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Durning, Steven J. MD, PhD; Artino, Anthony R. Jr PhD; Schuwirth, Lambert MD, PhD; van der Vleuten, Cees PhD
Dr. Durning is professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Dr. Artino is associate professor of preventive medicine and biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Dr. Schuwirth is professor of medical education, Flinders University, Adelaide, Australia.
Dr. van der Vleuten is professor of medical education, Maastricht University, Maastricht, the Netherlands.
Correspondence should be addressed to Dr. Durning, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814; telephone: (301) 295-3603; e-mail: email@example.com.
Deciding on a diagnosis and treatment is essential to the practice of medicine. Developing competence in these clinical reasoning processes, commonly referred to as diagnostic and therapeutic reasoning, respectively, is required for physician success. Clinical reasoning has been a topic of research for several decades, and much has been learned. However, there still exists no clear consensus regarding what clinical reasoning entails, let alone how it might best be taught, how it should be assessed, and the research and practice implications therein.
In this article, the authors first discuss two contrasting epistemological views of clinical reasoning and related conceptual frameworks. They then outline four different theoretical frameworks held by medical educators that the authors believe guide educators' views on the topic, knowingly or not. Within each theoretical framework, the authors begin with a definition of clinical reasoning (from that viewpoint) and then discuss learning, assessment, and research implications. The authors believe these epistemologies and four theoretical frameworks also apply to other concepts (or "competencies") in medical education.
The authors also maintain that clinical reasoning encompasses the mental processes and behaviors that are shared (or evolve) between the patient, physician, and the environment (i.e., practice setting). Clinical reasoning thus incorporates components of all three factors (patient, physician, environment). The authors conclude by outlining practical implications and potential future areas for research.
Deciding on a diagnosis and instituting a treatment strategy are foundational to the practice of medicine. There is no question that developing competence in these processes, which are referred to loosely as "clinical reasoning," is essential for physician success. Clinical reasoning has been a topic of research for several decades and much has been learned, to include insights into how physicians generate and test hypotheses through hypothetical-deductive reasoning1; case specificity, which has been subsequently renamed "context-specificity" to account for the unique nature of the situation or encounter beyond the facts in the diagnosis portrayed2–4; dual process theory, which pertains to analytic and nonanalytic reasoning (or pattern recognition),5 including its use in novices6; and script theory.7,8
Notwithstanding the many publications on clinical reasoning, there still exists no clear consensus regarding what clinical reasoning entails, let alone how it might best be taught and assessed, as well as the research and practice implications therein.9 Because clinical reasoning lies at the core of what a physician does,10 we believe this lack of consensus in the aforementioned domains could have a negative impact on the development of our learners and, ultimately, the care of their patients, because consensus in these domains is important to frame needed investigations and practices.
There are several definitions of clinical reasoning, and most do not converge to any great degree.9 Some of the definitional confusion surrounding the term is likely due to the different epistemological and theoretical frameworks that medical educators use when discussing the topic. In this article, we begin by describing two contrasting epistemological views of clinical reasoning and related conceptual frameworks. We then outline four different theoretical frameworks held by medical educators that we believe guide their views of the topic, knowingly or not. Within each theoretical framework, we begin with a definition of clinical reasoning (from that viewpoint), and we discuss learning, assessment, and research implications. We end by outlining practical implications and potential future directions. We believe that discussing these frameworks (and their underlying assumptions) could help advance our understanding and assessment of clinical reasoning.
At the outset, we should note that we also believe that these two epistemological views and four theoretical frameworks and views apply to more than just clinical reasoning. As such, the issues discussed in this article could also apply to other medical education topics such as professionalism or clinical competence. However, in this article, we will use clinical reasoning as our primary example. Ultimately, we hope this article will help medical educators move the teaching and assessment of clinical reasoning from a largely "black box" topic to one where research can make important advances. We believe that making such advances constitutes a societal obligation in that helping our learners develop and improve clinical reasoning should eventually translate into improved care for our patients.
Epistemology involves the study of the nature, scope, construction, and limitations of a person's (or a group's) knowledge. It aims to answer questions such as, What is knowledge? How is it acquired? How do we know what we know? Research to date has found that clinical reasoning expertise combines both knowledge and experience, and, as such, we believe that understanding clinical reasoning's epistemology is central to understanding clinical reasoning.
From the standpoint of clinical reasoning, we often discuss two main epistemological perspectives: objectivist and constructivist. From the objectivist (or logical/positivist) perspective, for whichever domain is being considered (in this case, clinical reasoning), there is one truth that is revealed or can be discovered.11 Thus, from this viewpoint, teaching can be thought of as the process of conveying this one truth, and learning can be thought of as the process of acquiring knowledge so that one can discover this one truth. Experience is seen as less important (because there is one truth to be discovered), and, as such, lectures, whereby experts convey their ideas on the truth, are seen as a pervading instructional method and an effective means of learning.
From the constructivist viewpoint, "knowledge is a compilation of human-made constructions"12—"not the neutral discovery of an objective truth."13 From this perspective, teaching emphasizes providing learners with representative experiences. This is done so that, from a learning perspective, one can construct meaning. From this epistemological viewpoint, merely providing learners with static facts is insufficient for learning. Providing experiences whereby learners can construct meaning is key. The constructivist viewpoint has led, in part, to the emergence of problem-based and case-based learning; in these approaches, the teacher becomes a facilitator of learning as opposed to a lecturer or conveyor of facts. Stated another way, the teacher acts as "a guide on the side" as opposed to "a sage on the stage."
These two different epistemological perspectives—objectivist and constructivist—have relevance to clinical reasoning. The question becomes, is clinical reasoning a construct with one truth, or is it a construct that varies on the basis of the specifics of the situation and, notably, on the basis of the person doing the "constructing"? In other words, is clinical reasoning a trait or a state (varies with the situation), or a combination of the two? This is a central question to approaching the learning and assessment of clinical reasoning. Indeed, the perspective one takes leads to important assumptions and implications for the learning and assessment of clinical reasoning. The epistemological viewpoint taken will drive how one sees "signal," or true, variance and how one sees "noise," or error, variance in clinical reasoning.
Constructivism views knowledge as accruing between individuals by means of social interactions and social negotiation. Each individual's construction of this idiosyncratic relationship would be different—It is not the construction of one "truth." An example that illuminates this epistemological distinction that influences learning and assessment is student motivation. Many people think of motivation as a trait (either you have it or you don't), but others think of it as a state (you have it in certain circumstances, and/or the idea of motivation is constructed differently by different individuals—i.e., there is no one truth). A medical metaphor could be blood glucose measurement. If blood glucose measurement is a "trait," then one would expect the same findings with each value taken. If blood glucose is a state, then one would expect variability in measurements.
These two viewpoints would have different notions of error variance, or noise. For example, variation in student motivation would be seen as the expected "signal" from the "state" perspective, and as noise, or error, from the "trait" perspective. In other words, one's epistemological perspective drives how one views and interprets findings in studies both in the laboratory and in naturalistic settings involving clinical reasoning or other constructs. Take, for example, the physical location for the clinical reasoning event. If clinical reasoning is a trait (one truth), then variation in clinical reasoning from location to location would be unexpected and considered error, whereas if clinical reasoning is thought of as a state, then lack of variation from location to location could raise questions about the accuracy of the assessment of clinical reasoning.
Our epistemological viewpoint largely determines the theoretical lens through which we view learning. Below are four common theories used by medical educators to understand learning (and, by extension, teaching and assessment).
Behaviorism,14 in its purest form, considers only behaviors (observable actions) as meaningful. A person with this theoretical perspective would thus consider clinical reasoning as incorporating only what can be directly seen in the clinical encounter. From the strict behaviorist viewpoint (Note: There is a continuum of behaviorist perspectives), the clinician's thought processes and emotional state would not be considered important parts of the reasoning process. Behaviorism argues that clinical reasoning is learned through behavioral modification; that is, we learn to reason on the basis of the contingent rewards and punishments we receive. Or, in an expanded view of behaviorism, we can also learn reasoning vicariously by watching others be rewarded and/or punished for their behaviors in clinical practice. Neobehaviorists, on the other hand, would view thoughts and emotional states, which result from prior experiences, as important aspects of an individual's behavior in relation to a stimulus.15 Notably, however, these proponents would hold that thoughts and emotions are shaped by prior stimuli and are important only in that they can shape responses to future stimuli. The emphasis is on describing, modeling, and predicting responses to stimuli, not on understanding human thoughts and emotions. Thus, from this perspective, one's behavior (in response to a stimulus) leads to internalization of thoughts and feelings as a result of behavior, which influences subsequent responses to stimuli; thoughts and feelings are not the origin of behavior but the response to behavior.
From the behaviorist perspective, learning, teaching, and assessment should entail observable actions because we are most interested in an individual's response to stimuli. In terms of research implications, this theoretical viewpoint would consider studying the workplace, its rewards and punishments, as paramount to describing, modeling, and predicting clinical reasoning. For example, a prominent behaviorist (Skinner) approached language development purely as a process of reward and punishment.14 In rebuttal, Chomsky15 (a neobehaviorist) noted that such a view could not account for our ability to produce sentences that we have never heard. In sum, understanding clinical reasoning is not a focus of the behaviorist perspective. Though not a prominent theoretical perspective in medical education today, components of the behaviorist theoretical perspective are evident in the focus on medical education outcomes (the behavior) and competency-based medical education, which often come at the expense of process measures. What is desired in these frameworks is displaying the "behavior" (competency), whereas understanding how one obtains the competency is not so much the focus. It is important to recognize that behaviorism emerged, in large part, from an objectivist epistemology, which we will return to in the next section.
Information processing theory is a pervading perspective in medical education today. Theories that fall under information processing include, for example, script theory7,8 and dual process theory.5 In medicine, illness scripts can be thought of as incorporating all of the features that can be seen in a given diagnosis, as well as the range in presentation that can be seen and still be consistent with the illness (diagnosis).7,8 Dual process theory argues that physicians use two general processes when approaching the task of clinical reasoning: analytic reasoning, whereby a physician actively compares and contrasts options (diagnostic or therapeutic) while deciding on the best option, and nonanalytic reasoning, which entails pattern recognition, or immediately recognizing the best option to take without actively comparing and contrasting options.5 Analytic reasoning is effortful and believed to be slower than nonanalytic reasoning, which is believed to be effortless and immediate.5 How scripts and these two processes (analytic and nonanalytic) interact is not fully understood. For example, what leads a physician to switch between analytic and nonanalytic reasoning? Or, instead, is clinical reasoning, broadly speaking, more of a continuum than an "either/or" phenomenon? Is analytic reasoning always effortful, or can it be so well practiced in an expert that it only seems effortless? How do various contextual factors affect reasoning? Even the process of pattern recognition (the fast process) is not a well-understood phenomenon.6
Cognitive load theory (CLT)16 is another important, and more contemporary, information processing theory that some have used to help explain clinical reasoning.17 CLT refers to limitations in our cognitive architecture and suggests that we can hold (or process) only a finite number of informational "chunks," or units, at a given time; the number of chunks is assumed to be no more than nine. CLT also specifies different types of cognitive load.16 Further, CLT provides a hypothesis to explain how we overcome the limitations of our working memory by accessing long-term memory and using "chunks" of knowledge in working memory.16
Information processing theory became popular with the emergence of the computer, and this theory typically uses the computer metaphor: We store information in a symbolic fashion that is recalled later for accomplishing clinical reasoning tasks.5,18 Unlike the behaviorist approach, information processing theory places greater value on a physician's mental processes (that are not observable); the emphasis is on understanding the construct (here, clinical reasoning) rather than coming up with a model to predict the observable behavior (behaviorist approach). One can see how these two theoretical viewpoints can conflict—understanding as opposed to observation and prediction.
From the information processing viewpoint, clinical reasoning can be defined as the internal mental processes (versus observable behaviors) that a physician uses when approaching clinical situations. Furthermore, as the emphasis is on mental processes, information processing theorists believe that clinical reasoning can be taught by giving trainees organized, incremental pieces of information and/or varying the individual pieces of information that lead to subsequent improved clinical reasoning performance. However, the emphasis on clinical reasoning as an internal mental process makes learning clinical reasoning challenging. That is, the emphasis is on acquisition of well-organized knowledge, although experience (through refining knowledge) also plays an important role in this viewpoint. However, from the information processing theorist's perspective, specific situational factors—the environment of the clinical encounter and the interactions between patients and physicians—are believed to be of less value.18 These specific situational factors are largely seen as theory-unrelated and, therefore, are considered to be unwanted sources of variation (i.e., situational factors are artifacts of the measurement method and not the focus of study). In other words, information processing theory does not explicitly address the clinical context or the weighing of informational units or details that lead the physician to the diagnostic and treatment plan.
From an instructional perspective, the format of instruction does not need to be in a clinical setting, and indeed CLT would argue that, at least at first, this teaching should involve low-fidelity or low-authenticity methods (i.e., paper cases of basic components of the diagnosis or therapy). Additionally, CLT would argue for slow progression, where learners progress to more complex clinical presentations once they learn "the basics." Furthermore, extraneous load (that which is imposed by the teaching method itself) should be minimized as much as possible, with a focus on the intrinsic load (that which is related to the complexity of the content) that can lead to more learning effort (germane load). It has been argued from the CLT perspective that learning should start with well-defined problems, first in nonauthentic settings, and followed by gradual increases in the complexity of the problems (i.e., the authenticity of the learning environment). This theory places a priority on acquisition of knowledge and the notion that teachers should be content experts who primarily provide knowledge structure and organization to trainees so that they can build their illness scripts.
From the information processing perspective, an oversimplified (but, we believe, useful) analogy to help the reader is the idea of "transferring or transporting" information from the mind of the expert into the mind of the trainee.18 From this viewpoint, lectures could be a very useful approach to learning. Research implications entail studying the ways that information is presented so that it can be easily and efficiently encoded into memory and retrieved later. A medical education example might involve an objective structured clinical exam (OSCE) station pertaining to the oral presentation. From an information processing theory perspective, the emphasis would be on understanding the trainee's knowledge structures, and thus assessment and feedback would be directed toward knowledge construction and organization. From a behaviorist perspective, the emphasis would be on the behavior displayed and predicting performance in future iterations of the oral presentation, and therefore the emphasis for evaluation and feedback would be on the observable actions, with far less emphasis on understanding mental processes.
Generally speaking, both behaviorism and information processing theory (or cognitivism) fall under the umbrella of objectivist, or positivist, epistemology. The primary goal with both approaches is being able to communicate or transfer knowledge to learners in the most efficient and effective manner. One important key to efficiency and effectiveness is the notion that complex processes and ideas can be broken down, or simplified, into basic components that are agreed on by all involved. Such an approach would argue that effective instruction should remove extraneous information (potentially irrelevant information, including contextual complexities) to improve learning.
Although not traditionally thought of as theories of learning, psychometric theories pervade medical education and shape the way we view numerous topics, including clinical reasoning. These theories address the concept of clinical reasoning as a domain that can be measured in a reliable and valid way, where "reliability" refers to reproducibility and "validity" refers to the extent to which we measure what we intend to measure. Psychometric theories do not make any specific claims with respect to clinical reasoning (they are not learning theories, per se), and so what we discuss applies to any construct viewed through these theories.
From the psychometric perspective, we are attempting to measure a latent (unobservable) construct like clinical reasoning ability. From this perspective, there is an objective truth we are trying to capture (i.e., this is an objectivist, or positivist, epistemology). Many such theories view latent constructs like clinical reasoning as traits (versus states), and we have discussed this assumption previously. But, psychometric theories19,20 do require the researcher to explicitly state the nature of the construct of interest and its characteristics, and they further require that the explication be done in a way in which the challenging of assumptions is possible. Kane19 further explicates that the variability of the construct (in this case, clinical reasoning) may be an element of its nature and should not necessarily be seen as construct-irrelevant variance. Such psychometric views incorporate construct underrepresentation (i.e., small samples) and thus may require large samples to test hypotheses.
If reasoning cannot be captured in a reliable and valid manner, then the construct of reasoning is questionable or, at least, is in need of refinement. This is a view much like the behaviorist perspective—If you can't see or measure it, it probably is not relevant. Further, like behaviorism, the psychometric viewpoint puts emphasis on what is observable, but it goes even further, placing even more emphasis on what can be quantified, in a repeatable way, and used to predict future performance. From this perspective, it is not known whether reasoning can be measured (and, as an extension, learned, which is a topic of debate in the medical education literature today) unless the construct and outcome behavior can be clearly defined, both in a reliable and valid fashion. Assessments can be created once the construct is clearly defined, per the guidelines above. For psychometricians, research is focused on constructing reliable and valid scores using well-developed measurement tools, which may be used to teach and assess clinical reasoning. Returning to our oral presentation OSCE station example mentioned above, if the performance cannot be quantified in a reliable and valid fashion, this calls into question the construct being assessed.
Situativity theory18 argues that clinical reasoning is rooted in the specific situation (as does behaviorism). Two leading theories are situated cognition and ecological psychology.18 Situated cognition argues that thinking (cognition or reasoning) is nested in experience, and to understand reasoning means to understand the particulars of the situation and experience. Ecological psychology proposes that reasoning is the result of a goal-driven person interacting in an information-rich environment. In both of these theories, the environment, or practice setting, and the interactions between the physician, the patient, and the health care team are critical. This assumption represents one departure from the above-stated theories. That is to say, from a situated perspective, the environment and the interaction are seen as part of the measurement phenomenon, or true variance, as opposed to noise or measurement error. The physician is responsible for the final diagnosis and therapy, but she or he is influenced meaningfully by these other factors (environment and participants). Clinical reasoning, from a situativity perspective, entails consideration for all the factors specific to the patient, the physician, and the encounter or practice setting, as well as their interactions. From this viewpoint, clinical reasoning represents all that occurs in the clinical encounter that specifically pertains to the diagnosis and therapy of the patient. Furthermore, situativity theory would argue that clinical reasoning is likely nonlinear, and thus our statistical methods to measure and compare clinical reasoning may not fully capture the variance in this construct. And whereas other theories may acknowledge nonlinearity as a possibility, situativity theory proposes that nonlinearity is the most likely model.18 From a situated perspective, linearity is likely to occur only in straightforward presentations, typical diseases, and/or inauthentic laboratory (study) settings.18
In terms of instruction, situativity theories stress the need for workplace assessment. Teaching should also emphasize authentic instructional formats. Assessments should include the views of all participants in the encounter and the setting. These theories would agree that behaviors and information processing (i.e., scripts, dual process, and cognitive load) are all part of clinical reasoning but that, separately, they represent an incomplete description for all but the most straightforward cases.
When we consider the epistemological and theoretical lens through which we view clinical reasoning, important assumptions, challenges, and implications emerge for learning, teaching, and assessment. Furthermore, by considering other theoretical frameworks, additional questions and potential solutions come to light that were not apparent when we consider only a single theoretical lens. It may be that certain theoretical frameworks make more sense depending on the specifics of a given clinical situation, and so we believe that flexibility in one's approach is warranted. Thus, it is important to recognize, as Alfred Korzybski famously stated, that "the map is not the territory."21(p190) That is, just as no single map can completely and accurately represent the physical terrain it depicts, no single theory of learning (or reasoning) can fully and accurately represent the underlying mechanisms of complex cognitive processes. As abstractions, theories, by their very nature, are simplified versions of some more complicated (and not fully understood) phenomenon. What is more, it is important that we do not confuse maps with territories—that is, that we do not confuse our theoretical models of reality with reality itself. Instead, we should acknowledge that each theory provides a different way of viewing reality and, as such, enlightens us about different aspects of what is actually happening. We therefore would argue that theories are inherently constructivist in nature.
We believe that clinical reasoning encompasses both the mental processes as well as the behavior exhibited in terms of diagnostic and therapeutic decisions and that the mental processes and behavior are shared (or evolve) between the patient, physician, and environment. Clinical reasoning thus incorporates components of information processing, behaviorism, and situativity, respectively. We need to approach the topic with the precision that psychometric theory provides, but additional considerations, outlined below, need also to be incorporated. Thus, a new perspective toward clinical reasoning is needed to advance the field.
Each of the clinical reasoning theories discussed above poses important challenges and has important limitations. Each has helped move our understanding of clinical reasoning forward. Clearly, none of these theories is sufficient alone, and thus we propose a model that explicitly incorporates elements of all the theories to help us move our understanding forward. The model (illustrated in Figure 1), which combines a variety of clinical reasoning theories should be tested empirically to see whether the model is sufficient and advances our understanding and prediction capabilities. Further, we believe that the theories reviewed above are particularly incomplete when addressing the early clinical learner. For example, behaviorism's focus on only what can be directly seen in the clinical encounter, largely ignoring thought processes and emotional states, excludes important features of clinical reasoning. Behaviorism is identified as "experience" in Figure 1.
Information processing theory was developed largely from the study and understanding of experts; we believe that it falls short in explaining what may be going on in the more junior learner. With its focus on knowledge and its organization in the physician, it also does not efficiently take context into account. We believe that the information processing theories represent important physician factors (i.e., dual process and script theory) and interaction between physician and patient (cognitive load, which also represents a physician factor). The model also helps explain how scripts are activated as well as the processes influencing the trainee's sensitivity to information (CLT). Information processing theory is identified as knowledge and cognitive load in the "physician factors" circle of Figure 1.
Psychometric theory focuses on the need for precision in measuring the construct of clinical reasoning. Indeed, we believe that medical educators should strive to improve the measurement precision (reliability and validity) of the components or factors underlying our model (physician, patient, and environment); however, by solely focusing on one of these factors, much is lost in what is actually going on during a real clinical encounter (reasoning as one example of a construct to be assessed). Attention to reliable and valid measures of each of the component parts is represented in Figure 1 by the three connected circles.
We believe that situativity theories provide a useful overarching view of clinical reasoning. These theories bring a social perspective to clinical reasoning and outline factors specific to the physician, patient, and setting (and their interactions), which gives us a more inclusive view of what is occurring in terms of clinical reasoning (i.e., an important additional way of viewing the "territory"). But these theories do not specify the "component parts" of each of these three factors, let alone what drives the interactions (bidirectional arrows in the figure). The other theories can help determine or shape the specific factors. In the explanatory text adjacent to the figure's circles, we have included examples from behaviorism, information processing, psychometrics, and other theories and conceptual frameworks.
An important implication expressed in the figure is the notion of nonlinearity. As the individual components underlying each factor can interact in dynamic ways, our current models for assessing clinical reasoning often fall short of what is actually occurring. Currently, psychometrics focus on linearity, or the idea that the outcome should be the result of a single chain of consecutive events. We believe that the figure makes it apparent that clinical reasoning (like many other constructs) entails the interaction of discourse with a patient in an environment and that understanding leading to diagnosis and therapy evolves from and entails interaction of potentially a large number of component parts (we have listed only some of the potential mix of interacting components underlying each factor). All of the preceding theories, with the exception of situativity, would argue against the possibility of nonlinearity. This does not mean that every clinical encounter will proceed nonlinearly but only that the phenomenon of clinical reasoning possesses nonlinear attributes, which may be apparent in many encounters.
A metaphor to illuminate the differences between linearity and nonlinearity is driving a car. We believe this is particularly useful given the recent discourse on this point in recent publications.22,23 A traffic jam represents a nonlinear event; that is, the movements (or lack thereof) of individual cars in a traffic jam can have nonadditive (and indeed profound) effects on the flow of traffic (to include accidents). A driver in a traffic jam must pay close attention to component parts (i.e., the other cars) to successfully navigate the jam. This is unlike driving one's car down a highway without any traffic, which is a metaphor for a linear event or a carefully structured laboratory experiment. Then, of course, there are the "in-between" situations (varying degrees of traffic), which can be linear or potentially nonlinear. Certainly, one's driving skills in linear events are also important in nonlinear situations; however, the skills in the former situation (linear driving event) do not necessarily account for all that is needed in the latter (nonlinear driving event). One can successfully drive with drowsiness, a blaring radio, and/or a loud conversation when there is no traffic; it is far more difficult to successfully navigate under these circumstances in a traffic jam. We believe that our integrative figure and inclusive theory illuminate these features for the practice of medicine.
We would argue that education and assessment should focus less on the single best route through an encounter and focus more on the context as well as the "boundaries" or range of acceptable performance in an encounter. The difference between an expert and a nonexpert from this perspective is that the nonexpert's performance may not fall into one of several "trajectories" of acceptable performance. In contrast to psychometric, information processing, and behaviorist perspectives, there is not one "true" or correct path to the answer; there are often multiple, equally acceptable paths. What defines expertise is performance within a set of boundary conditions. Our theoretical framework (Figure 1) encompasses this approach.
Implications for learning entail focusing on the context and component parts. An example of this is self-regulated learning theory, a triadic, reciprocal loop that encompasses activities undertaken before engaging in a task, activities while engaging in a task, and reflection during or after engaging in a task. The specific activities in these three domains are dependent on the context of the activity, which includes the environment and the participants. Importantly, training in multiple phases results in large improvements in performance, and analysis of this nonlinear model could result in explaining the majority of the variance in the outcome with incorporating measures from each domain.
Further educational implications of this model include focusing more on the participants and the environment. Our model would place a much greater emphasis on the importance of teamwork, interdisciplinary education, and the patient's perspective. Such an approach also stresses how information other than the content or "script" of the diagnosis can affect decision making for good or ill. Indeed, research is emerging that supports the importance of contextual factors on experts' reasoning.16,24
Challenges to the model include the potential for nonlinearity. Fortunately, experts in this field have demonstrated that understanding complexity and complex systems can be straightforward, as the interactions can be understood by looking at the problem from a broader view and considering first- and second-level interactions as opposed to trying to explore all potential interactions. Clearly, new quantitative methods are needed to demonstrate numerically the existence of nonlinearity. Fortunately, such models exist,25 and in situations similar to those of medicine, these models explain more of the variance in the outcome of interest than do linear methods.25 Qualitative methods and mixed methods can be particularly illuminating of the existence of nonlinearity and could be used to inform/revise the framework we present. Indeed, mixed methodology probably represents the best way to test or demonstrate that our theoretical framework reflects actual practice.
As a final metaphor, take a major league baseball player who can consistently throw strikes (the strike zone represents the boundaries) but for whom throwing the ball in exactly the same location from one pitch to the next is not desirable (or possible). We believe such a perspective is particularly helpful in naturalistic settings (such as the clinical encounter), where so many variables can, and often do, interact. In such settings, predicting or observing for a static behavior (behaviorist and psychometric theoretical perspectives) or for understanding what is going on in a physician's mind without taking into account the environment or interactions (information processing theory) is likely to be not very fruitful.
Acknowledgments: The authors wish to thank Dr. Olle T.J. Cate for his helpful review and suggested revisions to the manuscript of this article.
Funding/Support: None.
Other disclosures: None.
Ethical approval: Not applicable.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent those of the Department of Defense or other federal agencies.
© 2013 Association of American Medical Colleges
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The Spa At Mt Hood - Mount Hood Spas
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Mt Hood Oregon Reservations
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68010 East Fairway Ave.
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text:
John Collins wrote:
> I've just installed Yellowdog Linux 3.0 on an iBook2. Subsequently I have
> run apt-get to upgrade all the packages to the newest versions. Almost
> everything has gone well but......
> I can't seem to enable trackpad tapping.
> /etc/sysconfig/trackpad contains the line TRACKPAD_OPT=tap
> but tapping is not enabled.
> I modify /etc/fstab to contain a line
> /dev/sda /mnt/usbdisk vfat noauto,user,rw 0 0
> for a removeable usb disk, but when I reboot the entry is gone and I can
> no longer mount the disk as a normal user. How do I get the entry to
> stick, better still to automount on insertion?
> Finally, for now I think. Under X the keyboard map is fine all the keys
> work as expected, but when I login in at a console, I get my @ and my "
> mixed up. How do I set the keyboard map for a console login?
> john collins
Hi, John--
I'm no expert, and I can't help you with all of your questions. However, I
can offer a suggestion regarding the removeable usb disk not being
Under Gnome or KDE look for a menu, under System Settings, Server Settings,
cclick on Services. Then look for an entry in the Services window, named
"kudzu". Untick that entry. It will prevent kudzu from initializing at
start and re-writing your fstab entries.
As to your keymap problems, you might go to the Yellow Dog site and search
the lists (located upper right) for keymap. There's been lot's of
discussion about keymap entries/configuration on the lists as of late.
Hope this is helpful. FWIW, YDL is *the* best distro for Macs, IMHO.
Hope all is well,


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WASHINGTON - U.S. Rep. Spencer Bachus will be watching election returns from Rosewood Hall in Homewood tonight, hoping he can dispatch his three spirited Republican challengers without a runoff. The polls closed at 7 p.m.
Bachus, R-Vestavia Hills, is running for an 11th term in the Birmingham metro area district, but this time he drew multiple challengers who questioned his conservative credentials and personal integrity. Add in a general dislike of Congress and an anti-incumbent sentiment nationally, and Bachus found himself digging deeply into his otherwise flush campaign account to fend them off.
Fellow News reporter Robin DeMonia is reporting from Rosewood Hall tonight, and said Bachus' team told her they made 30,000 live phone calls to voters leading up to today's voting.
"Congressman Bachus has been fighting in Washington on the issues that his constituents care about, and he always takes this responsibility seriously," Michael Staley, Bachus' chief of staff, said tonight from Homewood. "That is why Spencer and his whole team feel confident going into tonight."
Challenging Bachus is Scott Beason of Gardendale, a 42-year-old, well-known and ambitious state legislator who has been at the center of some of the biggest political events of the last year: immigration reform, Jefferson County's financial trouble, and the public corruption scandal over gambling legislation. Beason couldn't match Bachus' massive fundraising machine, so he combined a bit of the old and new tactics: door-to-door visits and social media. Beason is watching election returns from Gardendale Civic Center tonight.
Reporting from Gardendale tonight is my News colleague Thomas Spencer, who talked to Beason before the polls closed.
"We feel good but it is hard to tell," Beason said. He said he didn't have the kind of polling data that he would have liked because of the expense of polling a large congressional district.
"Today is the only poll that matters," he said.
The polling place at the Gardendale Civic Center had 3,534 voters today.
Also on the GOP ballot is Blount County Probate Judge David Standridge and Al Mickle of Alabaster, a veteran and pharmacy technician in his first run for office. As the county's top election official, Standridge was at the Blount County Courthouse tonight, working.
If no candidate gets 50 percent of the vote, the top two vote-getters will compete in a runoff six weeks from now.


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Featured Golf News
The Gifted Life of a Young Golf Course Architect
The kid architect handed me a golf ball. "Your goal," said Jay Blasi, "is to bring it back."
I was playing my first round at the wild and woolly Chambers Bay, the upstart Northwest muni that in its first year of operation was awarded both the U.S. Amateur (2010) and the U.S. Open (2015). Blasi was 28 when he wrote himself into golf history by sharing design credits for Chambers Bay with Robert Trent Jones Jr., and Bruce Charlton. The facility is on everyone's "best-of" lists; it's the only course built in the past 45 years to be anointed with a U.S. Open.
It was Blasi's first design effort. The first time he stepped on the property he was 25, a kid literally playing in a massive sand box in what would become an acclaimed $20- million project. "I couldn't have dreamed of a better opportunity," he said. "The site cried out for a great links course."
And a dream would soon come true. Not of winning the U.S. Open, but of designing a course on which it was played. "I was a well-behaved kid, especially when we traveled and ate at one of those restaurants where they brought out the crayons," said Blasi. "I'd flip over the menu and draw a golf hole."
His directive to me had more to do with his faith in the design of Chambers Bay than my ability to hit the ball straight. Blasi, who was on-site during construction more often than his cohorts at the firm, Robert Trent Jones II, knows every slope and shoulder of every nook and cranny on the expansive site overlooking Puget Sound. A big part of the design's success is very wide fairways that, while giving poorer golfers safe landing spots, demand impeccable placement by those trying to make par. Each hump and bump in them is - in effect - a hazard.
We looked closely at No. 5, a gorgeous, downhill par-4 that seems to run right into the Sound. The fairway seems impossible to miss. But the key is a bunker that sits smack in the middle-front of the green. To get to a right pin placement, you must drive along the right side of the fairway - and vice versa for a left pin location, in each case working the ball off mounds that drain into the green.
The slope from the back tees at Chambers Bay is only 133. There are almost no forced carries, very little rough and, yet, on tumbling greens with diabolical pin placements, the course can and will be devilish for the entrants in next summer's U.S. Amateur.
By the way, I didn't lose the ball Blasi gave me.
He's now finishing up work on The Patriot, the brainchild of Dan Rooney, a PGA golf pro and F-16 pilot who will move the headquarters of his association, the Fallen Heroes Foundation, to the facility outside Tulsa, Okla., when it's completed later this summer. The course winds through property that involves canyons and outcroppings. Blasi also crafted a splendid 30-acre practice facility at Stanford University that features practice greens true to the designs of Pete Dye, Alister Mackenzie, A.W. Tillinghast, Donald Ross, Tom Fazio and both senior and junior Robert Trent Jones.
"You are limited in practice only by your imagination," said Blasi, whose thoughts and those of his dad, Jac, never loomed far from golf. "He brought a couple of little plastic clubs to the hospital when I was born," said Blasi of his father.
Jac, a teacher, worked summers at a county club near the family home in Chicago. He learned enough about greens to build one in the backyard. When the family moved to Madison, Wis., the next home had two greens with bunkers. At one point, Jay drew up a scorecard for their backyard "nine."
Jac and Jay made golf pilgrimages to Harbour Town in South Carolina, Pebble Beach in California and, later, St. Andrews, Carnoustie, Royal Dornock, Cruden Bay, Nairn and Kingsbarns in Scotland.
OK, many of us love golf. And who wouldn't want to design a golf course? But how is it accomplished? Like anything else, you just go for it.
A near scratch player, Blasi played high-school golf but wasn't good enough to continue in college. He looked to enroll at the University of Wisconsin in search of a degree in business and eventually get a job. He knew how precious few golf architect jobs were available. Like none.
His parents said "Whoa." They didn't forget his written published goal in the high school newspaper, not just to design a golf course but one that would host a U.S. Open. "They challenged me to chase my dream," Blasi said gratefully. "They knew what I really wanted to do."
In reading the bios of the great architects he decided that the college major he needed was Landscape Architecture, which Wisconsin offered. "I knew something about golf holes," he said, "but I knew nothing about soils and trees, about irrigation and drainage. Landscape Architecture was perfect."
His senior project involved designing a second course at the university's golf course, University Ridge, which fortuitously had been designed by the staff at Robert Trent Jones Jr.
After college, Blasi applied everywhere. He had a good phone interview with Charlton, the president of RTJII, but nothing developed. After graduation, he went to work for a landscape firm in Baltimore. Three weeks later came a call from California. Blasi journeyed to Palo Alto to meet with Charlton, who in the meantime had been called away from the office on an emergency.
"I was just sitting there alone when Bobby came into the office," said Blasi of Robert Trent Jones Jr. The two talked and talked. They chatted about University Ridge, the one he played, the one he added 18 holes to in the college project, and the one Bobby designed in the first place. Mostly they talked about the love of the game shared by an older man and a younger one.
Blasi was hired. He did anything and everything in the office. He went back through old plans and designs in the RTJ archives. "I would have been happy to work on any course, anywhere," said Blasi. "When I saw the pictures of the site at Chambers Bay, I couldn't believe I could be a part of something so special."
A purist even at such a young age, Blasi pushed for a par-free Chambers Bay. He said he will continue his personal war on par, rough, cart paths, carts and artificial ponds. All but the par-free element are no part of Chambers Bay, as pure a course as architects and the movement of 1.5 million cubic yards of sand and dirt could produce.
Just after Chambers Bay opened, Blasi played a round there with his dad, brother and uncle. At one point, they all stopped and looked over the course that Jay helped build. They peered over the dunes, across the railroad tracks and westward into the blue waters of Puget Sound.
Jay summed up the group's feelings. "All my dreams have come true," he said. Indeed, they had.
Blaine Newnham has covered golf for 50 years. He still cherishes the memory of following Ben Hogan for 18 holes during the first round of the 1966 U.S. Open at the Olympic Club in San Francisco. He worked then for the Oakland Tribune, where he covered the Oakland Raiders during the first three seasons of head coach John Madden. Blaine moved on to Eugene, Ore., in 1971 as sports editor and columnist, covering the 1972 Olympic Games in Munich. He covered five Olympics all together - Mexico City, Munich, Los Angeles, Seoul, and Athens - before retiring in early 2005 from the Seattle Times. He covered his first Masters in 1987 when Larry Mize chipped in to beat Greg Norman, and his last in 2005 when Tiger Woods chip dramatically teetered on the lip at No. 16 and rolled in. He saw Woods' four straight major wins in 2000 and 2001, and Payne Stewart's birdie putt to win the U.S. Open at Pinehurst. Blaine now plays golf at Wing Point Golf and Country Club on Bainbridge Island, Wash., where his current index is 12.6. In 2005, Blaine received the Northwest Golf Media Association's Distinguished Service Award. He and his wife, Joanna, live in Indianola, Wash., where the Dungeness crabs outnumber the people.
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Mental Health Center
Suicide Risk High for Middle-Aged Whites
Oct. 21, 2008 -- It's a troubling trend that researchers say we know little about.
A new study shows that middle-aged white people are at high risk for suicide, as the U.S. suicide rate spiked among that group during 1999-2005.
Researchers found that white women made up the largest increase in suicides, although white men still make up the largest number of people who kill themselves.
Suicide rates were down among African-Americans and remained stable for Asian and Native Americans among that same time period.
The study and report by Guoqing Hu, PhD, from Central South University in Changsha, China, and colleagues included co-author Susan Baker, MPH, from the Johns Hopkins Bloomberg School of Public Health.
Why the increase? In a news release, Baker says researchers are not sure: "While it would be straightforward to attribute the results to a rise in so-called mid-life crises, recent studies find that middle age is mostly a time of relative security and emotional well-being."
She urges further research to "explore societal changes that may be disproportionately affecting the middle-aged in this country."
Researchers crunched numbers from data based on files from the National Center for Health Statistics on suicide trends from 1999 to 2005.
Suicide Rates
Here are the main results:
- The suicide rate for white women 40-64 years old went up 3.9% per year during the study period.
- The suicide rate among white men in the same age group increased 2.7% per year.
- Overall suicide rates went up for whites -- 1.1% per year. Suicide rates went down significantly for African-Americans -- 1.1% per year.
- Suicide rates remained stable for Asian and Native Americans.
The authors write that suicide is the fourth-leading cause of death among people aged 10 to 64.
In a news release, Baker says the results signal a change that could lead to better prevention. "Historically, suicide prevention programs have focused on groups considered to be at highest risk, teens and young adults of both genders as well as elderly white men. This research tells us we need to refocus our resources to develop prevention programs for men and women in their middle years."


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PayDay: The Heist Cheats
[Edited by Gen_Nukem, 5/23/2012 1:59:59 PM]
But the question I always have is, what exactly are they updating in the game that "breaks" the trainer and perhaps is there a way you could build into your trainer apps a mechanism that would allow us, the users, to patch our trainer over the internet. In essence when steam patches a game that breaks the trainer, the trainer will have a button or some other process that checks for an update from CH, apply it so that we don't have to keep checking for updated trainers. I guess it wouldn't change the fact that you guys still have to update on your end, but just a thought.
[Edited by Gen_Nukem, 6/26/2012 4:20:14 PM]
The Super armor cheat is nearly useless on Overkill difficulty. Actually correct that, it's useless in Overkill. I guess what I'm trying to say is, this function only makes you a tad stronger.
firewall and other security software.
on trainer and game.
version and distribution.
• Unlimited Ammo
• Add Cash
+ 1 more options
• 1152 x 600
• 1280 x 960
• 1280 x 1024
• 1600 x 1200
• 1920 x 1200


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Police: Human remains found near Overlea High School
Remains identified as adult man
UPDATED 5:07 PM EST Feb 27, 2013
A Baltimore County worker found human skeletal remains in a wooded area next to Overlea High School on Monday.
Detectives said a county worker made the discovery around 1:30 p.m. Monday in a wooded area right near the school building.
The remains have been taken to the medical examiner's office.
On Wednesday, police said the remains were tentatively identified as belonging to an adult man. Police are waiting for DNA results to confirm the man's identity.
Police said there were no signs of foul play.
Anyone with information is asked to call Baltimore County Police at 410-307-2020.
Copyright 2013 by WBALTV.com All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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I've never done any of these articles before, so I'm not sure if this is proper format, but here goes.
According to ESPN, we have now released Gary Brackett, Dallas Clark, Joseph Addai, Melvin Bullitt and Curtis Painter:
This is a huge blow to our chances of fielding a competitive team for the next year. While this should not be our main concern, as we are in a rebuilding state, it will certainly feel to all of us Colts fans that we are throwing the "Manning era" team members under the bus, so to speak. This may be a necessary maneuver, but I must say that I do not understand the release of all these players after the re-signing of Robert Mathis.
I'm not sure which of these players' release hurts the worst, but it is hard to see an almost complete dissimilation of the team we've all grown to love over the past decade. I had yet to see an article on here about it, so thought I would post one of my own so that I could see how everyone else felt. I can only hope this makes more sense after the draft and any offseason moves.


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SHENANDOAH JUNCTION - The Jefferson High School Theatre Department has transformed a selection of Anton Chekhov's short stories into a two-hour production in just a few weeks. With the help of dedicated students and three artists-in-residence, director Steve Glendenning is ready for this weekend's performance.
"This performance is a series of original plays. Students selected seven of Chekhov's short stories that they adapted for the stage. It's a series of 10, with three that had previously been in play format," Glendenning said.
The cast and crew decided last week to include an additional character that will serve as a narrator of sorts, Glendenning said.
Article Photos
Journal photo by Michelle Horst
Jefferson High School students Koty Crawford and Dominic Massimino perform in "Check Out Chekhov," opening this Friday.
"We had 10 separate standalone plays, so to have a thru-line, we created a character that we are calling the 'guide.' She comes in and kind of gives the set up for each one," he said, adding it's similar to what Neil Simon did with a play called "The Good Doctor," which is a selection of short stories.
Adrienne Sowers, a former student of Glendenning, served as one of the artist-in-residence, and taught the students along with Daniel Stevens and Joshua Riese. She described the theater class as a "master" class that students in post-secondary theatrical programs would experience.
"We start every day with a self-guided foot massage to get them connected to the ground," Sowers said. "Exercises getting them kind of keyed into their bodies."
Fact Box
If you go:
What: "Check Out Chekhov"
Where: Jefferson High School
When: Friday and Saturday at 7 p.m., Sunday at 3 p.m.
Tickets are $5 for students and $7 for adults
As for the play itself, Stevens said that Chekhov's tone expresses many emotions and the students were taught how to portray what he called a "bipolarity of tone."
"A perfectly executed Chekhovian monologue will often have laughter, tears and personal crisis and laughter again, in a minute and a half," Stevens said.
"You can really get into interesting deep emotions that you can't usually dish out," senior Mitchell Wajda said.
Wajda is both acting in the performance and was part of the student group which translated the short stories into the performance through computer software that drafts plays.
The storyline of the play travels through different decades. Senior Katlyn Simmons worked on both the technical side of the production as well as costume design. She said design students come up with ideas and sketches, and decide what fits well with the performance. Costumes for "Check Out Chekhov" were borrowed from The Old Opera House in Charles Town.
"The set is been coming together pretty well. We are just finishing up some painting," Simmons said.
Sowers and Stevens studied together in the theater program at West Virginia University, and collaborated to bring some of the techniques from their training to Jefferson High School. They both said the students have willing to learn new things despite having approximately two weeks shorter than normal to prepare for the performance.
"They have been genuinely enthusiastic, and they are willing to take risks," Stevens said.
"Check Out Chekhov" opens Friday at Jefferson High School.
- Staff writer Michelle Horst can be reached at 304-725-6581.


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GW Men's Basketball Finalizes 2012-13 Game Dates
Colonials Add 16-Game A-10 Slate to Non-Conference Schedule; Information for Local and Regional TV Games to be Announced
MBB Season Tickets Info Page
2012-13 MBB Schedule | 2012-13 MBB Schedule (PDF)
Download the 2012-13 GW MBB Schedule: Google Calendar (Click the '+' button in lower right corner) | Apple iCal
14 Games, 14 Days OOC Schedule Release Coverage
Follow @GW_MBB on Twitter
WASHINGTON - Dates for all 29 regular-season games of George Washington men's basketball's 2012-13 schedule have been finalized with the release of the team's 16-game Atlantic 10 Conference slate.
GW's 13-game non-conference schedule was released in July and is highlighted by a home game against Kansas State on Dec. 8 and road games at power conference foes Notre Dame (Nov. 21), Rutgers (Dec. 11) and Georgia (Jan. 4).
Information regarding game times, local and regional television, Federal News Radio audio streaming and 1500 AM radio broadcasts, and GWsports.com All-Access video streaming for the entire 2012-13 campaign will be announced in the coming weeks.
The Colonials will open A-10 play on Jan. 9 against St. Bonaventure at the Charles E. Smith Center, followed by a CBS Sports Network nationally televised showdown at Xavier on Jan. 12.
Additional highlights include Temple's final visit to the Smith Center as an A-10 member on Jan. 16, and inaugural A-10 meetings with new league members Butler and VCU on consecutive weekends. The Colonials host the Bulldogs on Feb. 9 before visiting the Rams on Feb. 16.
Along with the release of the 16-game A-10 docket, the league also announced that GW's Dec. 8 home contest against Kansas State will be nationally televised on CBS Sports Network at 2 pm. The Colonials will also host Senior Day against the Dayton Flyers on March 9 in a game that will be broadcast regionally by CBS Sports Network.
The home game against K-State will mark one of the season's key gameday promotions with the BUFF OUT. Below is a tentative gameday promotion schedule, with additional promos to be announced in the coming weeks.
2012-13 GW Men's Basketball Home Gameday Promotions Schedule
GW, which played a schedule last season which was rated in the Top 60 in the NCAA Ratings Percentage Index (RPI), will face a total of 13 postseason teams between its non-conference and Atlantic 10 schedules in 2012-13, including seven 2012 NCAA Tournament participants in Kansas State, Notre Dame, Saint Louis, St. Bonaventure, Temple, VCU and Xavier. Coach Lonergan's alma mater Catholic, whom he led to the NCAA Division III National Championship in 2001, will also visit Smith Center this season when the Cardinals travel across the city for an exhibition on Nov. 3.
GW welcomes back several key lettermen in 2012-13 including Lasan Kromah, Dwayne Smith, John Kopriva, David Pellom, Nemanja Mikic and Bryan Bynes. Those returners will be joined by a sextet of newcomers brought in under Coach Lonergan in Villanova-transfer Isaiah Armwood, incoming freshmen and Washington Post All-Met guards Joe McDonald and Kethan Savage, and international prospects Kevin Larsen (Denmark), Paris Maragkos (Greece) and Patricio Garino (Argentina).
For questions on becoming a season ticket holder, please call the GW Athletics Ticket Office at 202-994-7325 or email Director of Ticket Sales Shelli Anderson at email@example.com.


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Amnesty International welcomes continued 10-year commitment for traditional Aboriginal homelands
Amnesty International welcomes today's joint renewed commitment between the Federal and Northern Territory Governments to invest $221 million over ten years for the provisions of basic essential and municipal services to remote outstations.
This announcement indicates that both levels of Government have listened to the concerns of Aboriginal Peoples living on homelands.
The human rights organisation hopes this announcement represents a genuine recognition of traditional homelands. It is also hoped that this leads to a new collaborative era between the two governments and Aboriginal homeland communities.
Amnesty International calls for this renewed commitment to translate into a genuine partnership with the communities living on their ancestral lands. The two governments need to work alongside homeland communities to identify longterm solutions to ensure their viability.
Over twenty years of research confirm Aboriginal Peoples on homelands are able to maintain their cultural identity, are healthier and live longer.
The inquiry into the Stronger Futures legislation heard overwhelming evidence of concern from Aboriginal Peoples wanting to stay on their traditional homelands.
Amnesty International has outlined the extreme disparity in funding between homelands which support 35 percent of Aboriginal Peoples in the Northern Territory and Growth Towns. The vast majority of government spending in the Northern Territory continues to only be allocated to people living in Growth Towns which only make up 24 percent of the Aboriginal population.
Amnesty International continues to call for the two Governments to implement an overarching plan for homelands to be adequately funded in the upcoming Federal Budget and for any levels of funding for Aboriginal affairs in the Northern Territory to be equitably dispersed to reflect where Aboriginal people actually live.


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Brent Burke Due Back In Court For Article 32 Investigation
UPDATED 7:19 AM EDT Oct 12, 2011
A Fort Campbell soldier will be back in a military courtroom later this week.
Click Like For Louisville News Updates:
Brent Burke is facing an Article 32 investigation in connection with the deaths of his ex-wife, Tracy Burke, and her former mother-in-law, Karen Comer.
They were found shot to death in their Rineyville home four years ago.
In August, an Army investigating officer recommended Burke be charged with premeditated murder.
A civilian judge dismissed charges against Burke after two mistrials and two hung-juries.
Copyright 2012 by WLKY.com. ©2012 Hearst Properties Inc. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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Praying Mantis
Introducing the Woodland Praying Mantis…I love these awesome peaceful creatures. Enjoy!
© 2013 Michael Red Crow Mulholland Photography ~ Sector 7 Studio Productions
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This entry was posted on September 30, 2013 by michaelmulholland. It was filed under Canon 5D Mark III, Environment, Forest, Insects, Los Angeles, Macro, Michael Red Crow Mulholland, Mother Earth, Mountains, Nature, Photographer, Photography, Sector 7 Studio, Spiritual, Telescopic, The Great Spirit, Wildlife and was tagged with Canon 5D Mark III, Insects, Macro, Michael Red Crow Mulholland, Michael Red Crow Mulholland Photography, Nature Photographer, Nature photography, Photographer, Photography, Praying Mantis.
2 responses
Indeed, an awesome, beautiful sentient being. Nice photos!
September 30, 2013 at 3:46 PM
Thank you so very Sir, many blessings.
September 30, 2013 at 4:30 PM


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|Dust Raven
Or put an invisible cloak over something?
|Shar Tahl
|Darth Grall
Imo, it goes invisible for the duration, including the material in it. The object is the chest, it's contents are part of it and don't need to have the spell cast on them either since they're carrying them. Treating it otherwise wouldn't be inline with the intent of the spell, not to mention it would make a person a much better containter than a chest which is just dumb.
What happens when you cast invisibility on a character right after lunch?
...I have to admit, this actually could be important for creatures with Swallow Whole.
First instinct is to roll with "everything becomes invisible". Man...that's pretty horrifying really.
|Adamantine Dragon
|Malachi Silverclaw
I had a DM in 2nd ed that ruled the PCs can't see through invisible walls!
He also ruled that invisible PCs could automatically be seen by NPCs, on the grounds that if the NPC thought that there was stuff happening that didn't have a visible source, that the only explanation was that there must be some invisible creatures responsible, therefore gaining a 'disbelieve' save because Invisibility is from the illusion school!
It didn't work the other way, for some reason...!
RAW since it is being cast on an object it doesn't get the same bonus as a creature in that all items carried (or in the chest) would disappear, and reading the description of illusion(glamer) indicates it actually changes the chest to be seen through, so you could see the contents of the chest. this imo doesn't really do anything but make a 2nd level spell (invisibility) into a highly specialized and crappier version of a 3rd level spell (clairvoyance to look inside the chest).


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Thanks for the stellar advice, BeckaSki and Goldstar. I'm super disappointed in myself for giving in the sweets - it doesn't even feel like giving in, I just mindlessly ate them because they were put in front of me! The zero tolerance approach seems like a good idea, and that's originally what I did through out the week - it just tests your willpower even more when you can't control what's in your pantry because you share it with 2 other roommates! But none the less, I think it's time to put my willpower back to the test, realize that I can do this, and know that the milkshake everyone else is having is not nearly as good for them as it tastes.
My 7th Day of the challenge is just beginning, and although there were bumps in the road, there is no reason it can't be smooth from here on out. Day 7 here we go.


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VERNON — A Vernon resident encountered an unwelcome intruder last week, waking up to find a bear in the kitchen.
The bear climbed onto the deck of the house on the 500 block of Grandview Drive on Wednesday morning and broke a screen, police said.
Once inside the home, the bear turned on the water in the kitchen sink and made a wet mess on the counter, police said. The bear then tore through food in the cabinets before it climbed back out the window once the resident began screaming, officials said.
When police arrived minutes later, the bear was nowhere to be found. Police notified the state Division of Fish and Wildlife.
The resident was not hurt.


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Yesterday we reported that a Pagani C9 prototype was wrecked on the Autobahn in Germany. We have, however, received confirmation that it was not a C9 prototype and was instead a Zonda testing a C9 engine.
Nonetheless, the Pagani Zonda is still an extremely expensive car, even without a prototype engine. The engine in the C9 is said to be a 700-horsepower version of the Mercedes-Benz SL65 AMG Black Series' 6.0-liter twin-turbo V-12.
The car was wrecked so badly that it only left one clue to its real identity, even for those with astute eyes and deep knowledge of Paganis. It's such a minor detail that we didn't notice it until we received the confirmation that it was a Zonda-bodied vehicle. Look at what remains of the left rear part of the car and you'll notice one taillight with a clear hole for another above it. The Zonda sports these taillights while the C9s spotted all have a cluster of three taillights placed in the upper corners of the rear end.
Click here to see the photos of the wrecked Pagani at Autobild.


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Artist: Ho Don
Album: Tiny Bubbles
Genre: Pop
Ho Don
Tiny Bubbles
Tiny Bubbles
Thanks to Granite Music Corp for these lyrics.
words & music by Leon Pober
Tiny bubbles (tiny bubbles)
In the wine (in the wine)
Make me happy (make me happy)
Make me feel fine (make me feel fine)
Tiny bubbles (tiny bubbles)
Make me warm all over
With a feeling that I'm gonna
Love you till the end of time
So here's to the golden moon
And here's to the silver sea
And mostly here's a toast
To you and me
So here's to the ginger lei
I give to you today
And here's a kiss
That will not fade away
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text:
U.S. Supreme Court rejects claim that class waiver in arbitration clause fails to effectively vindicate federal statutory rights
June 21, 2013
View Attachment
Published in American Express Co. v. Italian Colors Restaurant
(June 20, 2013, No. 12-133)
Extending its recent string of pro-arbitration decisions, the U.S. Supreme Court ruled that an arbitration clause containing a waiver of the right to proceed on a classwide basis is valid and enforceable in a lawsuit asserting federal antitrust claims, even if it is uneconomical to proceed with the claims on an individual basis.
The Supreme Court reaffirmed that arbitration clauses must be rigorously enforced according to their terms, including where they foreclose class proceedings, and that this principle applies to federal statutory claims unless they contain a contrary congressional command. The Court held that federal antitrust laws do not embody any congressional command against class waivers in arbitration clauses.
The Court also clarified the "vindication" principle. The Court has previously suggested that under this principle arbitration clauses need not be enforced if they operate as prospective waivers of a party's right to pursue federal statutory claims. The Court explained that this principle is limited to provisions forbidding the assertion of statutory claims in arbitration and may also prohibit filing or administrative fees so excessive as to preclude access to the arbitral forum. The Court held that the vindication principle is not violated by a class waiver requiring individual arbitration, including where the expense involved in proving a claim on an individual basis renders it uneconomical to proceed in the absence of a class action.


text:
If we are in debt to the treasury or the treasury is broke, why cant they just print more money to get us out of debt. I have never followed politics, so I probably sound really stupid, but I would like someone to explain it to me. (As broken down as possible please. )
18 thoughts on "Why cant the treasury just print more money to get us out of debt?"
Because that causes inflation and devalues dolar.
Money is nothing but a representation of the economic power of a country, if you print more money you don't change your economic value.
you need to do some research on inflation
That is slightly illegal, so no.
Okay so basically we did the dollar value will go down. So pretend there is one gold nugget in the world right. So that makes I really valuable, yet if there was hundreds of them than the value will go down since here are a lot of them. So if we print to much money our dollar will hardly be worth anything
The reason they cannot print more money is because everytime more money is printed off the value of the dollar goes down so say in the United States the dollar is worth a little more than a canadian so if they print more the value would decrease to the point where we would have to pay more for everything without increase of pay.
Simple answer without going into major detail is the more they print the more worthless it becomes,
If you had 1,000,000 collector items they would be worth so much, but if there were only 50 they would be worth more because there are not that many out there.
basically they already do that and the only reason they can is because the dollar has reserve status.. pretty soon there will be nobody left that will buy t bills though if i understand it correctly, the fed is already about the only buyer, buying t-bills with printed dollars .. it has to stop somewhere .. the money gets dispursed into the system and devalues the currency.
First of all, the U.S. Treasury has illegally ceded that responsibility to the privately owned Federal Reserve.
Secondly, if money were printed wooly-nilly, the value of that money would fall sharply. Which is actually happening!: http://en.wikipedia.org/wiki/Quantitative_easing
Ever since we dropped the gold standard there is nothing to back our moneys value, so yes its worth only what we say it is. However the more money in circulation the less valuable it is. We cannot pay our national dept this way because we owe other countries money for material goods and such. For example. You make koolaid, but as you drink it you add more water after a time the koolaid is no longer sweet or flavorful but there is still the same amount
a question allot of people ask. but if we just printed mass paper money it wouldn't have a value would it? i mean a 5 pound note is only worth what we say it is. so if we pumped loads of money into the economy then we would start thinking whats the point in this paper? because the same situation happened in Zimbabwe the government just printed more money and now everyone had wheelbarrows of million (whatever there currency is) notes. which was worth nothing due to bread and tax's had risen. you cant just "print money" because that money has to go some were. and who are we in debt to? if printing money was as easy as you think it is. it wouldn't work would it? because money enters the public no matter what e.g paying builders for road works.
Money-creation and growth in money supply is not bad in and of itself, but it must be based on economic fundamentals. If there is not a corresponding increase in the production of goods and services, then inflation will erupt, as too much money chases the same amount of goods and services and prices are bid up.
The point is that it is good and normal to create new money, but that is limited by what the real economy can absorb, otherwise inflation breaks out.
The Tech Guy
Because that would lead to inflation, which would only worsen the current economic situation. Inflation is the increase in price and decrease of the monetary value of money. In other words, printing more money would only decrease its value. This means that more money would be required to be something at a certain price. For example, let's say that the price of a water bottle was $ 1 before inflation. Now let's imagine that after inflation you now need $ 10 to purchase that same water bottle.
The government borrows by selling Treasury securities to investors http://www.publicdebt.treas.gov/
The value of the Dollar is is determined by how many bonds private investors are willing to hold If the government were to "print" the debt, (which would actually involve the Federal Reserve buying more bonds), investors would sell off their bonds, the value of the Dollar collapse, and you would pay $ 1000 for a loaf of bread very shortly
Not really a dumb question. I hope people are being nice to you about it. Simple explanation is picture you and five other people are playing poker. You each have exchanged 100 dollars in cash for 100 dollars in chips (one dollar per chip). At the end of the game, you will exchange your chips for cash.
But what happens if one of the players has a little machine, and as he runs out of chips, he just makes some more? It devalues the worth of all the chips. At the end of the game, there should be (regardless of who has them) 600 chips, and 600 dollars in cash. But because of the dude with the chip machine, there is 600 dollars in cash, and 2400 chips. So instead of each chip being worth a dollar, each chip is now only worth 25 cents.
So if the government just prints more money, the money looses value. It is already happening. Prices are not really going up, the value of our money is going down.
Lets say during your poker game, you go to the bar, and buy a soda for one chip. Soda cost a dollar, the chip is worth a dollar. Later, after the chip machine dude has made a ton of extra chips, you go to the bar, and a soda now cost 4 chips. The value of the soda did not change, it still cost a dollar. It is that your chips are worth less then a dollar now.
Hope this make sense. Hope you didn't think I was talking down to you.
Have a great day.
Because money IS debt. We can NEVER get out of debt with the current system. Period. Since the *private corporation* the "Federal Reserve" (nicely given name- makes you think it is a US government entity, doesn't it?) was given over control of the money supply, we must "buy" money with interest-bearing government bonds. The bonds need to be paid back with interest. Where does the money for the interest come from? By selling more government bonds for more money, which is also charged interest.
In other words, "Printing" your way out of debt is akin to digging yourself out of a hole or standing in a bucket with both feet and trying to lift yourself off the ground. It can't happen. The system is designed as a giant ponzi scheme to enrich the few at the expense of the many- you and me.
There is a way out, which is issuing our own debt-free currency and raising the reserve on the money changers (the banks) to 100%, meaning they could NOT loan out more money than they actually had. In less than 5 years all of our debt could be repaid.
President Andrew Jackson did this, printing greenbacks (backed by "the full faith and credit of the USA"). He was immediately attempted to be assassinated. Luckily, both guns misfired and the President lived. It took 70 years for the banks to regain control.
Another famous President tried the same maneuver. He signed an executive order to print, essentially, "greenbacks". You may run into one occassionally. It is noticeable by the date 1963 and the red ink on the front of the bill. That president was promptly assassinated a week later. His name was John F. Kennedy. His replacement, President Johnson's first act was to undo this act and set the banks back on course.
When you know the truth, it is not only not stupid, it is absolutely terrifying.
It would cause inflation and (booms and busts).
Riddle me this – and I understand why more money in circulation causing inflation, etc., but I don't understand 2 thing:
1. Why does printing more money mean all of a sudden everyone will have more dollars to spend, i.e. the treasury prints more money and it ends up in my bank account?
2. Why don't we just print more money to get us out of dept., i.e. print in and send it to China – don't put it into circulation and cause hyper inflation, etc. – just pay off the debt.?
I realize these questions come from a lack of understanding! Thank you.
Excuse the typos….
The treasury should print money since via the constitution they are the only ones that have the legal authority to do so.m the fed creates money because in 1913 the government gave the 12 fed banks the right to which sold us up the river. We should get rid of th fed reserve and our government should print its own money and inflation would not be a concern. Inflation happens because the fed reserve prints money out of thin air, not our government.


text:
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From Veterans Affairs Puget Sound Health Care System University of Washington School of Medicine Seattle, WA 98108.
Potential Financial Conflicts of Interest:Grants received: Grant from the John A. Hartford Foundation, Inc., to the American Geriatrics Society, administered through Wake Forest University.
Requests for Single Reprints: William R. Hazzard, MD, Geriatrics and Extended Care (S-182-GEC), Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108; e-mail, email@example.com.
The progressive aging of the U.S. population presents an unprecedented demographic challenge to our health care system. To address this imperative, gerontology (the study of aging) and geriatrics (the health and social care of the elderly) must become embedded into medical education at all levels, especially the postgraduate training of all residents and fellows (except perhaps pediatricians). Furthermore, since the needs of elderly patients are typically chronic, progressive, and complex and the care of these patients is quintessentially multidisciplinary, communication and collaboration among specialists must be a cardinal feature of effective geriatric care. In this picture of the world of geriatric care, general internal medicine and family practice will share the leading role in primary care, skillfully orchestrating contributions from all of the medical subspecialties, neurology, psychiatry, physiatry, and surgery (including its subspecialties and related disciplines, such as anesthesiology and emergency medicine). This editorial focuses on partnerships between general internal medicine and geriatrics.
Where do geriatricians fit in this world? Here geriatrics functions as a "supraspecialty" (1), practiced by a relatively small cadre of certified geriatricians and their multidisciplinary teams concentrated principally in academic health centers. They maximally leverage their professional efforts as researchers and clinician-educators who provide exemplary, coordinated, longitudinal care to some of the oldest, most frail and vulnerable patients across a continuum of sites and levels. Geriatricians must assume such focused roles because so few U.S. medical graduates—currently less than 1% (2)—pursue geriatric fellowship training after residency in internal medicine or family practice. Even if all certified geriatricians were to remain full-time academic faculty—at least half to date have not—their efforts would not meet the geriatric education needs of all medical students and residents. Nor would clinical education confined to geriatric venues be appropriate: Education should occur wherever care is delivered, which will be widely dispersed throughout the academic health center and into the community. Thus, the great preponderance of geriatric care and geriatric education will be delivered by nongeriatricians, with geriatricians broadly facilitating such disseminated education while focusing their direct clinical teaching on geriatric ambulatory care clinics and long-term care venues. As a result, much geriatric instruction must always come from generalist physicians: chief residents, fellows, and attending physicians in clinics and on hospital units, as well as academic staff in areas such as epidemiology, biostatistics, and health services research.
These considerations make a compelling case for general internal medicine to incorporate geriatrics into the training of internal medicine residents. The field must embrace this challenge. However, neither logic nor urgency necessarily dictates reality, and at many academic centers the 2 parent academic units coexist in a relationship that is independent at best and sometimes frankly indifferent or even frosty. This perplexing conundrum generated the study, sponsored by the Society of General Internal Medicine and co-led by Seth Landefeld and Christopher Callahan, that is the subject of the supplement in this issue. Supported by the John A. Hartford Foundation, this initiative was conceived during a Hartford Foundation-sponsored Geriatric Education Retreat in General Internal Medicine; held in 1999, the retreat was cochaired by Landefeld and Eric Larson as 1 in a series of similar 5-day conclaves (3). The challenge to general internal medicine that arose from this retreat was clear: View the care of the elderly, gerontology, and geriatrics as an opportunity; ignore this challenge at your peril. The views of the attendees were eloquently articulated by Larson in his Annals article "General Internal Medicine at the Crossroads of Prosperity and Despair" (4) and subsequently reinforced by Harold Sox, another attendee (5).
The papers in this supplement (6–9) speak to the logic and necessity of academic general internists and geriatricians forging a synergistic partnership to assure excellence in geriatric training of medical students and internal medicine residents. The authors focus on the barriers that have inhibited such a partnership: workload, money, and attitude:
1. Inadequate numbers of trained, enthusiastic, and charismatic faculty: too many busy, overextended, otherwise preoccupied faculty from general internal medicine and geriatrics who have little contact with each another and little overlap in their perceived agendas.
2. Inadequate resources: mostly too little money to protect the time of faculty and fellows from competing clinical or administrative demands.
3. Inadequate respect paid to geriatrics by the academic general internal medicine community: Too often, we hear a familiar proclamation by general internal medicine faculty: "But I already do that," a code phrase suggesting that they have little to learn from geriatricians, whom they perhaps regard as being of lesser caliber.
On the more positive side, the authors offer suggestions to overcome these barriers. These must ultimately include far more robust and equitable funding, most importantly from Medicare, which must reverse its longtime, seemingly perverse underfunding of the care of the oldest and frailest Americans, especially by generalists. Division heads and internal medicine department chairs (and, by extension, deans and hospital directors) must support opportunities for general internal medicine faculty to acquire special expertise in geriatric education in primary care settings. General internists and geriatricians who wish to see the partnership of their disciplines flourish mush convince these powerful leaders by meeting their expectations for productivity in research and research funding.
Finally—and most promising and natural—the path to long-term success would start with a joint commitment by general internal medicine and geriatrics leaders to generate a new cohort of faculty who work at the interface between the two disciplines. These future leaders must have full clinical and academic credentials and skills in both disciplines. The path would lead through internal medicine residency and continue with a year of geriatrics fellowship training and at least 2 years of research fellowship training in either division. Most fellows would acquire skills in the public health ("macro") sciences and earn a Masters degree (Masters in Public Health or its equivalent). We can expect these well-prepared academic generalists to compete successfully for extramural career development awards and thrive in divisions of general internal medicine or geriatrics as educators, researchers, and exemplary clinicians throughout long, satisfying, and productive careers.
William R. Hazzard, MD
Veterans Affairs Puget Sound Health Care System
University of Washington School of Medicine
Seattle, WA 98108
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