text: Creating "Innovator's DNA" in Health Care EducationArmstrong, Elizabeth G. PhD; Barsion, Sylvia J. PhDAcademic Medicine: March 2013 - Volume 88 - Issue 3 - p 343–348 doi: 10.1097/ACM.0b013e318280cb7b Articles Abstract Author Information Article Outline Serious deficits in health care education have been identified recently, yet proposed solutions call for faculty skill sets not typically developed in health professional schools or in continuing professional development (CPD) programs. The authors propose that addressing the oft-cited problems in health care education (e.g., it is not learner-centered and does not take advantage of insights gained from the learning sciences) requires faculty to develop "innovator's skills" including the ability to facilitate organizational change. Given increased social responsibilities and decreased financial resources, it is imperative that more health care educators and health care delivery system leaders not only become innovators themselves but also develop systems that support the next generation of innovators. Dyer et al conducted a comprehensive study of successful innovators and found five behavioral and cognitive "discovery" skill sets that constitute the "innovator's DNA": associating, questioning, observing, networking, and experimenting. This article uses the prism of innovator's DNA to examine a CPD program for health care educators, the Harvard Macy Institute (HMI), whose overarching purpose is to develop innovation skills in participants so that they can build their own educational models customized for implementing changes in their home institutions. A retrospective review of HMI alumni from 1995 to 2010 suggests that innovator skills can be taught and applied. The conceptual framework of the innovator's DNA provides a useful model for other CPD program leaders seeking to enable health care educators to develop the capacity for successfully examining problems and then customizing and implementing organizational change to solve them. Dr. Armstrong is clinical professor of pediatrics, Harvard Medical School, and director, Harvard Macy Institute, Boston, Massachusetts. Dr. Barsion is president, SJB Evaluation and Research Consulting LLC, New York, New York. Correspondence should be addressed to Dr. Armstrong, Harvard Macy Institute, 100 Cambridge St., Suite 2002, Boston, MA 02114; e-mail: firstname.lastname@example.com. Abstract Changing Health Professional Education The Innovator's DNA The HMI Program Evaluation Building the Five Innovation Discovery Skills Skill 1: Associating, making surprising connections across ... Skill 2: Questioning, breaking out of the status quo and co... Skill 3: Observing, detecting small behavioral details that... Skill 4: Networking, finding and testing ideas by meeting w... Skill 5: Experimenting, relentlessly seeking new experience... Extending the Skills In Sum References In this article, we discuss calls for significant change in the delivery and impact of health care education, and we suggest a strategy to foster the environment and develop the skill sets required for designing and implementing such change. The strategy is for health care education program leaders and faculty to teach five research-based innovator skills. We use the Harvard Macy Institute (HMI) program to illustrate how leaders can implement the strategy successfully. Back to Top | Article Outline Changing Health Professional Education The Lancet Commission on the Education of Health Professionals for the 21st Century1 makes a strong case that health professional education must be redesigned to bring about change that has a "global outlook, a multiprofessional perspective, and a systems approach." The authors of that report argue that meaningful change occurs when health care professionals experience "transformative learning" (developing the leadership skills necessary to become enlightened change agents)—rather than just the "informative learning" (acquiring the knowledge and skills to become experts) and "formative learning" (socializing with others in the field and absorbing values to become professionals) that the Lancet Commission authors found to be the norm in many health professional education settings. The Carnegie Foundation for the Advancement of Teaching, on the basis of two major studies on the academic preparation and training of physicians and nurses, makes assertions consistent with those from the Lancet Commission. The 2010 report on educating physicians2 asserts that medical education is flawed: It is not learner-centered and does not take advantage of the insights gained from learning sciences; it makes "poor connections" between formal knowledge and experiential learning, and it fails to develop habits of inquiry and innovation in learners. The study of nursing education3 identifies many significant problems including an inadequate quality and quantity of faculty development opportunities; too little focus on the scholarship of teaching and learning; not enough support for teaching the skills of inquiry, reflection, and research; and systems that do not support students in becoming agents of change. To illustrate, the report on nursing education3 reads, in part, In order for today's students to be prepared to meet the reform challenges in practice settings—and be influential leaders in the political and public arenas for improved health care systems—they will need to learn theories of organizational development and policy-making, as well as strategies to change organizations. The challenge for health care educators is how to take the multiple calls for transformational change and actually foster the environment and develop the skill sets required to design and implement major innovations. More health care educators and health care delivery system leaders must not only become innovators themselves but also develop systems that will support the next generation of innovators. Back to Top | Article Outline The Innovator's DNA In The Innovator's DNA: Mastering the Five Skills of Disruptive Innovators, Dyer et al4 identified behavioral and cognitive "discovery" skill sets that make up the "innovator's DNA." On the basis of interviews with nearly 100 innovators, as well as on comprehensive analyses of innovative businesses, they identified and comprehensively characterized five discovery skills that ignite successful innovation: (1) associating, making surprising connections across areas of knowledge, (2) questioning, breaking out of the status quo and considering new possibilities, (3) observing, detecting small behavioral details that suggest new ways of doing things, (4) networking, finding and testing ideas with individuals from diverse backgrounds in order to gain radically different perspectives, and (5) experimenting, relentlessly seeking new experiences, trying on new roles, and exploring the world. One of Dyer and colleagues' major findings is that although innovators typically have or develop the five competencies on their own, these five skills can be taught and learned. Herein we use the prism of the innovator's DNA to examine a continuing professional development (CPD) program for health care educators, the HMI—the overarching purpose of which is to develop skills and create a mind-set in participants (scholars) that encourages them to build their own educational models customized for implementing change in their home institutions and in their fields. Back to Top | Article Outline The HMI Launched in 1995, the goal of the HMI is the same today as when it began: to enable participants both to put into practice self-directed learning and to build their own educational models customized for implementing changes in their home institutions. Rather than a "cookbook" or one-size-fits-all approach to educational innovation, the intent was to build capacity to promote sustainable, institution-specific change. The HMI offers four courses, each held annually at Harvard University5,6: Program for Educators in the Health Professions (an 11-day winter session and a 6-day spring session, with progress on a required project monitored by an HMI faculty member between sessions), Leading Innovations in Health Care and Education (a 6-day session in June), Systems Approach to Assessment in Health Professions Education (a 6-day session in March), and Starting in 2013, Become a Digital Citizen—Technology in Health Care Education (a 5-day course in October). Each course features journal clubs; project groups with step-back consultation (a short presentation by a scholar on his or her project plan followed by immediate feedback from colleagues, including their suggested strategies for implementation and evaluation); large-group interactive sessions during which scholars discuss case studies drawn from business, public health, engineering, and education; and small-group discussions. The HMI faculty teach and model the skills of educators and innovators by explicitly inviting scholars to observe and consider which of the many teaching strategies in use have potential in their own settings. Focused discussion of and reflection on HMI practices stimulate scholars to invent new strategies and create plans to practice differently at their home institutions. The faculty encourage scholars to raise probing questions, to study innovation and change management, to reflect on the material and its possible application in their lives, and to learn from colleagues. Scholars are challenged to examine any personal and organizational assumptions that form barriers to change and to identify options that foster "transformational learning."7 Theories from the fields of business and organizational development, such as disruptive innovation (i.e., a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors)8 and systems thinking, become part of the scholars' powerful arsenal of tools for understanding the options for and implications of organizational change. To force scholars out of their comfort zones, the HMI includes a strong experiential component that begins with the application to the program. HMI applicants must define a project or identify an institutional challenge, vetted by their home institution, that they plan to act on when the course is complete. Project topics occur across the education and health care continuum (e.g., new learning technologies, assessment strategies, institutional policy change). Throughout the course, scholars think about how to apply theories and methods from multiple disciplines to solve the real problems occurring at their home institutions. As they devise plans to implement changes, they receive constructive, specific feedback both from faculty and from fellow scholars. Scholars use the project or challenge throughout the program as the centerpiece for testing principles and theories within the context of their own local realities. Because the projects and problems are individual, HMI faculty neither advocate a single template for solutions nor proscribe one methodology for arriving at solutions; rather, participants determine what action(s) will best address their individual needs as well as those of their institution. At the end of the winter session, participants in the Program for Educators in the Health Professions write their own personal and institutional strategic action plans. These plans constitute commitments to action between the scholars and HMI faculty and include a requirement for the scholar to present a scholarly poster and abstract about their project during the spring session. Scholars often have contact with HMI faculty between the winter and spring sessions and after the course is completed (e.g., seeking assistance for completing scholarly papers, asking for networking suggestions, participating in multinational and interinstitutional collaborations). Examples of the kinds of changes that began with an HMI project idea include an academy for health care educators, interprofessional workforce development planning for new faculty, and competency-based graduate medical education program. Back to Top | Article Outline Program Evaluation In 2010, HMI leaders conducted an online, retrospective survey of alumni from the three then-extant HMI programs for health care providers and educators (listed above). Harvard Medical School's institutional review board deemed the project, which occurred as part of a review of HMI's first 15 years (1995–2010), to be exempt research. The population of health care provider and educator alumni was 2,200, and e-mail addresses were available for 1,572 (71%) of these past scholars. Of these 1,572 alumni, 606 scholars (39%) responded. In addition, in 2010 and 2011, HMI leaders conducted structured telephone interviews of 67 past HMI participants. Alumni from each of the three courses and from across the 15-year period were randomly invited to participate in the interviews. A caveat in interpreting these data is that no information is available from those participants with whom HMI had not been able to sustain contact; thus, generalizing the findings herein to all HMI participants is inappropriate. Further, our intent was to gather descriptive data rather than conduct a quasi-experimental or experimental study, so ascribing causation is not possible. That said, the quantitative survey evaluation findings, coupled with the open-response feedback from alumni on the survey and during the interviews, provide consistent evidence that hundreds of scholars became more involved in health care education and innovation after participating in HMI. Importantly, the scholars themselves attributed the reason for their change to their experiences at one or more of the HMI courses.9 We have culled, from the extensive evaluation data available, the qualitative and quantitative findings most relevant to the innovator's skills, and we have presented them here with further information both on each of the five competencies and on how HMI faculty seek to teach these competencies, practice them, and ensure that they become part of the repertoire of all scholars. We took the illustrative quotes, verbatim, from open-ended responses to the survey and interview questions, which afforded participants the opportunity to explain their experiences in their own words. We also include data from two closed-ended items. The responses to one item—"When you think of the HMI course you took and other continuing education courses you have taken, how does the HMI course compare?"—shed light on whether and how well innovators skills were taught in HMI courses compared with other CPD courses the respondents had taken. A second question listed instructional strategies that HMI uses and asked respondents to indicate whether they felt any of 10 CPD strategies (such as "learning in small groups" or "developing a new network of colleagues") were unique HMI strengths. Here the intent is to examine how innovation skills are taught. Back to Top | Article Outline Building the Five Innovation Discovery Skills Skill 1: Associating, making surprising connections across areas of knowledge According to Dyer et al,4 making unexpected connections is central to innovation and requires the innovator to create the time and circumstances to experience different ideas, individuals, and organizations. They write, "when the brain is actively absorbing new knowledge, it is more likely to trigger connections between ideas." Having a place, concentrated time, and opportunity—such as is afforded through the HMI—for new experiences and reflection, removed from the day-to-day workplace, facilitates associating. When HMI began, the program director observed—and, according to their end-of-course evaluations, many scholars during the early years of the program concurred—that most CPD programs for educators in health care professions were held within a single department or institution (i.e., a hospital or school), led by someone from that institution, and, hence, afforded participants little or no opportunity to learn from others outside the organization, which limited the range of possible solutions to a given problem and may even have masked the fact that there was a problem. HMI brought together health care professionals from different institutions, countries, and disciplines and introduced multiple opportunities to talk, learn, and reflect on common and unique challenges. Most survey respondents (90%) viewed HMI as better at "fostering reflective practices" than other CPD courses they had taken. Scholars valued seeing a situation in a new light: For us, the interface with the Schools of Business and Education presented at HMI directly impacted our faculty's knowledge and ability to operate outside the provincialism of our own discipline. Without being able to imagine the collaboration of the School of Medicine and School of Nursing, none of this important educational work would be serving our students today (emphasis added). HMI programs require reading and discussions designed to go well beyond scholars' usual academic experiences. One scholar describes the experience: Whether teaching, facilitating discussions, trying to generate ideas, redirecting ideas, you are working with curricula at such a different level, it explodes your thinking each time. Further, 65% of all survey respondents reported that "reading literature outside of fields" they usually peruse was a unique strength of HMI, and 83% of those who took the Leading Innovations course identified "exploring/applying concepts derived from business" as a unique HMI strength. Scholars appreciated the exposure both to new fields and to the HMI faculty (87% identified the faculty as a unique strength) who represent diverse disciplines including business, engineering, instructional technology, and educational outcomes measurement. To illustrate, one scholar commented: The most substantial impact for me was adding a business-oriented perspective to my educationally oriented experience. This, coupled with a new language related to innovation and change, has been very effective in giving me ways to get my institution's administration on board. I also have a broader understanding of ways in which the challenges I feel as a health professions educator mirror those faced by other professions, thus increasing my view of potential collaborations. Back to Top | Article Outline Skill 2: Questioning, breaking out of the status quo and considering new possibilities Dyer et al4 write that questioning is the "creative catalyst for the other discovery behaviors." True innovators ask probing and provocative questions that keep coming at a problem from different and unexpected angles. Although questioning alone does not mean the results will be innovative, pushing stakeholders to ask as many questions as possible about the problem, rather than rushing to brainstorm a solution, will increase the likelihood of breaking out of the status quo. Questioning is a systematic way of thinking and avoids the mistake of coming up with a seemingly brilliant solution to the "wrong" question.10 Faculty use the projects that scholars bring to HMI not only to encourage scholars to question the status quo at their own institutions but also to provide an opportunity for other scholars and faculty alike to offer insights as they inquire about the rationale behind each scholar's project and the proposed solution. One scholar explains: In order to get into the program as a participant, you need to have a project in mind: This makes you think about how you can apply what you're being taught directly to the project that affects your life. That makes you a more active learner and a more active participant. Scholars envision new possibilities through their discussions with faculty and one another. Over three-quarters of respondents (81%) thought HMI "supported feedback from colleagues" better than other CPD programs. To illustrate, one scholar reports: The first valuable lesson I learned at HMI is that it is not where you sit on the hierarchical ladder that empowers you: Wherever you are, empowerment comes from your ability to see beyond your position. Suddenly every challenge looked like an opportunity to me. Terms like "lack of resources," "credential barriers," and "cultural barriers" were miraculously erased from my dictionary. As preparation for using the Harvard Business School large-group case method11,12 (through which students read the case study in advance and discuss it later in class with one another while the professor encourages dialogue and helps analyze and summarize findings), scholars receive instructions about the value of and techniques for actively listening to one another. A heightened understanding of varying perspectives helped the scholars consider new ways of thinking about a question or problem before considering potential solutions. Scholars are not the only ones considering new possibilities. As faculty listen to scholars' questions and learn about their projects, they are challenged to create new case studies, readings, exercises, and learning strategies that align with the current and projected needs of the HMI community. Back to Top | Article Outline Skill 3: Observing, detecting small behavioral details that suggest new ways of doing things Dyer et al4 believe that innovators take themselves out of their routine environments and create opportunities to see through the eyes of others; they are careful observers, curious to see firsthand how different stakeholders react to the same situation or how various organizations handle similar problems. By observing what does and does not work and by puzzling over differences from prior experiences, innovators sharpen their observational skills. HMI incorporates exercises through which scholars observe teaching sessions. First, the scholars collect data about the sessions (e.g., Who is sitting where? How much time is spent in discussion versus lecture? What types of questions are asked and by whom? How many students are involved versus tuned out?). Next, scholars analyze and interpret the observational data, and then they reflect on their own values, asking themselves to observe their own reactions (e.g., Why do I feel that way? What does my reaction tell me about myself and my beliefs about learning?). Such self-observation provides a window into one's own assumptions and values, which in turn, opens up the potential for seeing new possibilities. The underlying teaching style has allowed me to have insights into my unrecognized biases, question my assumptions, and freed me to consider a broader spectrum of options to promote my goals … true on a personal, as well as professional level. Back to Top | Article Outline Skill 4: Networking, finding and testing ideas by meeting with individuals from diverse backgrounds in order to gain radically different perspectives Dyer et al4 discuss how innovators build relationships and networks. Innovators go out of their way to meet people outside of their field. Individuals who network to meet people inside their field are typically seeking access to resources or ways to advance their careers. In contrast, "idea networkers" seek out individuals who are not like them in an effort not only to gain new perspectives and learn new things but also to test ideas. A researcher analyzing innovation at Bell Labs13 found that Most feats of sustained innovation cannot and do not occur in an iconic garage or the workshop of an ingenious inventor. They occur when people of diverse talents and mind-sets and expertise are brought together, preferably in close physical proximity where they can have frequent meetings and serendipitous encounters. Eighty percent of the survey respondents reported that the HMI program was much better in "encouraging teamwork" than other continuing education courses they had taken. Scholars' experiences with HMI were shaped by their fellow participants who represented a range of professions (e.g., clerkship directors, directors of nursing education, veterinarians, ministers of health, pharmacists, medical school deans) who work in institutions from across the world. Since HMI began, scholars have represented over 400 institutions from more than 100 countries (including Australia, Singapore, the Netherlands, Chile, Saudi Arabia, Canada, Mexico, India, Taiwan), and numerous collaborations have occurred as a result. Two scholars specifically noted the advantages of such collaboration: We have many opportunities within our specialties but few across specialties and even cultures and countries. My personal/professional growth as a consequence has contributed to my ascent to leadership. The collaboration with other educators from around the world was both empowering and affirming. I was more confident about my ability to contribute to the education system in my home institution. HMI has nurtured an ongoing community of scholars both through frequent personal contacts and through reunions at national and international meetings of professional associations. With the growth of social media, virtual networking has added new opportunities and dimensions to communicating during and after the course. Scholars and faculty now send Tweets to colleagues during classes to share ideas, resources, or URLs. They use LinkedIn and Facebook to maintain connections made at HMI and to build new networks after the course is over. HMI is evaluating alternative ways to use social media more deliberatively during courses and to use electronic networking to bring alumni from different cohorts and from diverse backgrounds and perspectives together. Back to Top | Article Outline Skill 5: Experimenting, relentlessly seeking new experiences, trying on new roles, and exploring the world. Of the five discovery skills, Dyer et al4 found experimentation to be the best differentiator between innovators and noninnovators. They identified three kinds of experimentation: trying out new experiences; taking apart products, processes, and ideas; and testing ideas through pilots and prototypes.4 By trying out new teaching methods in the safe HMI environment, scholars experience new roles firsthand and can assess more accurately how they feel about those roles and how they might fit in their own work environment. When working through case studies, faculty work with scholars to pull apart protocols, concepts, and initiatives from other industries, allowing the scholars to experience problems and solutions from different workplaces and contexts. One scholar noted that this process was particularly valuable: The case-based lesson of learning in which we would take some example, discuss it, walk it through and then dissect it out—in terms of what worked and what could have been done better [and], what we did that was wrong—was really very helpful. That actually served as a model for what we did when I returned to my own institution. Simultaneously, scholars are challenged to identify issues relevant to their institution or to their HMI problem or project and to consider ways to adapt new processes and solutions to their own contexts and/or endeavors. One scholar commented on the long-term effects that this experimenting at HMI had on his/her own work: The Leaders program I did in 1999 … provided me with new insights, tools, and strategies which are used on a daily basis a decade later and which are especially useful for challenging, multidisciplinary "change" projects. Learning about and examining theories about institutional change in their own and other fields helped scholars to develop the tools, confidence, and inspiration they needed to tackle educational change at their home institutions. Most survey respondents (89%) indicated that HMI was better than other CPD courses in "encouraging them to invent or design their own strategies" for innovation. For example, one alumni reported: This program changed my view of my role in the health care system to think of medical education as a mechanism to impact patient care … this program equipped me with concepts and tools that I used to lead a network initiative to better train residents on central lines, interprofessionalism, and patient safety. As a result, four years after taking the program and leading this initiative, our CLAB [central-line-associated bacteremia] and complications rate are reduced significantly. Effecting such long-lasting change is exactly what the HMI was designed to do. Scholars' testimonials and survey results (85% of survey respondents thought the HMI was better than other CPD courses in leading to "a real change in their performance") both attest to the HMI's success at creating change agents. Back to Top | Article Outline Extending the Skills To test whether HMI's pedagogical approach could be replicated and extend its reach beyond the courses held annually, HMI sought to develop local cadres of innovators at institutions nationwide and internationally by giving priority to accepting individuals from institutions that sent scholars in previous years and whose leaders believe it is important to build a local group of change agents. To date, 157 institutions have sent five or more participants to HMI over the years; many have sent 20 or more. By developing a nucleus of faculty with a common understanding regarding education and innovation, there is a critical mass to challenge the status quo, champion significant change, and collectively create a long-lasting legacy. Having people go to HMI has made all the difference in a very short period of time in our ability to move things forward, to function, and to really make things work better for students and faculty. Back to Top | Article Outline In Sum Advocates for reform in health care education call for innovative approaches to address increasingly significant and changing responsibilities for health care team members within an era of fewer financial resources.1–3,14 The challenge, then, is how—given this daunting context—to translate consistent and compelling recommendations for change into actionable strategies through education of faculty, administrators, and students. The retrospective findings from the HMI evaluation suggest that CPD programs can develop the five innovator's skills and can enable health care educators to build capacity to successfully design and implement long-lasting organizational change. Although the innovator's DNA is a recent construct, other CPD program leaders may also be developing innovation capacity among health care educators. To provide evidence of a causal path, CPD program leaders and evaluators should develop a clearly delineated outcomes logic model15 with predicted, clear paths from CPD → innovator skills → implementation → implementation outcomes so as to guide the design of an experimental or quasi-experimental study with assessment measures for each step in the path. In their study of the environments of teachers who support the creation of innovators, Wagner and Compton16 assert that the underlying culture and assumptions in research universities may constitute significant barriers to the production of innovators. Across multiple universities, they found that faculty who were viewed by their young innovator students as mentors were often marginalized by university leaders and administration or by other faculty because they did not conform to the content of an individual departmental domain, nor did they do the highly specialized types of research needed to merit promotion in the traditional tracks. Wagner and Compton's findings remind us that reward systems—explicit and implicit—in academic health centers play a critical role in creating an environment that supports innovation.The educational academies movement is one example of the ongoing effort to overcome institutional barriers to change, as illustrated by this statement from the American Surgical Association Blue Ribbon Committee Report on Surgical Education14: Surgical faculty members also need recognition and support for their efforts in residency education to facilitate development, implementation, and evaluation of innovative educational approaches. Also, such recognition and support is necessary for the much-needed changes in continuing education. Richard Miller,17 president of the F.W. Olin College of Engineering where the curriculum is explicitly designed to create innovators, describes three distinct processes required for innovation: (1) creativity, generating original ideas, (2) inventiveness, taking original ideas and discovering insights that have value, and (3) innovation, having original ideas and insights that have value, then implementing them in ways that change the way people live and the way institutions function. As new CPD programs are created and existing programs reexamined, it seems increasingly critical that their leaders and faculty consider ways to build innovator's skills which not only have value for the individual but also contribute to the advancement of innovation that is needed to improve the lives of those they serve. Acknowledgments: The authors thank the Josiah Macy Jr. Foundation for the grant (HMS CHS M19366-101), which funded the program evaluation conducted between June 2010 and February 2011, as described in this document as well as for their initial grant, used to fund the development of the Harvard Macy Institute (HMI) and the 1994–2000 courses. They are very grateful to the HMI community of faculty and scholars for their participation in this study and their ongoing support of the HMI community. Funding: Funding for this study came from the Josiah Macy Jr. Foundation (HMS CHS M19366-101). Other disclosures: None. Ethical approval: In July 2010, the Harvard Medical School institutional research board granted exempt status to this research, based on 45 CFR 46.101(b)(2).Back to Top | Article Outline References1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923–1958 Cited Here... 2. Cooke M, Irby DM, O'Brien BC Summary of Educating Physicians: A Call for Reform of Medical School and Residency.. 2010 San Francisco, Calif Jossey-Bass Cited Here... 3. Benner P, Sutphen M, Leonard V, Day L Educating Nurses: A Call for Radical Transformation.. 2009 San Francisco, Calif Jossey-Bass Cited Here... 4. Dyer J, Gregersen HB, Christensen CM The Innovator's DNA: Mastering the Five Skills of Disruptive Innovators.. 2011 Boston, Mass Harvard Business Review Press Cited Here... 5. Armstrong EG, Doyle J, Bennett NL. Transformative professional development of physicians as educators: Assessment of a model. Acad Med. 2003;78:702–708 Cited Here... 6. Harvard Macy Institute. Web site. www.harvardmacy.org. Accessed November 15, 2012 Cited Here... 7. Kegan R, Lahey LL How the Way We Talk Can Change the Way We Work: Seven Languages for Transformation.. 2002 San Francisco, Calif Jossey-Bass Cited Here... 8. Christensen C The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail.. 1997 Boston, Mass Harvard Business School Press Cited Here... 9. Barsion SJ. Harvard Macy Institute: Evaluation Report to the Josiah Macy Jr. Foundation. 2011 [unpublished report] Cited Here... 10. Drucker PF The Practice of Management.. 1954 New York, NY Wiley Cited Here... 11. Garvin DA. Making the case. Harv Mag. September–October 2003:56–66 Cited Here... 12. Barnes LB, Christensen CR, Hansen A Teaching and the Case Method. 19943rd ed Boston, Mass Harvard University Press Cited Here... 13. Gertner J The Idea Factory: Bell Labs and the Great Age of American Innovation.. 2012 New York, NY Penguin Press Cited Here... 14. Debas HT, Bass BL, Brennan MF, et al.American Surgical Association Blue Ribbon Committee. American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004. Ann Surg. 2005;241:1–8 Cited Here... 15. Armstrong EG, Barsion SJ. Using an outcomes-logic-model approach to evaluate a faculty development program for medical educators. Acad Med. 2006;81:483–488 Cited Here... 16. Wagner T, Compton RA Creating Innovators: The Making of Young People Who Will Change the World.. 2012 New York, NY Scribner Cited Here... 17. Miller RK. From the ground up: Rethinking engineering for the 21st century. Proceedings of Symposium on Engineering and Liberal Education. 4–5 June 2010:13–20 http://www.union.edu/events/integration/2010_docs/2010-ele-proceedings.pdf. Accessed November 15, 2012 Cited Here... © 2013 by the Association of American Medical Colleges


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Appropos the latest list of taken-over Lembi apartment buildings I noted earlier this month, a "plugged-in tipster" tells SocketSite:
Coastal Capital of Sausalito, which bought a portfolio of loans secured by Lembi properties, foreclosed on the properties [Thursday}. Coastal reportedly paid $24.1 million (64% of face value) for the package of loans originated by Tamalpais Bank. The sales … totaled $29,049,100. Pretty nice annualized return! It should be noted that a Coastal affiliate did some of the buying.
Among the foreclosed upon properties sold: 1235 Bay, 2285 Bay, 1125 Broadway, 479 Buena Vista East, 6242 Geary, 315 Hyde, 1651 Larkin, 725 O'Farrell, 1701 Turk, and 2350 Van Ness.

subset: commoncrawl


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WAUPACA, Wis. — An Oklahoma man who DNA evidence recently tied to a 1990 sexual assault is considered a person of interest in a 1992 double murder in Waupaca County, sheriff's officials said Monday.
Glendon Gouker, 41, was charged Wednesday with sexually assaulting a then-20-year-old woman in November 1990 in Iola. DNA evidence from the assault was resubmitted to the State Crime Lab, and Gouker was found to be a contributor to the DNA, according to the state Department of Justice.
The break in the case came in 2011, when evidence was resubmitted to the state crime lab for analysis as part of an investigation into the 1992 fatal stabbings of 23-year-old Tanna Togstad and 35-year-old Tim Mumbrue.
Waupaca County Sheriff Brad Hardel said Monday Gouker is a "person of interest" in the homicides, noting "he may have information on the crime."
He would not give many details on how Gouker has been linked to the Weyauwega-area homicides.
"If you take a look at the attributes of the crime, some things are similar," Hardel said.
Gouker, who is incarcerated in Oklahoma and is being extradited to Wisconsin, was scheduled to make an initial court appearance Thursday in Waupaca County Court.
A message left Monday for Gouker's attorney in Norman, Okla., was not immediately returned
A criminal complaint filed in 1990 said a masked man pulled a then-20-year-old woman into an Iola park and sexually assaulted her by using of threat.
"I want you to know this was nothing personal," he told her, according to the complaint. "I'm just doing my job."
Besides the DNA evidence found on the scene, police later recovered several hunting knives, a camouflage jacket and a knit stocking cap mask from Gouker, authorities say.
Gouker moved to Oklahoma in 1993, the complaint said.
The DOJ has yet released concrete evidence suggesting Gouker's connection to the homicides, but police are hoping Waupaca area residents might be able to provide information that could help the case.
"The killer, or killers, of this couple left evidence behind when they entered Togstad's home and savagely murdered the victims. We're now looking to the community for tips to help us identify a match to the DNA left at the crime scene," Hardel said in a statement.
Gouker can face up to 25 years in prison if convicted of the assault charge.
02/04/13 17:30


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My Reviews
IE Tab
Rated 2 out of 5 stars
"Missing plugin" error prevents use. Updating or backdating IE to any version doesn't fix the error, though I doubted it would as you continually say IE doesn't matter for the plugin.This review is for a previous version of the add-on (2.0.20120203.1-signed.1-signed).
The Pirate Bay Forwarder
Rated 4 out of 5 stars
Not working for me, unfortunately, and probably won't any time soon. The official mirror is blocked by my ISP, but I know one myself - could you perhaps add the ability to specify a mirror to use instead? Otherwise, very nice idea.This review is for a previous version of the add-on (1.0.1.rev66.1-signed.1-signed).
All-Glass for Firefox
Rated 3 out of 5 stars
My suggestion is being able to choose what gets glassed, and what doesn't. Say I want the tab bar to be transparent, but not the bookmarks bar or the status bar?
Newgrounds Classic
Nice job Rated 4 out of 5 stars
Very nice, quite sleek, only thing I would suggest is, like the original NG theme, is to make all of the toolbars gray.
Actually, I have to admit I prefered the original NG theme, could you 'covert' that to FF3?
You'd have to get permission, but it's easier than changing tons of little tweaks to make it into a clone and get hated by the people who like this one, not that one.
(This console, not that console. This character, not that character.)
Firefox for Windows Vista
Wow. Just Wow. Rated 5 out of 5 stars
I had this in FF2.
I'm sad to leave it behind it FF3.
I want it back! Make it for FF3!
Newgrounds Theme
Wow! Rated 5 out of 5 stars
Great job, used this since it first came out but I'm really sad it isn't yet ready for FF3.
Bookmarks Synchronizer
Rated 5 out of 5 stars
Brilliant job!
Excellent for keeping my links up-to-date when i'm too lazy.
To create your own collections, you must have a Mozilla Add-ons account.


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~ James McCandless
Product Notes
"Great poetry...don't be surprised if other poets start swiping his prized lines..." Pete Seeger "Powerful, deeply moving, poignant, funny, marvelous..." Studs Terkel, WFMT "The city's most chilling songwriter..." Dave Hoekstra, Chicago Sun Times "Rattles the bones..." Cliff Furnald, Dirty Linen \'...one guy managed to get it all down in one album. Succinct, to the point and with great warmth and humor.\' Jeff Ritter, Broadside What can you say about this James McCandless character? Geographically speaking, he was born out west and raised in Chicago, so he really doesn't know if he's supposed to be a cowboy or a gangster. He has played guitar and studied, taught, performed and recorded music since the age of six. Other than that, he hasn't worked a day in his life. Ever since the time Studs Terkel told him that Federico Fellini said, "All art is autobiographical", the door flew open for Jim to confidently write about any damned thing he wanted to. His music has been recorded by Kat Eggleston, Martin Hayes & Dennis Cahill, Jimmy Moore, Sean Keane, Arty McGlynn, Nollaig Casey, Bell & Shore, Susan Shore & Don Stiernberg, Dan Bern, and Body Parts; he has worked with Julianne Macarus, John Williams, Hayes & Cahill, Larry Nugent, Gan Ainm, Liz Carroll, Buddy Mondlock, Frank Tedesso, Jano, Andrew Calhoun, Victor Sanders, Brian Anderson, Jim Craig and Tom Dundee. Jim has also performed with P.J. Hayes, Greg Brown, Joan Baez, Odetta, Chris Smither, Sean O'Driscoll, Claudia Schmidt, John Fahey, Tim O'Brien, Jim Post, Natalie McMaster and Tom Paxton. "There's a tightly-knit new wave of Chicago singer-songwriters who might be loosely classified as street intellectuals. The heavies in the group include Frank Tedesso, Dan Bern and James McCandless, the last being fortunate enough to display his craft on a splendid debut record, "Faultline." McCandless has a resonant voice that sounds like Johnny Cash and Roger Miller. His approach is set within the keen Chicago style of topical, country-folk songwriting pioneered by John Prine and Steve Goodman. What McCandless songs like "Kareem and Me" may lack in melody, they make up for in wit: "Kareem and me goin' bald together, it's almost an honor when I think of it in that regard." Or, the honky-tonk saga of "You've Gone Hollywood": "You think your britches are bigger than they really are, you'll prob'ly swallow Quaaludes from a Mason jar." McCandless can also be a desperate romantic in material such as "Waiting Out The Morning," a haunting tune basted in country soul, and the ambitious title song, which reminds us how close we are to the edge..." Dave Hoekstra, Chicago Sun Times.
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One of the core services of the Loss Prevention Program is providing education, training and information on ways agencies, universities and community and technical colleges can prevent or reduce loss.
The type, subject matter and availability of education and training vary based on the needs and requests of agencies.
To register for training classes, contact your agency training representative or refer to the training web page.
The Office of Risk Management (ORM) maintains a collection of loss prevention videos for Washington State agency use only. These videos are provided for risk management training and other agency loss prevention initiatives.


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Google Groups
Removing a relation in a GridField
Oct 5, 2012 6:53 AM
Posted in group:
SilverStripe Core Development
The GridFieldAddExistingAutocompleter helps making relation between objects. I would expect the scaffolded the GridField to offer a button to remove relations but there is only a button to delete the whole object. Is there a solution for this issue?
Further I suggest that objects may only be deleted in their own ModelAdmin for security reasons.
Next post


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Schwarz C, Pilger A, Kuster N, Adlkofer F, Rüdiger
Radiofrequency electromagnetic fields (UMTS, 1,950 MHz) induce genotoxic effects in vitro in human fibroblasts but not in lymphocytes
International Archives of Occupational and Environmental Health, Springer Berlin / Heidelberg Volume 81, Number 6 / May 2008, Pages 755-767
Schwarz C, Pilger A, Kuster N, Adlkofer F, Rüdiger HW.
Division of Occupational Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
OBJECTIVE: Universal Mobile Telecommunication System (UMTS) was recently introduced as the third generation mobile communication standard in Europe. This was done without any information on biological effects and genotoxic properties of these particular high-frequency electromagnetic fields. This is discomforting, because genotoxic effects of the second generation standard Global System for Mobile Communication have been reported after exposure of human cells in vitro. METHODS: Human cultured fibroblasts of three different donors and three different short-term human lymphocyte cultures were exposed to 1,950 MHz UMTS below the specific absorption rate (SAR) safety limit of 2 W/kg. The alkaline comet assay and the micronucleus assay were used to ascertain dose and time-dependent genotoxic effects. Five hundred cells per slide were visually evaluated in the comet assay and comet tail factor (CTF) was calculated. In the micronucleus assay 1,000 binucleated cells were evaluated per assay. The origin of the micronuclei was determined by fluorescence labeled anticentromere antibodies. All evaluations were performed under blinded conditions. RESULTS: UMTS exposure increased the CTF and induced centromere-negative micronuclei (MN) in human cultured fibroblasts in a dose and time-dependent way. Incubation for 24 h at a SAR of 0.05 W/kg generated a statistically significant rise in both CTF and MN (P = 0.02). At a SAR of 0.1 W/kg the CTF was significantly increased after 8 h of incubation (P = 0.02), the number of MN after 12 h (P = 0.02). No UMTS effect was obtained with lymphocytes, either unstimulated or stimulated with Phytohemagglutinin. CONCLUSION: UMTS exposure may cause genetic alterations in some but not in all human cells in vitro.
Deutsche Zusammenfassung
EMF-Portal >>>


text: Missed the first Ira Sohn west conference? Here is your chance to catch the complete notes via BTIG's Mike O'Rourke. Presenters included John Burbank of Passport, Barry Rosenstein of Jana, Brian Zied of Charter Bridge Capital, Mitch Julis of Canyon, Jeffrey Ubben of ValueAct, Robert Rosner of Buena Vista Fund, John Taylor of the John Taylor Rule, Chris Chabris, and Richard Farber of Kayne Anderson. Ideas discussed include the future of the world, Dutch company TNT, Charles River Labs, Sirius XM, Valiant Pharma, Taiwan Semi, the Libor-OIS spread, Natty and Patriot Coal. So for all those who still hold on to the illusion that alpha is possible in this market, read on.


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Death in the Garden, Blood on the Flowers
Until I read Yeti's post on Wednesday, I had only heard one song from Irving: their catchy-as-hell contribution to the Dimension Mix, "Army Ants in Your Pants" (mp3), which my girlfriend played incessantly for a while when it first came out.
But it's this song that has me hooked. Recalling elements from The Beatles, Belle & Sebastian, The Zombies, and Elephant 6, all on the same song, this track has me very excited for Irving's upcoming full-length, Death In The Garden, Blood On The Flowers (due out April 4, 2006 on eenie meenie) And even more excited to see them live at SXSW.
Irving The Curious Thing About Leather mp3
Be Irving's friend
Read about the kick-ass Ship Collective, made up of Earlimart, Irving, The Silversun Pickups, and more
Speaking of SXSW...
March 15 @ Stubb's (Austin): Belle & Sebastian, Cat Power, and Mogwai
See you there!


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"The Fremont Centre Theatre in South Pasadena is one of the great Art
secrets of the San Gabriel Valley!" –Pasadena Star News
Become a Jewel of the FCT!
Help us continue to bring imagination to our stage! Please consider giving us a tax-deductible donation and become a Jewel of the FCT! Donations may be made in your own name or in honor or memory of a loved one. You are welcome to contribute any amount, or select a donor level:
Jade $25+, Ruby $100+, Sapphire $250+, Diamond $500+, Emerald $1,000+, Hope Diamond $5,000+
To Give By Mail:
Download our donation form here. Include a check made out to Fremont Centre Theatre and mail to:
Fremont Centre Theatre, 1000 Fremont Ave. Ste. 100, South Pasadena, CA 91030.
Have Your Own Chair!
For a tax deductible donation of $850, you will get a chair especially for you or someone you wish to honor! The chair includes a name plaque and will be reserved when you attend a show. Please call (626) 441-5977 for more information.
How to Help the FCT Without Spending a Dime!
Amazon will now donate 0.5% of the price of your eligible AmazonSmile purchases to Fremont Centre Theatre when you shop at AmazonSmile! Visit smile.amazon.com and follow these steps:
1. Sign in with your existing email address and password, or create a new account, and then select Fremont Centre Theatre.
2. Get the AmazonSmile1Button the easiest way to start your shopping at AmazonSmile.
3. Share your support on Facebook and Twitter.
Remember: The Fremont Centre Theatre only benefits when you start at smile.amazon.com!
AmazonSmile is the same Amazon you know. Same products, same prices, same service. We thank you for your support!
Ralph's Grocery Stores will donate up to 4% of your grocery bill to the FCT if you register your Rewards card at www.ralphs.com.
To enroll online, visit www.Ralphs.com and follow these steps:
1. Click Sign In (or Register for a new account).
2. Click on 'My Account' (In the top right hand corner)
3. On your account page, scroll down to Community Rewards.
4. Click EDIT and search for Fremont Centre Theatre.
5. Select our name and click ENROLL - You're all done*!
To Enroll at Checkout:
Send us your name & mailing address and we will mail you a letter that you can present to the cashier upon checkout. You must present your Rewards card (or phone number) at checkout to complete enrollment.
*Enrollment in the Community Contribution Program expires each year in August. You must re-enroll beginning September 1 each year to continue your support of Fremont Centre Theatre.


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The Grant County Braves played the Pioneers of Simon Kenton on Feb. 21 at Walton Verona, losing 84-60. It was a first round game for both teams in the District 32 tournament.
Copyright © 2018
The Grant County News is your source for local news, sports, events, and information in Dry Ridge, KY and the surrounding area.


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Bewertungen für Massimo's Unterkünfte
Bewertungen für den Gastgeber Massimo
Massimo is our insider tip. His helpfulness help us to save nerves and time. We were the first time in Italy and wanted to visit Milan and the EXPO. We don`t speak a word of Italian. That`s why he came up with the train station and help us with the purchase of tickets. His instructions were great. We came without effort by car to a parking lot, the obvious only knows Italians. Then we drove another 10 minutes to the Metro and were happy at the EXPO.
Massimo helped us in the first purchases. Again we saved time and money. He speaks very good English. We were able to talk well.
We thanks Massimo for his support and recommend him as attentive host.
very helpfull and patient, gave us all the information we need.
great english speaker.


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We are a locally based, independent, family owned business that endeavours to always provide friendly, professional, courteous and reliable service at a value for money price.
Whether you're a residential client with a one off garden clean up, would like a comprehensive, scheduled garden care maintenance programme or anything in between, make Botanica your first choice.
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Botanica is the 'one stop shop' for all your property maintenance needs. For a full description on how we can help you do business, please click here.
Of-course, Botanica Mowing and Garden Care is fully insured, OH&S compliant and is a proud member of the Independent Lawn Mowing Contractors of Australia. We rate yours, and the public's safety as highly as ours. Please take the time to view our Services tab for a comprehensive list of our scope of works. We can be reached via phone on 0419 121 121 or contact us here.
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What does GNP mean?
Definitions for GNP
Here are all the possible meanings and translations of the word GNP.
Princeton's WordNet
gross national product, GNP(noun)
former measure of the United States economy; the total market value of goods and services produced by all citizens and capital during a given period (usually 1 yr)
Suggested Resources
What does GNP stand for? -- Explore the various meanings for the GNP acronym on the Abbreviations.com website.
Anagrams for GNP »
Chaldean Numerology
The numerical value of GNP in Chaldean Numerology is: 7
Pythagorean Numerology
The numerical value of GNP in Pythagorean Numerology is: 1
Sample Sentences & Example Usage
I don't have a problem with guilt about money. The way I see it is that my money represents an enormous number of claim checks on society. It's like I have these little pieces of paper that I can turn into consumption. If I wanted to, I could hire 10,000 people to do nothing but paint my picture every day for the rest of my life. And the GNP would go up. But the utility of the product would be zilch, and I would be keeping those 10,000 people from doing AIDS research, or teaching, or nursing. I don't do that though. I don't use very many of those claim checks. There's nothing material I want very much. And I'm going to give virtually all of those claim checks to charity when my wife and I die.
Images & Illustrations of GNP
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"GNP." Definitions.net. STANDS4 LLC, 2018. Web. 18 Mar. 2018. <https://www.definitions.net/definition/GNP>.


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The abandoned lodge emerges from the dark, wet woods. It is warm and light inside – carpeted halls and wood banisters welcome your step, draw you deeper past branching rooms. What mysteries, forgotten treasure, and danger await within these decrepit walls?
released 17 November 2012
Music by Beau Devereaux
Artwork by Reuben Sawyer


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Engine Mechanical problem
1987 Nissan Truck 4 cyl Two Wheel Drive Automatic 310000 miles
I have a 1987 Nissan pickup 4 cylinder FI, the other day I was driving down the street when my car just shuts off I pull over and try to start it. It cranks( so im guessing its not the alternator or starter) but it doesnt want to turn over. Im pretty sure its getting gas cause I can smell it somewhat when I try to start it
Please Help
have the same problem?
Saturday, December 6th, 2008 AT 6:55 PM