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What's In An Instrument Panel? by:Tanner Proctor
Most of us drive every day, but do not pay close attention to the gauges in our car. We all look at the speedometer in an attempt not to get pulled over, but sometimes even that is not enough to prevent a pretty pink ticket.
We should be paying more attention to some of the other gauges in our cars for very good reason. The reason is simple. They are there to alert us to the condition of the car as we drive down the road. The cars gauges can be our warning that something is wrong with the car before everything breaks.
However, many vehicles today do not have much more in the way of "gauges" than a speedometer and gas gauge (which are the only ones most people pay any attention to), but rather have "warning lights". When auto makers discovered that the average driver in today's world never looked at the other gauges, and were not educated about what they meant anyways, they decided to do something that would do a better job of getting the attention of the driver. Warning lights replaced the traditional gauges and have been a better way of getting the drivers attention (in most cases) when there was a problem.
If you're lucky enough and have a car that still has gauges, you should pay attention to them. The water temperature gauge is there so that you know when things are heating up so that you can make sure that the car is not getting too hot. A car overheating is a particular problem in the heat of the summer time. The average street car normally operates between 200-210 degrees Fahrenheit. If you see the water temperature creeping above that, you should pay close attention and stop the vehicle if it continues to climb, otherwise you will be on the side of the road with a bunch of steam coming out and you could possibly ruin some major parts of your car's engine.
The oil pressure gauge is another gauge found in an instrument cluster. This gauge reads the pressure (or force) of the oil through the engine. This is important to know, because a loss of oil pressure usually means some big problems are imminent if you continue to drive the car. This loss of pressure, whatever the cause, means that the parts of the engine that need lubricating while running are likely not getting it. If you do not stop the car and turn it off, then you can break something inside and that can be real expensive to fix or replace.
RPM's on the dash are in a gauge called a tachometer. RPM's tell you the revolutions per minute that the crank of the engine is turning. This is important to know because the higher the RPM's, the faster everything is turning. The faster the parts turn, the tougher it is for them to be lubricated enough to counteract the heat generated in the motion. That, in turn, can mean a broken engine or at very minimum, one that does not last for long. Street cars and trucks generally run between 2000-3000 RPM's while driving down the road, and even less when they are idling in the driveway. For some reference point, compare that to a NASCAR race car, which runs around 8000-9000 RPM's and Indy cars, which run between 12,000-13,000 RPM's.
A less common gauge in the car is the oil temperature gauge. While oil pressure and water temperature are more important, oil temperature can also indicate some potential trouble. If the oil gets too hot in the engine, then the oil will break down, causing it to lose its lubricating ability. Lubrication in the engine is crucial to it running, so when it breaks down that can mean big trouble and possibly destroy an engine. Generally most cars that have gauges do not have an oil temp gauge because the water temperature will heat up before the oil, so if you see the water temperature getting too hot and stop, the oil temp should never be a problem.
The instrument panels in our cars are something that more people should pay attention to. If you have gauges, you should learn what each gauge really means and pay attention. However, many cars today have warning lights instead of gauges. In my humble opinion, warning lights in your cars instrument panel usually come on too late. Speaking as someone who understands and prefers gauges, you need to understand that if a light comes on in your dash, you are already into the trouble zone and should park the car very soon.
About the author
Tanner has learned care car from a young age. His dad worked as an auto mechanic and raced cars. Tanner could be found in the garage with his dad most every weeknight and at the race track on the weekends during the summer.
Tanner's biggest pet peeve about cars today are the lack of real car gauges in the instrument panel.
Article Source:


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The number of PCB layers is 25% more than normal memories. This provides better efficiency and performance since the power layer and the signal layer has a farther distance between each other. Without the interference between the power and the signal, it can offer players the overclocking pleasure and a high stability overclocking memory module.
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We have had some great ball players on WBS in the past, but none any better than UCLA and NFL defensive end and linebacker Bruce Davis.
In this episode, we lament the horror that is the Bruin defense, we respond to your calls, AND we talk to Bruce Davis! (47:03).
He joins the show to talk about his time with the Bruins, the current state of the team and the TALEGATE App (available on itunes and android). Share your gameday experience with other fans and athletes with Talegate.


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Your Gift Can Have an Added Benefit - 50% Tax Credit Back to You!
Gifts to support the Residential Program at Denver Children's Home qualify for the Colorado Child Care Tax Credit Program. This program allows taxpayers who make a monetary contribution to promote child care in Colorado claim a state of Colorado income tax credit of 50% of the total contribution. In-kind contributions of property (non-monetary donations) do not qualify for the credit. Eligible donors will receive a Child Care Contribution Tax Credit Certification (DR 1317) with their gift acknowledgment. Since we specialize in restoring hope and health to traumatized children and families, we are not tax advisers; but we have provided an example below on how this added benefit helps lower the cost of your gift to the Home.
For additional information on the Colorado Child Care Tax Credit Program click here.


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Dementia Care
People with dementia can often feel anxious, depressed and confused. The more everyone in their life understands what they are going through the better we can help them to maintain, improve, or regain their mental well-being.
Our expert team is more than used to working with those suffering from dementia and making their lives easier and more comfortable.
What we offer your loved one -
- Continuity of care to help your loved one stay at home
- Support with memory and mental stimulation
- Help with shopping and cleaning
- Trips out, walks in the park and other activities.
- Transport to doctor's or hospital appointments.
- Cleaning, laundry and other household chores.
- Help to remember key events and appointments.
- Conversation and companionship.


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"A man who stops advertising to save money is like a man who stops a clock to save time." – Henry Ford
Many business owners make the mistake of ignoring social media. Whether you own or manage a large corporate company or a small start-up, social media is a very powerful tool to get your business noticed. The only way to grow a business is to grow your customer base; and the easiest way to get people to notice you is to be visible on social media.
Everybody is on social media
Ignoring social media is almost as bad as not being visible online. The businesses you want to target with your marketing still has humans managing and owning them. Chances are that the decision-makers do have Facebook accounts. Facebook has 2 billion monthly active users compared to Twitter which only has 330 million monthly active users and LinkedIn with 500 million users. LinkedIn is still the social media channel of choice for many businesses, but Facebook is the social media platform where you will be able to reach the most potential customers. Facebook might just be the place they become aware of your brand.
"Ignoring online marketing is like opening a business but not telling anyone." – Unknown
Show people who you are
Brand awareness refers to the extent to which your customers are familiar with the quality or image of your brand. You can create brand awareness by being visible online. This ties in with your reputation, and it is important to manage the way you are perceived. Many individuals, when creating content, think of the company and how they promote the company instead of finding solutions to consumer problems. Remember, you're creating content for the consumer; whether you're running a B2B or B2C operation. Place yourself in the consumer's shoes and promote the company from that point of view.
Building a following
Business clients care very much about your intentions and values. What better way to show them that you value your clients than having nice conversations with other clients on Facebook where they can see it? Linking to transparency, they can see how you respond to client concerns and decide if they want to do business with you. They can also see if your brand identity suits the idea of what they have in mind for themselves. You can direct your marketing campaigns at anyone you wish, making it very personal. Irrelevant audiences will not be exposed to your brand and you won't waste any money on them. It is possible to target very large, but very specific, audiences.
What you need to get started
Don't spread yourself too thinly across all the social media platforms – the only thing worse than no social media is unattended social media. Choose one or two platforms where you will engage with your followers regularly. Also decide on regular intervals to post content so that your followers see enough of you, but not too much. Once you have decided which platforms you want to use (hint: use Facebook), have someone with a creative eye design a nice profile picture and banner image for you. It's also a good idea to ask them for branded templates you can use for your posts.
What should you share on social media?
You can share some "how-to" videos to assist your clients with issues they might encounter. You can also share industry news that they might find interesting, or you can share your own news relating to new product releases or services that you are working on. Another good idea is to create a blog and share the posts on your social media platforms. Remember to brand your content with your logo; if it gets shared, people can still link it back to you.
Need some help getting your business visible on social media? We can help with Facebook advertising! Contact us for a quote.


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The sound of the whacks adds a very nice intensity to the activity. I enjoy it. I enjoy increasing and decreasing the tempo as I gauge the reactions of my playmate. I start light, with staccato little taps, a hard one mixed in every now and then just to keep things unpredictable. I ramp things up a bit and slow down to give harder strokes. After a certain amount of time passes, the brain releases certain chemicals to ease your suffering. This chemical release feels amazing and can vary from a slight buzz to a full blown euphoria. I feel it too. It is a visceral connection and can be surprisingly intimate.
The fact that the paddle has the greek letters of a sorority and a university emblem on it adds to its allure. It has a dedication on it,
Holding this paddle takes my imagination all over the place. What did Shakes and Donna look like? Did Shakes teach her little sister how to take a good punishment? For her own good? Was the paddle used on multiple initiates bums as part of humiliating hazing rituals? HHHmmmmm This powerful paddle has a rich history, I am sure.
The boy who gave this paddle to me did so not to manipulate the Mistress into getting what he wanted, but rather to repectfully communicate his desire. He does not want elaborate BDSM roleplays or strict protocols. He just wants a solid, good paddling on his butt. He wants to push his own limits by taking as many hard licks as he can. And as an added bonus, he likes to admire my pantyhose clad legs and touch them, ever so delicately. He has taken the most whacks of anyone I have played with. I am proud of him.


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I agree We use cookies on this website to help us provide the best user experience. By browsing this site you agree to their use - more information is available here.
It's been a busy period for HMRC and there have been a number of recent developments in the Scheme Reconciliation Service (SRS) world, let's take a look at some of the recent changes…
With the December 2018 deadline for reconciling GMPs looming, HMRC are seeing a massive increase in the number of SRS queries, so it's understandable that there may be a squeeze on their resources. But what impact will this have on the pensions industry?
HMRC announced on 5 August 2016 that they would not accept any new requests for new data to be provided through the Scheme Reconciliation Service (SRS), but what does this mean for the schemes that we administer?


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3 Perfect Tips On How To Keep Your Home Habitable Irrespective Of The Season
Most people consider the climate of the area when they are searching for a new house to reside or raise a family. Getting the perfect home can be challenging because there will always be seasonal variations. There are times you will have to deal with extremely high temperatures while in other times they will be very low making your home inhabitable. Climate change due to environmental degradation is also making life unpredictable, and people are suffering as a result. A good house should offer protection to you irrespective of the season. The following are the perfect tips to keep your house in good condition irrespective of variations in weather.
Seal your house
Cold air from outside can get into your home through loose openings on your doors, windows, and ventilation. You can overcome this challenge by sealing all these openings with weather strips. Such an approach ensures that hot air does not move out of the house when it is extremely cold. The same can be applied when it is the hot season. Hot air can get into your house through such openings and make the house uninhabitable. Check for all loose openings in areas such as the attic which are mostly ignored.
Install air conditioners
You do not have any say on how seasons should follow each other in a year. However, you can decide on the kind of lifestyle that you want to lead by installing various appliances. You do not have to suffer just because it is the cold season because you can warm your house through air conditioning. Breakdowns can be frustrating especially when you are just heading into a cold season. You can keep your boiler or home heater in good shape by contacting specialists such as Andrew Tyler – The Crawley Gas Engineer for all your repair and maintenance needs. Ensure that you use energy efficient appliance to cut on electricity bills.
Keep the house clean
A good number of people do not understand the relationship between cleanliness and weather variations. Blocked sinks and drainages can be the source of excess humidity in your house. Overgrown shrubs and flowers make it hard for snow to melt naturally during the cold season. Ensure that you clean your air conditioners frequently to ensure that they are efficient. Get rid of stagnant water within your compound because it can be a good breeding site for harmful organisms. Ensure that you dust your house frequently and keep all the fixtures clean.


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Meet the Chef
Chef Yashica has spent the last 7 years working to make Mattina's cuisine the best in Kingman Arizona. Chef attended Western Culinary Insitute in Portland Oregon where she was trained as a Cordon Bleu culinary expert.
When I asked her why she became a chef, her initial response was that she had always enjoyed cooking and the family atmosphere that existed in the kitchen around meal times. We went on with our conversation and spoke of her travels and time in Japan as well as her favorite dishes both in the restaurant and outside of it. It was when I asked about baking and pastries that she suddenly laughed and said "Actually the reason I became a chef was really so I could make croissants. I read about it in a book and the character in the book went to a Cordon Bleu culinary institute, so that was when I decided I should do the same." Croissants take a day and a half to bake and if not prepared correctly, they come out doughy. Yashica told me she has tried on several different occasions to make croissants. "The first time I tried to make croissants I took my time and focused on every detail and they still turned out done on the outside and raw on the inside. I didn't try them again for four years after that."
Don't worry though, Chef can make a wonderful croissant, as well as every amazing dish on the Mattina's Ristorante Italiano menu including her favorite, Sea Bass Vera Cruz. When she's not in the restaurant, Chef enjoys experimenting with different types of food. Her tastes run from Japanese cuisine of traditional Hot Pots and tempura, to Kobe beef to Korean BBQ.
We are very lucky to have Chef Yashica on our team at Mattina's. If you get the chance, visit Mattina's and say hi to Chef and the entire Mattina's family as they serve up the finest cuisine in Northern Arizona.
Dinner Menu


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Richard Hurrell, Director of Engineering
Richard began his career as an apprentice electrical engineer for British Steel. After achieving an HNC in Electrical Engineering and an Honors Degree in Instrumentation and Control Engineering, he was offered a full time position working in the steel industry.
15 years later, Richard decided to train as a teacher through the Open University. Richard joined the UTC in it's opening year.
Sim Richards, Teacher of Engineering and Design
Sim holds a life-long passion for designing, making, breaking, remaking and improving products in an effort to understand how things work and how they could work better.
He graduated from Swansea University with a BSc in Product Design. He spent two years working in Africa and Spain in the fields of solar power, ecological design and sustainable transportation and 10 years in the bicycle trade, latterly with his own business teaching bicycle maintenance and riding skills to thousands of young people across the south.
Sim qualified as a teacher in 2011 through the Oxon Bucks GTP program and since then has taught Engineering and Design and Technology at Cherwell School Oxford, before starting work at UTC Oxfordshire in September 2015.
Will Ratty, Teacher of Engineering and Design
Will graduated from Bradford University with an Honours Degree in Mechanical Engineering.
He spent 30 years in industry, paper mills, steel mills, as a self-employed design engineer, and ended up at Siemens, Eynsham, making MRI magnets.
After qualifying as a teacher, Will worked in Cherwell School and further education, including teaching Design Technology, BTEC, and HNCs to BMW Project leader staff.
Georgina Phillips, Teacher of Engineering and Design
Georgina studied Industrial Design and Technology with Education and completed her PGCE at Loughborough University. She taught in a secondary school in Northamptonshire covering Resistant Materials, Product Design, Food Technology and Graphic Design for 11 years.
In 2016 Georgina joined UTC Oxfordshire as she was excited by the new type of education it promised to provide.
Kate Tyler, Teacher of Engineering Mathematics
After working as a Registered General Nurse for 10 years Kate completed a degree in maths with the Open University and her PGCE at Oxford Brookes University. Kate spent 11 years teaching maths at Matthew Arnold School.
Kate joined the UTC in 2015 and teaches all year groups including GCSE, A levels and maths for engineering.


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This is the website for Brownsea Open Air Theatre. Lookout for our new website coming in October 2019
If you would like to contact us here at Brownsea Open Air Theatre, please send us your questions
and queries below. We will aim to reply to you within 24 hours.
The Box Office,
Brownsea Open Air Theatre,
Dept WS,
PO Box 338,
07845 782924
If you're a member of the press looking for official BOAT photography, please contact us for access to our exclusive Press Area.


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Throughout time, humanity has struggled with their sense of national identity. Who are they? Where did they come from, and what is their background? Various ethnic groups have had their sense of pride and national identity stripped from them through exploitation, racism, slavery, and colonialism. As our initiative's focus is to show the devastating effects of war, the Museum of Jewish Heritage in Battery Park, New York is the textbook honorable example we plan on following.
The Museum of Jewish Heritage is a living memorial to the Holocaust, which was one of the most repulsive crimes committed against an ethnic group in world history. The Holocaust was the systematic executions and genocide of the Jews during World War II based on their faith by the Nazi government of Germany and their collaborators throughout the world. Over 6 million Jews perished in the targeted persecution and millions were left homeless without and identity or means to start their lives over again. The Museum of Jewish Heritage explains their story pre-World War 1 and 2.
There are three levels of the museum. Level 1 is called Jewish Life a Century Ago: 1880 – 1930. Level 2 is The War against the Jews: 1930 – 1945, and level 3 is Jewish Renewal: 1945 – Present. Level 1 showed how the Jewish communities interacted with other ethnicities and races across the world. This exhibit starts at the year 1880, where empires either reached their peak (British, French, Italian) and other empires were showing signs of their collapse (Ottoman, German, and Russian). There were large Jewish communities in North Africa (Tunisia and Algeria), the Middle East (Lebanon, Palestine, Iraq, and Yemen) and in Europe (both Western and Eastern). Though the ancient Hebrew homeland of the Jews (the Kingdom of Israel) was stripped from them by the Roman Empire, around this time in history there wasn't much conflict between other faiths or ethnicities against those who practice Judaism. Jews enjoyed the highest honors of having the most respectable jobs in various nations that they resided in. They were doctors, teachers, historians, accountants, etc. and world government relied on them as the backbone of their economies. Then World War 1 came looming in, due to growing rise of nationalistic movements in countries such as Austria, Germany, Bulgaria, and Turkey. Various atrocities and genocides took place, but not against those of Jewish faith. Particularly, the ethnicities that faced genocide were Armenians, Greeks, and Assyrians, who were all encompassed inside of the Ottoman Empire and targeted by the Young Turks in their policy of "purifying Turkey." Post WW1 saw the collapsed of the Second Reich (German Empire) and loss for the Central Powers. From this, a gang of misfits used this opportunity to use their bigotry and hatred against the Jewish community. They were known as the Nazis. The Nazis compromised of Adolf Hitler, Josef Goebbels, Heinrich Himmler, and Herman Goering as their leaders and they primarily attacked those of Jewish faith to their rise to power. The Nazis officially took power in 1932 when Hitler and his party won the general elections of 1932 and immediately began a targeted persecution against Hebrews, such as segregation, anti-Jewish laws, and abductions of intellectuals.
Level 2 is The War against the Jews: 1930 – 1945 explained in detail the segregation of Jews by placing the Star of David on as an armband to distinguish them from regular Germans and placing them in very constricted ghettos, such as the infamous one in Warsaw, Poland. When Nazi Germany ignited World War II by invading Poland, they used a systematic campaign of rounding up Jewish people throughout Europe. They did this with the help of the SS, Gestapo, and Nazi sympathizers and collaborators in Austria, France, Bulgaria, and other areas in the Middle East and North Africa. A particular mural on the second floor that shocked me was an explanation of how the entire world knew about the Holocaust, yet refused to act on the atrocities. Various American businessmen did business with the Nazis and were complicit with the forced labor camps of Jews since it benefited their own profits. One such examples is the Volkswagen car company that knowingly used forced labor to make their vehicles. Denmark was the only Nazi occupied country that helped their Jewish population by sneaking them onto aid ships and sending them to Sweden, out of Gestapo reach. Every country Nazi Germany conquered, they placed a proxy government inside of that said country so that their collaborators either send Jews to their death in Poland or Austria, or had their collaborators and army kill them right then and there. It is interesting to note that almost none of these concentration or death camps were in mainland Germany, as most the public had no idea that their government was committing these horrific acts. When the war finally ended, millions of Jewish people lost their lives with millions more left homeless, as they could no longer trust their world governments to keep them safe anymore.
Level 3 is Jewish Renewal: 1945 – Present explains how the Jewish community thrived post Holocaust and kept their determination and faith. The British Empire forged the nation of Israel to the Jews, allowing them to return to their ancestral homelands in the Middle East. Many Jews from the Far East (Soviet Union), Western Europe, the Middle East, and North Africa all fled to Israel to start a new life, as they felt safe and secure in their own country of governance. Post WWII saw the Jewish community thrive like it has always thrived throughout its history. Facing persecutions and genocides throughout time, the Jews have held onto their national identity and self of pride. I would recommend this museum to anyone willing to visit this extraordinary and acclaimed place.
Aside from the teachings of Jewish history, the museum offer other services that allows you to interact with the community. Such events are the Hanukkah Gala, film screenings, Shabbat dinners, opportunities to engage with Holocaust survivors, and special previews of groundbreaking exhibitions. The museum even has a memorial garden dedicated to the fallen that the entire New York community can see. Overall, the Museum of Jewish Heritage is a once in a lifetime event that I would recommend to anyone to see. This heart wrenching place can touch even the darkest soul and is worth every penny of your time.


text: The Development of an Indigenous Health Curriculum for Medical StudentsLewis, Melissa PhD; Prunuske, Amy PhDAcademic Medicine: May 2017 - Volume 92 - Issue 5 - p 641–648 doi: 10.1097/ACM.0000000000001482 Articles Open Abstract Author InformationAuthors Article OutlineOutline Article MetricsMetrics Indigenous populations experience dramatic health disparities; yet, few medical schools equip students with the skills to address these inequities. At the University of Minnesota Medical School, Duluth campus, a project to develop an Indigenous health curriculum began in September 2013. This project used collaborative and decolonizing methods to gather ideas and opinions from multiple stakeholders, including students, community members, faculty, and administration, to guide the process of adding Indigenous health content to the curriculum to prepare students to work effectively with Indigenous populations. A mixed-methods needs assessment was implemented to inform the instructional design of the curriculum. In June 2014, stakeholders were invited to attend a retreat and complete a survey to understand their opinions of what should be included in the curriculum and in what way. Retreat feedback and survey responses indicated that the most important topics to include were cultural humility, Indigenous culture, social/political/economic determinants of health, and successful tribal health interventions. Stakeholders also emphasized that this content should be taught by tribal members, medical school faculty, and faculty in complementary departments (e.g., American Indian Studies, Education, Social Work) in a way that incorporates experiential learning. Preliminary outcomes include the addition of a seven-hour block of Indigenous content for first-year students taught primarily by Indigenous faculty from several departments. To address the systemic barriers to health and well-being and provider bias that Indigenous patients experience, this project sought to gather data and opinions regarding the training of medical students through a process of Indigenizing research and education. M. Lewis is assistant professor, Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, Missouri. A. Prunuske is associate professor, Department of Microbiology and Medical Genetics, Medical College of Wisconsin–Central Wisconsin Campus, Wausau, Wisconsin. An AM Rounds blog post on this article is available at academicmedicineblog.org. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: The University of Minnesota institutional review board deemed this project to be exempt from review, given its focus on curricular review and planning. Correspondence should be addressed to Melissa Lewis, University of Missouri School of Medicine, MA301 Medical Sciences Building, Columbia, MO 65212; telephone: (573) 882-2782; e-mail: firstname.lastname@example.com. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Abstract Minnesota Health and Medical School Context Guiding Principles Gathering Background Information (Steps 1–3) Preparing for the Stakeholder Retreat (Steps 4–6) Conducting the Stakeholder Retreat and Survey (Steps 7–8) Stakeholder survey content Stakeholder survey results Outcomes and Implications Limitations Next Steps Conclusions References References cited in Table 1 only Of all racial minorities, Indigenous* populations have the most dramatic health inequities in the United States, including significantly higher rates of cardiovascular disease, cancer, type 2 diabetes, suicide, and substance abuse.1–3 Compared with white populations, Indigenous populations have fewer educational opportunities, higher rates of unemployment and incarceration, and increased exposure to environmental risks, all of which are known contributors to health inequities.3,4 Within the health care system, Indigenous populations are more likely to be underinsured and to have reduced access to family medicine providers as well as to specialty care.5,6 Further, Indigenous individuals encounter challenges during medical visits that include bias, microaggressions, provider turnover, and a lack of understanding of Indigenous health beliefs.7–9 Historical and contemporary events related to policies of assimilation and genocide, broken treaties, and medical racism have resulted in increased distrust of Western medicine and research by tribal members.10 Given the breadth of health inequity for Indigenous people, we anticipate that health care providers would benefit from learning how to effectively work with Indigenous patients and communities. The Liaison Committee on Medical Education mandates the inclusion of teaching related to transparent cultural competencies in U.S. medical schools.11 These competencies include increasing awareness of gender and cultural bias and the development of skills to effectively provide treatment to people across cultures. As a result, medical school curricula are evolving to reflect these requirements, and licensure exams have been updated to include questions about health disparities and social justice.12,13 Medical students have reported that they believe that multiculturalism, bias, and racism should be a part of their curriculum.14 Students from underrepresented minority groups express that the presence of a health disparities course positively influenced their decision to attend a particular medical school.15 However, a curriculum tailored to the medical school's local and regional minority population may be even more effective than a general course in multiculturalism. In particular, Indigenous groups are not homogenous, so there is a need for medical schools to have a specific curriculum related to the local and regional groups that trainees will serve.15 However, it is important to note that the Leaders in Indigenous Medical Education Network, a network of medical educators from Australia and New Zealand, has emphasized the importance of teaching Indigenous cultural safety/awareness separately from multicultural awareness.16,17 The University of Minnesota Medical School, Duluth campus (UMMSD) is situated in a region that serves a significant Indigenous population, so it is critical for the school to offer meaningful Indigenous health content and threads throughout the curriculum. Incorporating feedback from Indigenous community members into the development of this curriculum is also critical. Therefore, we initiated a community-building and knowledge-gathering project to develop an Indigenous health curriculum for medical students to address Indigenous health disparities in our local tribal areas. The purpose of this project was to create didactic material for medical students to increase their knowledge and competency in the area of Indigenous health. In this article, we describe this project, including the guiding principles supporting this work as well as the first steps in this process of creating an Indigenous health curriculum for medical students. Back to Top | Article Outline Minnesota Health and Medical School Context Indigenous people represent 1.3% of the total Minnesota population and are the largest minority group in some rural regions of the state.18 There are seven Anishinaabe and four Dakota reservations, which were created by treaties on land that was, in part, their original homelands. In 2014, Minnesota was ranked number 4 in the nation for overall health.19 However, there remain persistent and large health disparities between Indigenous and white Minnesotans on almost all health measures. In particular, across all racial groups in Minnesota, Indigenous populations have the highest mortality rates.2 UMMSD is a regional campus of the University of Minnesota Medical School and is focused on years 1 and 2 of undergraduate medical education. It opened in 1972 and has the explicit mission "to be a leader in educating physicians dedicated to family medicine, to serve the health care needs of rural Minnesota and American Indian communities, and discover and disseminate knowledge through research."20 Mission statements often reflect institutional values and outcomes, and in reviewing the mission statements of all U.S. medical schools, we found that UMMSD is unique in its stated focus on Indigenous health.21 In working toward this mission, UMMSD has a strong track record of supporting Indigenous students pursuing medical degrees. In 1987, the Center of American Indian and Minority Health was established to support this mission, and an American Indian and Alaska Native physician pipeline was created. Since then, UMMSD has trained over 100 American Indian and Alaska Native physicians. Over the last five years, the incoming class has averaged 5.6 Indigenous students, representing 9% of the student body. In 1994, an elective course entitled "Seminars in Indian Health" was first offered to Indigenous students, and in 2013, was opened to all medical students. In addition, there are six medical school faculty members who are Indigenous, representing 15% of the faculty; Indigenous faculty make up just 0.1% of medical school faculty nationwide.22 Given the mission and history of UMMSD, this project to develop an Indigenous health curriculum represented the next logical step in advancing the mission of serving the health care needs of Indigenous people. Back to Top | Article Outline Guiding Principles We used the principles of community-based participatory research23 as well as a decolonizing methodology24,25 to embrace and gather knowledge from the local community around what content should be included in a medical school curriculum to improve the health of the local Indigenous community and to improve patient–provider interactions. The community-based participatory research approach invites a multidisciplinary team, using a flattened hierarchy, to approach an issue that has been prioritized by community members.26–28 The decolonizing and Indigenous approaches (which look different from traditional Western scientific methodologies) aim to use Indigenous beliefs and knowledge to guide the research methodology in an effort to restore equity and balance to Indigenous people throughout the research process.24–28 For instance, we used foundational Indigenous values and practices to guide conversations about the development of an Indigenous health curriculum, including using appropriate protocols to begin meetings, privileging Indigenous voices and belief systems, and providing local and traditional foods thereby supporting local Native-owned businesses (see Table 1). Table 1 We implemented the action research cycle to capture the needs of multiple groups over time. The steps in this model include plan, act, observe, reflect, and iterate; once these steps are complete, the cycle starts over again with a revised plan.23 We also incorporated Kern's six-step guide to curriculum development: (1) problem identification and general needs assessment, (2) needs assessment for targeted learners, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) evaluation and feedback.29 The combination of the community-based participatory research methodology, the action research cycle, and Kern's six-step guide to curriculum development led us to implement an 11-step, mixed-methods needs assessment that informed the eventual instructional design of the Indigenous health curriculum (see Table 2). In the sections that follow, we describe Steps 1–8 of this process in more detail. Table 2 Back to Top | Article Outline Gathering Background Information (Steps 1–3) The first three steps in this project were to listen and learn from key stakeholders and Indigenous health experts. From September 2013 to June 2014, we spoke with stakeholders within the medical school to learn about the mission, history, and current state of education around Indigenous health. During the same time period, we gathered information from programs around the world that had already implemented Indigenous health education curricula. We gathered this information using academic literature searches, Internet searches, phone calls, and in-person visits. To complete the literature search, we used the Ovid and Education Resources Information Center databases to identify any articles describing Indigenous health content within medical school curricula. We identified other relevant curricula using Internet searches and discussions with faculty from these institutions (see Table 3 for our findings). For example, the University of Washington School of Medicine Indian Health Pathway is an elective program incorporating course work, a research project related to American Indian health, four weeks of clerkships/preceptorships, and service learning experiences. The University of Hawaii John A. Burns School of Medicine offers an elective entitled "Healthcare in Native Hawaiian Communities" for fourth-year medical students; the course includes a rotation at an Indigenous-serving site where students are mentored and evaluated by a traditional healer. Table 3 Outside the United States, in Australia, New Zealand, and Canada, core competencies in Indigenous health have been identified.30,31 The Northern Ontario School of Medicine incorporates competencies that were identified in partnership with community members into the required courses taken by all medical students.32 Additional opportunities for medical training focused on Indigenous health are available post graduation, and many of these programs use Web-based training and have core pedagogies. For instance, an online training program in Indigenous cultural competency out of British Columbia allows physicians and mental health professionals to receive continuing education credits.33 In Australia, several universities have enacted pilot projects that implemented Indigenous cultural competency curricula for faculty, staff, and students.31 We compiled these international best practices in Indigenous health training to guide the development of our Indigenous health curriculum. Back to Top | Article Outline Preparing for the Stakeholder Retreat (Steps 4–6) Through our work during Steps 1–3, key medical school stakeholders became aware of and came to support our efforts to improve the Indigenous health content in the curriculum. In preparation for convening a group to decide on the specific content of this curriculum, we built relationships with local Indigenous community members through a mostly informal process of attending local events and engaging in conversations about this topic. This step was important because the medical school's presence within the community was critical to balancing an already-unbalanced hierarchy. To achieve this goal, we used a listener–learner lens. Next, in June 2014, we asked all medical school faculty to complete a baseline survey on the exact Indigenous health content already in the curriculum. Self-selected individuals—mainly faculty—then worked together to create an agenda for a retreat at which all stakeholders would come together and discuss what content should be included in the curriculum. Back to Top | Article Outline Conducting the Stakeholder Retreat and Survey (Steps 7–8) In June 2014, we held a retreat to gather stakeholders' opinions of what Indigenous health content should be included in the curriculum and in what way. All first- and second-year medical students, all medical faculty, and community members determined to be experts in Indigenous health were invited by e-mail or phone to attend. The faculty and staff created a list of potential community member participants. From this list, we used a quasi-snowball method asking these community members to invite other community members who they thought would be able to contribute to the retreat. We held an informal discussion at the retreat meant to guide curriculum development and implementation. In addition, we distributed surveys to all retreat invitees via e-mail to ensure that all voices would be heard, even those who could not attend the retreat. The University of Minnesota institutional review board deemed our project to be exempt from review, given its focus on curricular review and planning. Back to Top | Article Outline Stakeholder survey content We used the material we gathered during Steps 1–7 (see Table 2) to develop survey questions that would guide the actual curriculum development and implementation in a tangible way. We asked stakeholders to indicate how strongly they believed that certain content should be added to the curriculum, using a Likert scale from 1 to 5 (with 1 indicating "not important" and 5 indicating "very important") as well as how that content should be taught and by whom (both quantitative and open-ended response formats). Stakeholders also responded to the following broad, open-ended questions about the delivery and purpose of the Indigenous health curriculum: (1) What role should UMMSD have in moving forward Indigenous health? (2) What do medical students need to be prepared to work with Indigenous patients, families, and communities? and (3) What style of teaching is needed? Responses were coded by a student assistant and then confirmed by the first author (M.L.). We used descriptive qualitative analysis to identify themes. Back to Top | Article Outline Stakeholder survey results A total of 29 individuals participated in the survey, including 13 (45%) medical school faculty members, 5 (17%) medical students, 4 (14%) medical school faculty members from another institution (2 of whom were physicians), 3 (10%) staff, 1 (3%) faculty member from the University of Minnesota but not from the medical school, 1 (3%) clinical medical provider (e.g., physician or nurse practitioner), 1 (3%) tribal public health nurse, and 1 (3%) retired medical school faculty member. Respondents rated themselves an average of 4.5 out of 7.0 when they were asked how knowledgeable they felt about the topic of Indigenous health. However, 16 (53%) respondents rated themselves a 5.0 or higher. Respondents (more than one response allowed) indicated that they thought medical school faculty and tribal members (23 [26%] each) should teach this content along with faculty from other complementary departments (e.g., American Indian Studies, Education, Social Work, History) (19; 22%), community members (15; 17%), and others (e.g., local and regional experts, policy makers in government) (8; 9%). When asked about the type of content that should be added to the preclinical curriculum, all 14 content areas listed on the survey received at least a 6 out of 10, indicating that all topics held some importance to respondents (see Figure 1). The top-scoring content areas were cultural humility/cultural safety, general Indigenous culture/ways of being, social/political/economic determinants of health, and successful tribal health interventions, while the lowest-scoring content areas were sovereignty/politics, Indian Health Service/health policy/638 contracting, history of Indigenous people, and oppression/privilege/social justice. Figure 1 The responses to the open-ended questions resulted in two overarching themes: (1) collaborative spirit and action: a call to work collaboratively with Indigenous communities, other universities, interdisciplinary health professionals, and interdisciplinary departments that work with Indigenous people; and (2) holistic training of medical students to become effective providers to Indigenous patients. This second theme includes mandatory didactic and experiential training (highlighting Indigenous history along with social justice and cultural humility training) from experts in Western medicine and Indigenous communities. Specifically, in response to the first open-ended question, "What role should UMMSD have in moving forward Indigenous health?" respondents overwhelmingly discussed the importance of a true collaboration with other entities, such as other health professionals and Indigenous people of Minnesota. Responses ranged from "we should live up to our mission statement" to "[we should] work on connectivity with other institutions working to train MDs but also PAs, nurses, and other allied health professionals." Several responses highlighted the importance of listening to the needs of the community: "It's also important to do this in consultation with Minnesota's tribes, to ensure that community needs are under constant assessment and integrated deeply into this program." Responses emphasized that, given the mission, UMMSD needs to connect with Indigenous community members to guide the education of students in Indigenous health and to do so in a sustainable way. The second open-ended question, "What do medical students need to be prepared to work with Indigenous patients, families, and communities?" resulted in several responses related to education around Indigenous history and culture, cultural sensitivity, and Indigenous ways of healing. Specific educational requests included that medical students "need to understand the vast diversity that exists among American Indian peoples and nations." Another response suggested that specific educational content needed "a very basic 'AI studies 101.'… Basic info on IHS, service [opportunities] and obligations, interfacing with tribal governments, etc." This request for content on tribal health care systems and forms of government was echoed by another participant who called for in-depth cultural sensitivity training, thorough education of the true history of American Indians in the Americas, be well versed in the history of government, political and legal aspects that have surrounded, and continue to impact our people. They also need quality, hands-on residencies within agencies that provide health and social services for American Indians. Responses to this second question also addressed historical trauma, socioeconomic challenges, traditional healing methods, and Indigenous knowledge dissemination. For instance, one respondent indicated that medical students should be aware "of the history of mistrust and of different socioeconomic challenges. They need more than just an understanding of the basics of our culture." Another respondent offered that "a starting point is immersion and exposure to culture, traditional healing, and people's current experience and concerns in health care." A third respondent commented on Indigenizing the medical school by saying: Personally, instead of just training more Native [medical] students to be fluent in Western medicine, I'd prefer to see the university reform itself and its systems of knowledge production to cultivate the emergence of an identity as an Indigenous doctor/health worker, skilled in both Western and traditional. Responses to the third open-ended question, "What style of teaching is needed?" called for a mix of teaching methods. However, the combinations of teaching methods varied. Some suggested "mixed—didactic as well as experiential if possible" or "short lecture format (30 min) that focuses on one or two key points." Others recommended "panel" or "experiential." Regardless of which teaching style they recommended, many suggested that a connection to community teachers was necessary: Much of this is best learnt by immersion in the community so, if possible, a community visit should be included. At the very least there is a need for community/tribal members to teach this but also faculty who have worked with or are from these communities will be invaluable. Finally, several responses suggested bringing in speakers: Inviting physicians (both Native and non-Native) into the classroom to talk about their experiences with Indigenous patients can be very powerful, as well as inviting those patients themselves to talk about their experiences in—and frustrations with—our health care system. Back to Top | Article Outline Outcomes and Implications The purpose of this project was to engage stakeholders to identify the core content for an Indigenous health curriculum to be implemented in the first year of medical school and to identify strategies for delivering this content. Preliminary outcomes of this project include the addition of a seven-hour block of Indigenous lectures for first-year medical students taught primarily by Indigenous faculty from several departments, including American Indian Studies, Education, Family Medicine, and Biobehavioral & Population Health. This block includes sessions on the history of Indigenous people; sovereignty and politics; Indigenous identity; local (Anishinaabe and Dakota) culture (specifically, seasonal rounds) and spirituality; the history of medical racism; an Indian Health Service brief; and strategies for working with Indigenous populations. Lectures are delivered in the context of several driving theories selected by the curriculum team, including cultural humility, decolonizing methodology, and region-specific Indigenous lifeways (see Table 1). Numerous time- and environment-specific events contributed to the development of this curriculum. First, collaboration among Indigenous faculty both within and outside UMMSD was helpful in gathering a new and informed view of the needs of medical students. Second, UMMSD had reached a critical mass of Indigenous faculty that allowed for expanded discussions around Indigenous health and more diverse viewpoints. Third, UMMSD is part of a university, city, and state that have a higher percentage of Indigenous people compared with other regions, and this region is well known for its programs around Indigeneity. Fourth, UMMSD has had the mission to serve the health care needs of Indigenous communities for more than 30 years, which laid the foundation for improvement in Indigenous health education. Fifth, eliciting the opinions of Indigenous students and community members was significant in advancing these changes in the curriculum. Sixth, demonstrating what an Indigenous-led event looks like in holding the stakeholder retreat in the way that we did was powerful because (1) it allowed Indigenous guests to feel more comfortable in voicing their opinion, (2) it allowed non-Indigenous guests to learn in a nonthreatening way, and (3) it modeled an Indigenized medical school meeting. Although no studies have examined the effects of adding Indigenous health content to a medical school curriculum, one study did demonstrate that medical students' knowledge, attitudes, and confidence around health disparity information increased when this topic was taught in medical school.13 Further, medical schools with social missions graduate more students who choose to practice primary care and in underserved populations, suggesting that the mission and curriculum content of the university do influence the type of care students eventually provide.21 Finally, high school students in California who received an ethnic studies course had higher grades and attendance and course completion rates compared with those who did not take the course.34 These results were even more pronounced for ethnic minorities. Applying these findings to a medical school environment suggests that a curriculum that incorporates culture and diversity content may support the recruitment and retention of minority students. Back to Top | Article Outline Limitations We completed this project at a single institution, so we do not know if the methodology and outcomes are transferable to other institutions. However, our use of a region-specific model coupled with cultural humility theory provides other educators located across the globe with a model for curriculum development. Next, this project followed the development and implementation of an Indigenous health curriculum but currently lacks any evaluation to determine its effectiveness. However, we plan to assess the short- and long-term learning of students by examining their cultural empathy, cultural intelligence, social justice beliefs, and Indigenous knowledge. In the future, we plan to determine the impact of this Indigenous health curriculum on (1) medical students' interactions with patients and (2) patients' health outcomes. We also plan to assess the effectiveness of the experiential training techniques used to deliver the curriculum—objective structured clinical examinations, problem-based learning cases, clerkships, internships, and other immersive experiences—to determine which practices are most effective in preparing medical students to work with Indigenous communities.35–39 Back to Top | Article Outline Next Steps Our survey results suggest that (1) interdisciplinary collaboration, (2) the two-way sharing of knowledge with Indigenous community members and the subsequent incorporation of Indigenous health beliefs into medical education, and (3) experiential learning are valued next steps in this project. Therefore, we hope to engage community advisory boards as well as Indigenous health curriculum teams to guide this work in the future. Some universities have even created an elder-in-residence position to increase the presence of Indigenous people and expertise in medical education (e.g., University of Washington, University of North Carolina, Fort Lewis College, and McMaster University).39 Further, learning objectives for students and pedagogical principles40 for faculty and students must be created to guide future curriculum development. These guidelines can be integrated with the Liaison Committee on Medical Education cultural competence and health care disparities standard.41 Of course, these updates require training for faculty and staff to effectively work within an Indigenous pedagogy. In addition, some argue that there is a hidden curriculum in medical education that comprises the learning that occurs from trainees' exposure to the medical environment rather than the formal curriculum.42 We did not take into account the learning environment in this project, but we believe that it may have an important impact on students' beliefs and therefore practices, so we suggest that further inquiry is needed in this area. In our case, Indigenizing a medical school would involve changing the dominant practices and beliefs so that the learning environment and the people within it reflect Indigenous values. Back to Top | Article Outline Conclusions All UMMSD medical students now complete an Indigenous-specific health block in their first year of medical school. This change happened as the result of the efforts of many over decades and without grant funding, which some community-based participatory research theorists say is the only way to create flattened hierarchies between researchers and community members and continue interventions beyond grant funding periods.43 We believe that Indigenizing the process of medical school curriculum development was critical to the success of our project, and we hope to continue infusing Indigenous principles and ways of being into medical education and practice to create a true partnership between these communities. Ultimately, we hope that this Indigenous health content assists in reducing the systemic biases present in medical schools and clinics to decrease Indigenous health disparities. However, more exploration is needed to determine what medical training is most effective in creating positive health outcomes for Indigenous people. Acknowledgments: The authors wish to thank Dr. Melissa Walls, Stephanie Wille, and Lauren Vieaux for their contributions to this manuscript; Ge-Waden Dunkley and Gabrielle Benjamin for their assistance with the Internet search; Dr. Alan Johns for the historical content review; course directors Dr. Ruth Westra, Dr. Raymond Christiansen, and Dr. Jim Boulger for their support of this project; Dr. Jacob Prunuske for his time and expertise on mission-directed programs; Dr. Jim Allen and the Department of Biobehavioral Health & Population Sciences for supporting the stakeholder retreat; and the stakeholders and survey participants for their time and for sharing their expertise.* The term Indigenous encompasses a broad spectrum of people nationally and internationally who are native to their homelands (i.e., American Indian, Native American, First Nations, Aboriginal, Alaska Native, and Native Hawaiian). Although we use the term Indigenous in this article, we recommend that local and regional terms, in the tribe's own language, be used whenever possible. Although not a proper noun, we capitalize Indigenous to indicate that we are discussing a specific subgroup of people. Cited Here... Back to Top | Article Outline References 1. American Psychiatric Association. Office of Minority and National Affairs. Mental health disparities: American Indians and Alaska Natives. http://www.integration.samhsa.gov/workforce/mental_health_disparities_american_indian_and_alaskan_natives.pdf. Published 2010. Accessed September 12, 2016. Cited Here... 2. Indian Health Service. Disparities. https://www.ihs.gov/newsroom/index.cfm/factsheets/disparities/. Published March 2016. Accessed September 12, 2016. Cited Here... 3. Centers for Disease Control and Prevention. National diabetes statistics report, 2014. 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Phillips G; Project Steering Committee, Committee of Deans of Australian Medical Schools. CDAMS Indigenous health curriculum framework. http://www.limenetwork.net.au/files/lime/cdamsframeworkreport.pdf. Published August 2004. Accessed September 12, 2016. Cited Here... 18. United States Census Bureau. QuickFacts Minnesota. 2015. http://www.census.gov/quickfacts/table/PST045215/27,00. Accessed September 12, 2016. Cited Here... 19. United Health Foundation. America's health rankings: 2015 annual report: Minnesota. http://www.americashealthrankings.org/explore/2015-annual-report/state/MN. Published 2016. Accessed September 22, 2016. Cited Here... 20. University of Minnesota Medical School, Duluth Campus. Mission statement. http://www.med.umn.edu/about/our-campuses-duluth-and-twin-cities/duluth-campus. Published 2016. Accessed September 12, 2016. Cited Here... 21. Morley CP, Mader EM, Smilnak T, et al. The social mission in medical school mission statements: Associations with graduate outcomes. Fam Med. 2015;47:427–434. Cited Here... | PubMed 22. Association of American Medical Colleges. Diversity in Medical Education: Facts and Figures 2012. 2012.Washington, DC: Association of American Medical Colleges. Cited Here... 23. O'Toole TP, Aaron KF, Chin MH, Horowitz C, Tyson F. Community-based participatory research: Opportunities, challenges, and the need for a common language. J Gen Intern Med. 2003;18:592–594. Cited Here... | PubMed | CrossRef 24. Smith LT. Decolonizing Methodologies: Research and Indigenous Peoples. 1999.London, UK: Zed Books. Cited Here... 25. Lewis M, Myhra L, Walker M. Hodgson J, Lamson A, Mendenhall T, Crane DR. Advancing health equity in medical family therapy research. Medical Family Therapy: Advanced Applications. 2014:New York, NY: Springer Publishing Company; 319–340. Cited Here... 26. Minkler M. Community-based research partnerships: Challenges and opportunities. J Urban Health. 2005;82(2 suppl 2):ii3–ii12. Cited Here... | View Full Text | PubMed | CrossRef 27. Wallerstein NB, Duran B. Minkler M, Wallerstein N. The conceptual, historical and practical roots of community based participatory research and related participatory traditions. In: Community-Based Participatory Research for Health: From Process to Outcomes. 2003:San Francisco, CA: Jossey-Bass; 27–52. Cited Here... 28. Chilisa B. Indigenous Research Methodologies. 2012.Thousand Oaks, CA: Sage Publications, Inc.. Cited Here... 29. Kern DE, Thomas PA, Hughes MT. Curriculum Development for Medical Education: A Six-Step Approach. 2009.2nd ed. Baltimore, MD: Johns Hopkins University Press. Cited Here... 30. Indigenous Physicians Association of Canada. First Nations, Inuit, Métis health core competencies. A curriculum framework for undergraduate medical education. https://www.afmc.ca/pdf/CoreCompetenciesEng.pdf. Updated April 2009. Accessed September 12, 2016. Cited Here... 31. Universities Australia. Indigenous cultural competency framework. https://www.universitiesaustralia.edu.au/uni-participation-quality/Indigenous-Higher-Education/Indigenous-Cultural-Compet#.V9b8XKKuMRt. Published January 14, 2014. Accessed September 12, 2016. Cited Here... 32. Jacklin K, Strasser R, Peltier I. From the community to the classroom: The Aboriginal health curriculum at the Northern Ontario School of Medicine. Can J Rural Med. 2014;19:143–150. Cited Here... | View Full Text | PubMed 33. Provincial Health Services Authority in BC. Indigenous cultural safety online training program. http://www.sanyas.ca/home. Accessed September 12, 2016. Cited Here... 34. Dee T, Penner E. The casual effects of cultural relevance: Evidence from an ethnic studies curriculum. Stanford Center for Education Policy Analysis Web site. http://cepa.stanford.edu/wp16-01. Published 2016. Accessed September 12, 2016. Cited Here... 35. Crowshoe L, Bickford J, Decottignies M. Interactive drama: Teaching aboriginal health medical education. Med Educ. 2005;39:521–522. Cited Here... | View Full Text | PubMed | CrossRef 36. Kamaka ML. Designing a cultural competency curriculum: Asking the stakeholders. Hawaii Med J. 2010;69(6 suppl 3):31–34. Cited Here... | PubMed 37. Rogers KD, Coulehan JL. A community medicine clerkship on the Navajo Indian reservation. J Med Educ. 1984;59:937–943. Cited Here... | View Full Text | PubMed 38. Jones R, Pitama S, Huria T, et al. Medical education to improve Māori health. N Z Med J. 2010;123:113–122. Cited Here... | PubMed 39. Bach D. Elders-in-residence program brings traditional learning to campus. UW Today. February 6, 2015. http://www.washington.edu/news/2015/02/06/elders-in-residence-program-brings-traditional-learning-to-campus/. Accessed September 12, 2016. Cited Here... 40. Leaders in Indigenous Medical Education Network. Pedagogical principles & approach. http://www.limenetwork.net.au/content/pedagogical-principles-approach. Published 2016. Accessed September 12, 2016. Cited Here... 41. Association of American Medical Colleges. Cultural competence education. https://www.aamc.org/download/54338/data/culturalcomped.pdf. Published 2005. Accessed September 22, 2016. Cited Here... 42. Ewen S, Mazel O, Knoche D. Exposing the hidden curriculum influencing medical education on the health of Indigenous people in Australia and New Zealand: The role of the critical reflection tool. Acad Med. 2012;87:200–205. Cited Here... | View Full Text | PubMed | CrossRef 43. Doherty WJ, Mendenhall TJ. Citizen health care: A model for engaging patients, families, and communities as coproducers of health. Fam Syst Health. 2006;24:251–263. Cited Here... | View Full Text | PubMed | CrossRef Back to Top | Article Outline References cited in Table 1 only 44. Rincón AM. Berthold T, Avila A, Miller J. Practicing cultural humility. Foundations for Community Health Workers. 2009:135–San Francisco, CA: Jossey-Bass; . 45. Tervalon M, Murray-García J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9:117–125. PubMed | CrossRef 46. Kagawa-Singer M, Dressler WW, George SM, Elwood WN. The Cultural Framework for Health: An Integrative Approach for Research and Program Design and Evaluation. 2015. Bethesda, MD: National Institutes of Health Office of Behavioral and Social Sciences Research; https://obssr-archive.od.nih.gov/pdf/cultural_framework_for_health.pdf. Accessed September 12, 2016. 47. Paul D, Hill S, Ewen S. Revealing the (in)competency of "cultural competency" in medical education. AlterNative. 2012;8:318–329. 48. Mihesuah DA, Wilson AC. Indigenizing the Academy: Transforming Scholarship and Empowering Communities. 2004.Lincoln, NE: University of Nebraska Press. 49. Maresca T. Strengthening our roots: One region's experience with traditional medicine and healthcare settings. Paper presented at: Annual Advances in Indian Health Conference; May 3, 2011; Albuquerque, NM. © 2017 by the Association of American Medical Colleges


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How'd you like to tackle keeping motivated during the submission process on your LJ? I'm at that phase and am having a lot of trouble keeping motivated. Once the editing process was done (and getting myself through that was difficult), it was as if a switch had been flipped and I couldn't get myself going. If that had freed me up to go on to my next project, it would have been merely annoying, but it didn't. What's a good carrot for these sorts of situations?
Good question. The joys of writing are very different from the joys of sending out piles of pitch letters. It's also scarier for some people--until then, the only people who see your work are you and maybe a group of friends. Now you are putting your baby up for sale! The good news is that there are ways to motivate yourself.
Some of this depends on whether you write incrementally or in bursts. Some people (and I am not one of them) enjoy working steadily; others go for booms and busts. It doesn't matter which you are, though it does change what you may want to do.
A note first on the submission process for those who don't know it.
* For a short story, you typically send to one magazine at a time. Multiple submissions are frowned upon, because they all ask for exclusive rights for the first printing, so it is awkward if more than one accept you.
* For a novel, assuming you don't have an agent to handle this for you, then you need to get an agent. Yes, it is barely possible to sell a novel direct to a publisher, especially small presses or e-presses, but for a larger-scale publisher it is highly unlikely unless you know one of the editors personally. So you submit to agents, not publishers.
* For nonfiction, an agent can be helpful depending on your target audience. I didn't have one for Motivate Your Writing!, but it was a specialty item I sold to a university press. I tried to get an agent, but that's another story. I have one now, on the strength of having published and having a more "upscale" idea.)
I strongly recommend getting an agent for novelists, if only because they are motivated to submit your book when you aren't! Then you can get back to writing your next book while you wait for the agent, who is typically far more knowledgeable about who to submit to and what they want, and therefore much faster. Case in point: my wife Toni's first book, Down Home Murder, was sold to a publisher that had already declined her twice when she was sending on her own, directly to publishers (we didn't know any better). She got an agent, who knew that one particular editor at that house was looking for regional mysteries with female leads, and bingo! (www.tonilpkelner.com)
But back to you, assuming you are trying to get someone first. The trick, as always, is to make the process satisfying or at least find ways to make it as easy as possible. You can and indeed should send out multiple proposal letters to agents, which means you can turn it into a project instead of waiting around. The rule of thumb is when they ask for your whole book, that you should only do for one person at a time, because now they are investing serious time. But proposal letters are no problem. Send them out by the score!
(And in case you didn't know, there are books and websites that list agents and what they want. You can also scroll through acknowledgment pages of writers you like, to try and find their agents' names, who might like you, too.)
DO NOT send to agents who charge a fee. They are in the business of editing, not selling your book. What are they getting rewarded for? This is not just my recommendation, but that of numerous publishers, editors, and big-name agents.
So: now that we have defined the task, what are the carrots? Two kinds: intrinsic, and extrinsic. Intrinsic is hooking into your motives, extrinsic is finding ways to reward yourself "from the outside," as it were.
1. You get to go back to writing after sending out a batch, assuming the writing is the fun part.
2. Find ways to make the process fun, e.g., you have a preset list of agents, and you check off how many you have sent to. I tracked how many letters I sent, and how many came back. Note that even rejections can work to reinforce. My wife had a neat trick: every time she got a rejection, she had to send out another letter that day. That meant she always had something out there, and the rejection mobilized her to make sure there was more out there. For her, it was satisfying that her proposal was always in someone's hands. Salespeople, who may approach 100 people before getting a sale (or more! I know one consulting sales role where they only sell 12 projects a year, and approach 50-100 people a day looking for meetings!), think of it this way: "Typically I sell one project in 100 pitches. Each rejection is therefore making it that much more likely that I hit! One down, 99 to go. Two down, 98 to go." And so forth. Same principle: I have 50 agents to try out; odds are decent that one will want to read my book! Note that Toni's approach works better if you are a steady-as-you-go person.
3. If you are a boom-and-bust person, like me, might want to send out 20 and then wait until 10 come back before sending out another 20. Note the idea is to send out more than you were rejected from--this becomes perpetual motion, as well as a way to thumb your nose at fate--First you send 20, you have 20 out there. 10 rejections come back, you send out another 20, and that means you have 30 out there. 10 more come back, you send 20, you have 40 out there! You might want to take a break after 50, and let it go down a bit more...
4. Another person to reinforce you for taking action, e.g., spouse or writing group. It is helpful to have an objective perspective, and this can engage other motives.
Another side note: be sure to reward yourself for steps in the process--not just the final goal. Getting someone to read the "first three chapters and outline" (most agents will ask for something like that if they like your letter), is a victory. It's a funnel: send to a 100 agents, maybe 10 want to read your outline, then maybe 1 of those want to read your full manuscript. Getting to second-stage is a big deal.
Furthermore, you should also feel happy about approaching that level. Here are stages of improving rejection:
1. Form letter or your letter with a scribbled note "no thanks:" the lowest level.
2. Personal note of any description
3. Note referring to some aspect of your idea as positive "nice idea, but not for us" or "great concept, but story doesn't make sense."
4. Asking for your outline
5. Rejecting outline with no comment (unlikely, but it happens)
6. Rejecting outline with specific comment, even if negative
7. Rejecting outline with positive comment
8. Rejecting outline, but open to getting it again if rewritten in a specific way
9. Asking for the full manuscript
10. Rejection with no comment
11. Rejection with specific comment
12. Rejection with positive comment
13. Rejection with positive comment and openness to getting it again if fixed
14. Acceptance with reservations
See that? Fifteen steps! Track how far up the chain you have gone. "I'm up to rung 10!" "I skipped rungs 5-8!" For some people this is overwhelming, but if you like incremental improvement, this is for you.
Another general thought:
Set a strict goal of how many you want to send. For myself, once I had a proposal letter for my book, I searched through the book alphabetically and pulled out five or ten at a time who suited me. (Actually, I went through the book and noted people first, so that was a few hours of preliminary work.) Then I sent out batches of five.
1. M&Ms or whatever reward works for you strictly attached to actions taken, preferably something unique or rare, so you don't use them all the time. One per letter. Or five per letter. This is the Skinnerian approach! I knew a guy who kept track of the cigarettes he smoked and coffee he drank while writing his Great American Novel. But he smoked and drank coffee most of the time, so it had no reinforcing effect. Do be sure to set realistic reward patterns as well--for five submissions, for example.
I'm not sure I have any others, having stated the general principle! I suppose you could also block periods of time when you have nothing else to do but write your submission letters.
Hope that's a start...


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- Accepts Etsy gift cards
Leather Wrestling Dummies Circa 1940s
Product code #OA377
- Worldwide shipping
- All prices inc VAT
- Price is per dummy (2 available)
- Made from heavy leather with handle and lace up back
- Original makers label
- Original branding
- Czech, Circa 1940s
- Dark leather dummy measures 152cm tall x 108cm wide x 24cm deep
- Light leather dummy measures 259cm tall x 62cm wide x 22cm deep
Condition Report
No rips or major damage to the leather, the light dummy has someones name written on the back, other than that only very minor cosmetic wear.
As with all of our products this product is an original piece and has lived a life before it arrived at Otto's HQ. It has been sympathetically restored by the Otto's team to ensure it has a life for many more years to come. All of our products will show signs of patina and cosmetic wear, this we believe is what gives our products their unique charm. If you have any further questions regarding the condition of this product or any others please don't hesitate to contact us and we'll be happy to answer any questions you may have.
Otto's x
We offer a 14 day returns policy, buyer pays return postage. Item must be returned with a reputable courier and must arrive back in the condition it was sent out. No international returns under any circumstances.
Orders will normally be shipped out within 3 working days; all UK orders are sent using a next day shipping service. International customers will need to provide a best contact telephone number and an email address for our shippers before we can ship an order.
Large items will delivered by private courier or pallet service, so please allow a longer delivery and dispatch time. Please note, for pallet deliveries, the driver will provide a 'to the door' service - it is the customer's responsibility to ensure there is someone available at the address to bring the item indoors. If you require assistance with this you must inform us prior to shipping, so that we can use a more appropriate service of which there may be an additional charge.
Additionally, for larger orders or items shipped by pallet or private courier service, it is imperative that you provide a mobile telephone number before your order can be dispatched. Once your order is ready we will provide you with a day/date of delivery, which will be between the hours of 9:00 am – 6:00 pm. It is absolutely essential that you are at the address to take delivery and are reachable on the mobile number you provide. Failure to do so will result in a re-delivery charge by the pallet company of which we have no control over.
All our orders are extremely well packed and time and care is taken to ensure that your order arrives safely with you. In the unfortunate case you order is damaged we can open a claim with the courier and get the item either refunded or repaired (UK orders only).
Please note we cannot ship to PO Box addresses
Just contact me within: 14 days of delivery
Ship items back to me within: 30 days of delivery
But please contact me if you have any problems with your order.
Because of the nature of these items, unless they arrive damaged or defective, I can't accept returns for:
We offer a 14 day returns policy (UK only), buyer pays return postage. Item must be returned with a reputable courier and must arrive back in the condition it was sent out. No international returns.
We cannot be held responsible for any shipping delays in regards to customs clearance or if an incomplete address was provided.


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Golden Variegated Slender Sweet Flag
(Acorus gramineus Ogon)
Golden variegated slender sweet flag (Acorus gramineus Ogon)
Specific Plant Care:
Growing in wide fans, this plant forms into large low growing clumps. It has striking variegated bright yellow and striped foliage and is semi-evergreen.
- Plant Type - Pond Marginal
- Normally Available from - Mid March *
- Water Depth - 0cm to 5cm
- Height - 25cm to 35cm
- Position - Full Sun to Part Shade
- Growth - Slow
- Flowers - Jun to Sep
- Foliage - Semi-evergreen
- Hardiness - Hardy
Specific Plant Care:
Little maintenance is required. Trim just above the water surface after foliage has died back in Autumn to tidy leaving a little material to protect new shoots.


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In a move to progress human rights in the country, the UAE has launched its first labour guidelines to enlighten the almost one million workers here on their rights, duties and the law. It also seeks to curb relevant violations.
Announcing the innovative handbook, Major-General Obaid Mohair bin Surour, deputy director of the General Directorate for Residency and Foreigners Affairs (GDRFA), said the new directory is available in Arabic, Urdu and English.
"The pioneering guidelines, to be distributed for free to over 1 million workers in Dubai, is a model for all workers here to properly start their practical life in line with the country's laws."
The move comes shortly after the Permanent Committee of Labour Affairs (PCLA) in Dubai unveiled the details of a planned smart app to help the emirate's labourers remain in touch with them, and be fully aware of their responsibilities and rights.
Bin Surour explained that the most common crimes committed by workers include working for someone other than their sponsors - this draws a hefty fine of Dh50,000.
"Overstaying their visa and drug trafficking may land the worker in life imprisonment; drug abuse gets four years jail, and murder can lead to a life sentence."
Other crimes include absconding, rioting, theft, robbery, illegal consumption of alcohol, perjury, gambling and arson, he elaborated.
Through the new guidelines, workers are also taught about personal safety at worksites and the importance of using protective equipment such as safety helmets, ear protection, goggles, safety boots, dust masks, hi-visibility jackets and other equipment, Bin Surour noted.
"We also want workers to be fully aware of their rights regarding working hours, overtime, salary, medical benefits, days off, public holidays, end of service benefits, and accommodation allowances, in addition to others."
Bin Surour, who is also the PCLA chairman, said the labour reference book, prepared by specialised committees under the supervision of the Dubai Government and Legal Affairs Department, consists of three main sections.
"These are 'Welcome to the UAE', 'Know your duties and responsibilities', and 'Enjoy your time in UAE'.
"Although the handbook will eventually be given to the 1 million workers, the PCLA will initially distribute it to 100,000 workers at the Dubai medical fitness centres' training centres - mainly in the Al Muhaisana and Jebel Ali Free Zone (Jafza) areas."
The official noted that the intensive awareness campaigns have successfully developed worker's awareness by over 40


text: Sam Mayercik O: 615-661-7800 M: 615-509-1547 Home Agents Sam Mayercik 5,000+ sq ft Luxury home nestled in the Smoky Mountains - at 2,500 ft up, Gracehill is the highest home in Blount county with amazing, unlimited views. The property borders the Great Smoky Mountain National Park. Sitting on over 6 acres, this beautiful estate boasts 5 bedrooms, 5 1/2 baths, 6 fireplaces, over 2,000 sq ft of covered veranda's and porches, an owner's apartment, climate controlled greenhouse, 3-car garage, elaborate landscaping, small ponds and water features. Let's take a drive to the mountains and allow me the pleasure of showing you this stunning property. Sam Mayercik 615-509-1547 or email me at firstname.lastname@example.com Sam Mayercik REALTOR® Office: 615-661-7800 Mobile: 615-509-1547 Berkshire Hathaway HomeServices Woodmont Realty | Brentwood Office 5107 Maryland Way, Suite 100 Brentwood, TN 37027 Phone: 615-661-7800 Contact Me Now First Name Last Name Email Address Phone Number Message Any questions, comments, or feedback Submit Now!


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I've picked some Valentine's Day inspired goodies to share with you. Although we're not "celebrating" this year, and totally feel like it's a commercial holiday, the festivities are fun to indulge in. So in the spirit of commercial goodness and eco-friendly celebrating, here are some of the things I'm loving:
- A romantic number from Eko-Lab (LOVE LOVE this)
- Cutie petutie bloomers from Eko-Lab
- Simple Eye Masks from Eko-Lab (Yes, I'm loving this collection...just found it and I always get excited about finding new fabulous lines)
- Himalania Dark Chocolate Covered Goji Berries (I eat these all year long, I usually get the cacao dusted ones)
- Bonterra Rosè (what's better than pink wine? organic pink wine!)
- BsaB Bamboo Aromatherapy Candles and Pillars made entirely from plant materials. I'm a candle freak and am totally loving these!
- Nicobella Organic Dark Chocolate Truffles in Pure Cocoa Bliss, Walnut Flaxseed Crunch (Yum, right?), and Pumpkin Chai (Yum again!)


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We may collect and process the following data about you:
We may collect information about your computer, including where available your IP address, operating system and browser type, for system administration and to report aggregate information to our advertisers. This is statistical data about our users' browsing actions and patterns only. For the same reason, we may obtain information about your general internet usage by using a cookie file which is stored on the hard drive of your computer. Cookies contain information that is transferred to your computer's hard drive. They help us to improve our site and to deliver a better and more personalised service. They may enable us:
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The planet is our home; we need to be more responsible. Here's what I do.
Bag puss, a children's TV character from my childhood. A saggy old cloth cat.
If you've read my blog over the past few months you'll have picked up on my efforts to reduce the number of products that I use. I want to reduce the chemicals and their complications for the benefit of my health and the planet. This has resulted in no more shampoo, a deodorant that's natural and just soap for washing. The only product left that I want to tackle is moisturizer. I haven't found the answer to that one yet.
Meanwhile I'm becoming more aware of the advance of nature. I'm over forty five now so fifty is on the approaching horizon. I'm essentially not particularly vain but I do want to keep healthy while ensuring I do what I can to help my body and cells to keep repairing and sustaining.
I also know that collagen which gives our skin elasticity declines as we get older. So I decided to do some research to see what I could be doing to help my skin.
Firstly I didn't want a product based route. I'm not convinced that external remedies of that kind can do as much as feeding your skin properly.
I found a really useful website and was very pleasantly surprised.
Among the long list there I found plenty of foods that we already eat. It was like a recommendation supporting many of the vegetarian habits we have.
Soy products of all kinds.
Dark green vegetables are also excellent for skin so that means our delicious kale recipe is ideal.
Beans are something else we include in our diet very regularly.
Red fruits and vegetables are there on a daily basis with their exciting lycopenes. And there's plenty of variety.
Vitamin C features in our diet too.
Prunes are definitely something we'll need to look out for but blue berries are something else we grow.
Omega Acids from Nuts such as cashews, pecans, almonds and Brazil nuts get featured.
And I was pleased to see Flaxseed and omega-3 getting a mention of course.
I'm happy about cucumber and sweet potato but celery won't be on my list as I can't stand the stuff.
And turkey won't be on my plate any time soon.
When I saw Chocolate was good for your skin I was particularly pleased!
I'm not sure I can include Manuka honey as the air miles are pretty negative to bring it all the way from New Zealand but maybe there will be a European source one day.
Rose hips would be a good project to start working on as I've thought about foraging for these too.
Avocado Oil could be another interesting new adventure.
So the good news is I think my habits are already helping my skin and I can easily add one or two more.
Pass the prunes!
Does it matter if the leafy greens are purple?
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Plantbased Health Coach & Recipe Creator
a blog by a multilingual expat-since-birth, linguist, researcher, speaker, mum of three, living in the Netherlands and writing about bilingualism, multiculturalism, parenting abroad, international life...


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Providing the highest standards of quality services in money transfer and For-ex built strong relation stand on trust and 100% customer satisfaction.
WallStreet exchange offers great service using our exclusive partnership and foreign partners, whom are covering all over the world makes money transfer much easier and faster.
Our customer can earn points and existing rewards with cash back membership.


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Hash Brown Waffles
Watch the recipe video
Hash Brown Waffle
Are you still frying your hashbrowns in a pan?
- 4 lbs. (2 Kg) waxy potatoes
- 3 eggs
- ½ cup (125 mL) sour cream
- ¼ cup (60 mL) melted butter
- 2 Tbsp (30 mL) horseradish
- Salt and pepper, to taste
Grate potatoes, into a clean tea towel. Wrap it up and squeeze to remove most of the water. Mix together eggs, sour cream, butter and horseradish in a large mixing bowl. Toss in the grated potatoes and mix well. Season with salt and pepper. Spread about 1 cup of the potato mixture into each waffle square. Cook for 15 minutes or until potatoes are cooked and crispy.
Details:Prep time: Cook time: Total time: Yield: serves 4
So easy
So tasty


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Now I'm not big on New Year's resolutions, but I do like a challenge. So starting in December last year I decided to do at least one century ride per month and at least one overnighter per month for 2016. During warm months this isn't too tough and with the trips I have in the planning phases I'll get several centuries and overnighters on consecutive days. But during the cold months in Colorado it can take some gumption, planning and fortitude to get out, especially for the overnighter.
Last night was my first time sleeping outside in 2016. It happened to almost coincide with the full moon (that's tonight by the calendar I checked). I got an early start and did most of my two-hour climb with daylight guiding me. After dark, thanks to the moonlight and the lights on my bars and helmet, I did a bit of exploring, looking for new spots to lay my head for future trips. No luck, even after post-holing for 20 minutes, pushing my loaded fat bike. Alas, I turned around and headed to a familiar location for the night.
It was a bit colder than I expected (I woke to temps in the teens) and I ended the night sleeping in most of my clothes. I was really glad I brought a tent as I had room to add layers in relative comfort. The moonlight woke me on a couple of occasions but pulling my hat over my eyes helped me snooze in peace. Unusually I slept past the sunrise and got up at 7am. I used my soda can stove to make a breakfast of oatmeal and coffee. Hot liquids were amazing! I leisurely loaded up and was back on a favorite dirt climb heading up at 8am. I took my time, warming myself in the sun and thankful for the uphill effort. Soon I was shedding layers.
It was a beautifully clear and calm morning. I climbed to a more travelled dirt road and dropped into a once prosperous mining town. The cafe was closed, a bummer as more food was calling my name. I downed a Clif bar that I had kept warm in my jersey pocket, finished my water and climbing the last few hundred feet before a long descent back home.
It was a great night out, and not because I slept like a baby. I didn't. It was great because I rode a moonlit trail, turned off the day-to-day world and started the year right. Here's to at least 11 more!