovers also reside in Venus ruled Aries decan 3. None of the unrequited, yearning, courtly love of their neighbours Pisces, but full steam ahead passion. Aries decan 3, on its way to sensual Taurus may get the vote as the most highly sexed of all the decans, but god help us if this huge libido is bottled up. It can be massively self destructive if it is capped with nowhere to flow…
On the positive side the Venusian charm can also work to tame an aggressive audience. The power of art or humour to heal and be cathartic is also found here. Austin Coppock calls this decan " The Burning Rose; setting fire to the hearts of all that bear witness" he also visualises "a hippy places a rose into the barrel of a loaded gun" [1] echoing my "Make Love Not War" statement earlier.
Aries decan 3 have a black humour which can be how the sexual frustration is vented out, if they are not using this biting energy physically. They are sarcastic and can be bitter in their criticism. True they are bitchy, but they are hilarious with it. Therefore Aries decan 3 can actually make very good money as commentators, critics and raconteurs. It seems the theme of Aries decan 3 is to somehow keep balance while sailing this violent sea. These are the zodiacs bounty hunters. Life at sea can be perilous, gruelling and lonely at times with many setbacks. Aries decan 3 have mixed fortunes, but the most persistent will claim their prize.
Aries Decan 3 ~ Fixed Stars
Aries 21º 49′ ~ Delta Andromeda in Andromeda the chained Princess. 3.4*
Aries 21º 57' ~ Baten Kaitos in the heart of Cetus the Sea Monster 3.9
Aries 23º 16' ~ Acamar in the Eridanus the river 3.4
Aries 24º 13' ~ Kurdah in the neck of Cepheus the King 4.6
Aries 26º 16' ~ Delta Dorado in the Goldfish 4.5
Aries 26º 49' ~ Al Pherg in the cord of the Northern Fish of Pisces the Fishes 3.7
Aries 27º 51' ~ Vertex the Spiral Galaxy in Andromeda's thigh 4.8 [largest stars]
Aries 29º 23' ~ Alrisha in the knot of Pisces the Fishes 3.9
*Magnitude. Star positions for the year 2000
Sun Aries 3
Alrisha 29º "One who can solve problems by finding unusual or creative solutions. One who can be a mediator between groups" [2]
Bernadette Brady's interpretation might be a bit too tame for this volatile decan. She does use parans which are a different method of research, but I include it here because there are no other references for fixed star meanings for this decan. The Sun is exhalted in Aries which makes its strong, but combine that with monstrous potential of some of the stars could mean that these folk find it very hard to restrain themselves. One minute they are the life and soul of the party, generous and magnanimous, then the next, (if they are rubbed the wrong way), an explosive temper that comes from nowhere. Inside them there is the tension symbolised of the knot between the two fishes of Pisces swimming in different directions. This can make the native sometimes feel like they are splitting in two, sometimes this results in migraine headaches. Aries rules the head. The native sometimes has to conceed that they really can't have it both ways. The more evolved types will find an entertaining way to resolve the two-way pull dilemma. Austin Coppock acknowledges the entertainment value of the Sun in this decan " The natives often feel a need to test their abilities against groups of people and are often drawn to the performance arts such as dance, drama or comedy…" but also states that "Just as they are able to set fire to others hearts, the natives of this decan are easily inflamed themselves." [1] The sinking of the Titanic is a great example of this sensationalising decan whilst also falling victim to the malefic influence of the sea monster. The Titanic's dramatic plunge into the Atlantic ocean due to hitting an iceberg, made it the perfect subject matter for a disaster movie. In 1998 "Titanic" became the biggest grossing film of all time, again the film visually was played at "epic proportions" with awesome cinematography.
SUN ARIES 3 EXAMPLES: Titanic Hits Iceberg, J. P. Morgan, Charlie Chaplin, Emma Watson, Sarah Michelle Gellar, Kate Hudson, Mandy Moore, Omar Sharif, Sean Bean, Andy García, David Tennant, Emma Thompson, Peter Ustinov, David Letterman, Kourtney Kardashian, Maria Sharapova, Tim Curry, George Takei, Victoria Beckham, Joss Stone, Jayne Mansfield, Samantha Fox, Pope Benedict XVI, Jeffrey Archer, Paloma Picasso, Henry Mancini, Hayley Mills, Edie Sedgewick, Liz Renay, Frances Newton, Dodi Fayed, Oklahoma Bombing, Blake Fielder-Civil, June & Jennifer Gibbons, Linda Goodman, Erich von Däniken, Dolores Cannon, Emile Durkheim, Brady/Hindley Davison.
Aries Decan 3
Aries Decan 3 illustrated ebook (pdf). Includes Sun, (As above) Moon, AC, MC, Mercury, Venus & Mars & full fixed stars interpretations.
Aries Decans
All three decans as above. Upon checkout you will be taken to an encrypted, SSL page where you can make your transaction securely.


text:
Tom Ford Takes 2017
Designer Tom Ford is always a force to be reckoned with! He makes some of the most amazing pieces to me. His style and creations are always so suave and classic. Nothing like a property tailored tom ford suit! Tom Ford himself is very charismatic, quick on his toes, and knows his good side! I am so in love with his new Spring 2017 Collection! He also has been named as of GQ's men of the year which is much deserved. Check out some looks from his new 2017 men collection!
Tags: Men Fashion, Spring 2017, tom fordcontinue reading


text:
New Delhi: As Supreme Court on Friday struck down the Constitution's 99th amendment putting in place the NJAC and the NJAC Act, 2014, Justice Jagdish Singh Khehar said it intruded upon the independence of judiciary and primacy of chief justice of India in appointments to higher judiciary based on the collective wisdom of collegium of judges.
"..in the matter of appointment of judges to the higher judiciary, as also, in the matter of their transfer, primacy in the decision making process, inevitably rests with the chief justice of India. And that, the same was expected to be expressed, on the basis of the collective wisdom, of a collegium of judges," he said, rejecting the government's and others contentions to the contrary.
In his separate judgment, he reiterated that in the matter of appointment of judges to the higher judiciary, and also, in the matter of transfer of chief justices and judges from one high court to any other high court, under articles 124, 217 and 222, the CJI's primacy is liable to be accepted as an integral constituent of the above provisions as originally enacted.
Justice Khehar said the presence of the chief justice and two senior-most judges immediately after him in the six-member NJAC, which has now been struck down, was "insufficient to preserve the primacy of the judiciary in the selection and appointment of judges to the higher judiciary", including their transfer from one high court to another.
Rejecting the government's contention that the presence of these three would ensure the primacy of judiciary, he said that even if the three consider a nominee to be worthy for appointment, this ay be blocked by the exercise of veto by any two members including two eminent people.
Describing such a possibility as "out-rightly obnoxious", Justice Khehar said: "The reason to describe it as being obnoxious is this – according to the learned attorney general, 'eminent persons' had to be lay persons having no connection with the judiciary, or even to the profession of advocacy, perhaps individuals who may not have any law related academic qualification, such lay persons would have the collective authority, to override the collective wisdom of the chief justice of India and two judges of the Supreme Court of India."
The instant issue, Justice Khehar said would be "demonstrably far more retrograde", when the union law and justice minister also supports the unanimous view of the judicial component (CJI and Two Judges), because still the dissenting voice of the "eminent persons" would prevail.
"It is apparent, that primacy of the judiciary has been rendered a further devastating blow, by making it extremely fragile," he said, noting that the so-called primacy of judicial members in NJAC on their strength (three out of six) could be rocked by any two members blocking even their unanimous recommendations.
Justice Khehar also held the provision of the constitution amendment providing for the law minister's presence in the NJAC was "ultra vires" of the constitution as it "impinges upon the principles of independence of the judiciary" as well as "separation of powers".
He also held the clause providing for two eminent persons on the NJAC as ultra vires of constitutional provisions of the Constitution for a variety of reasons and violative of its "basic structure".
Brushing aside the government's contention to the contrary, Justice Khehar said that the trashing of the 99th amendment would automatically restore the operation of collegium system.