Full-time Specialists Research Articles

Feasibility and safety of remote programming in postoperative follow-up of cardiovascular implantable electronic devices

Objective: To explore the feasibility and safety of remote programming technology based on 5G cloud technology support platform in postoperative follow-up of cardiovascular implantable electronic devices(CIED). Methods: This study was a multicenter cross-sectional study. CIED patients from 12 hospitals lacking full-time follow-up specialists in Sichuan Province were enrolled from June 2021 to October 2021. All patients' devices received remote inspecting and programming by the follow-up specialist of the remote follow-up center of the Third People's Hospital of Chengdu through 5G cloud technology support platform. The baseline data, device alarm events, device reprogramming events, adverse reactions and satisfaction questionnaire survey results were collected. Results: A total of 195 CIED implantation patients were included, with an age of (72.5±11.3) years, including 103 males (52.6%). All patients completed remote inspecting and programming successfully, with a duration of (5.8±4.0) min. Ninety-one patients' CIED were reprogrammed, with a total of 104 parameter adjustments. No abnormal communication or adverse events occurred. The satisfaction questionnaire showed that 97.9%(191/195) of the patients trusted or relatively trusted remote follow-up and 86.7%(169/195) of the patients were willing to choose remote follow-up mode for device management. Conclusion: The remote programming based on 5G cloud technology support platform may be feasible and safe for postoperative follow-up of CIED patients.

Impact of a pharmacy technician on an interprofessional antithrombotic stewardship program at an academic medical center.

The need for monitoring and standardization of anticoagulation management has garnered the attention of national organizations, driving the implementation of antithrombotic stewardship programs (ASPs). Established ASPs have highlighted interdisciplinary collaboration between physicians, nurses, and pharmacists and demonstrated financial benefits and positive patient care outcomes. While pharmacy technicians are key members of the pharmacy profession, they are rarely utilized to expand clinical programs. The aim of this report is to describe the impact of adding a pharmacy technician to an ASP at an academic medical center. The departments of pharmacy and quality at West Virginia University Hospitals (WVUH) developed a business plan and financially justified an ASP. The ASP was implemented in January 2022 and consisted of 2 full-time clinical pharmacist specialists, 1 full-time clinical pharmacy technician, 2 full-time clinical nurse specialists, and 1 part-time physician medical director. The clinical pharmacy technician's primary role was to review patients' sequential compression device (SCD) compliance and newly started oral anticoagulants prior to discharge. The clinical nurse specialists educated patients newly started on oral anticoagulants within 24 hours of discharge and triaged any postdischarge medication access issues. The medical director provided high-level program oversight and acted as a clinical consultant on complex patient cases. In the first 6 months after the program's implementation, the clinical pharmacy technician made 174 recommendations to the clinical pharmacist specialists regarding discharge transitions of care and assessed SCD compliance in 246 patients. Of the 246 patients assessed, 217 patients (88%) were deemed to be noncompliant. The pharmacy department at WVUH successfully justified and implemented an interprofessional ASP at an academic medical center, which is the first ASP to date to incorporate a clinical pharmacy technician.

PSYCHOLOGICAL ASPECTS OF PROFESSIONAL RELIABILITY OF PHYSICAL TRAINING SPECIALISTS

The article examines the psychological aspects of the professional reliability of military personnel – full-time physical training specialists. An ascertaining experiment was conducted using psychodiagnostic tools. The characterological features of specialists are considered, the operational assessment of the severity of such characteristics of an individual as well-being, activity, mood, level of general and situational anxiety is given. The results obtained can be considered as an indicator of the psychological well-being of an individual as a whole and as a preliminary forecast for reliability in professional activities of specialists.

Impact of general practice/family medicine training on Japanese junior residents:reflective writing analysis using text mining.

We previously reported the impact of general practice/family medicine training on postgraduate training in Japan using evaluation criteria standardized nationwide. However, there is a possibility that new insights may be gained by analyzing the reflective reports written by these residents. Junior residents who participated in one-month general practice/family medicine training at one of five medical institutions with full-time family medicine specialists between 2019 and 2022 were enrolled in this study. They were assigned to submit a reflective report on their experiences and thoughts every day during the training. We analyzed these reflective writings using text mining and created a co-occurrence network map to see the relationship between the most frequently used words. Ninety junior residents participated in the study. The words that appeared most frequently in the sentences referring to clinical ability included "symptoms," "medical examination," "consultation," "treatment," and "examination." The words of "family" and "(patient) oneself" showed strong association in the co-occurrence network map. It was suggested that general practice/family medicine training greatly contributes to the acquisition of clinical abilities and deepens the learning of junior residents not only about patient care but also about family-oriented care.

The Long View: Leadership at a Critical Juncture for “African Art” in America

The Long View: Leadership at a Critical Juncture for “African Art” in America

Impacts of Vocational Training and Recreational Activities on Prison Inmates: A Case Study of Youthful Offender’s Correctional Facility, Hyderabad Pakistan

The current qualitative study was conducted at a young offender's correctional facility in Hyderabad, Sindh. In-depth interviews were conducted with a sample of 07 young, convicted convicts and 03 prison officials who were chosen using a purposeful sampling technique. Furthermore, the data were analyzed by using a thematic analytical approach. The study had two goals: one was to examine what kind of vocational training and recreational activities are available within the jail, and the other was to examine the impact of training on offenders. According to the study, offenders are provided with various vocational training and recreational activities, and as a result, they have positively impacted themselves. According to this study's findings, rehabilitative education plays an essential role in offender rehabilitation by changing behavior and attitude, boosting self-esteem and self-confidence, improving employment skills, reviving humanity, improving cognitive skills, promoting growth, increasing literacy levels, and transforming offenders into law-abiding citizens. The following study recommended that every prison in Sindh should provide educational, psychological, recreational, and motivational programs based on reformation and rehabilitation. The government and prison administration should employ full-time criminologist specialists who specialize in specific areas of prisoner rehabilitation to ensure the proper rehabilitation of offenders.

Training in Paediatric Clinical Nutrition Across Europe: A Survey of the National Societies Network (2016-2019) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition.

Disease-related malnutrition is common in patients with chronic diseases and has detrimental effects, therefore, skills in nutrition care are essential core competencies for paediatric digestive medicine. The aim of this survey, conducted as part of a global survey of paediatric gastroenterology, hepatology and nutrition (PGHN) training in Europe, was to assess nutrition care-related infrastructure, staff, and patient volumes in European PGHN training centres. Standardized questionnaires related to clinical nutrition (CN) care were completed by representatives of European PGHN training centres between June 2016 and December 2019. One hundred training centres from 17 European countries, Turkey, and Israel participated in the survey. Dedicated CN clinics exist in 66% of the centres, with fulltime and part-time CN specialists in 66% and 42%, respectively. Home tube feeding (HTF) andhome parenteral nutrition (HPN) programmes are in place in 95% and 77% of centres, respectively. Twenty-four percent of centres do not have a dedicated dietitian and 55% do not have a dedicated pharmacist attached to the training centre. Even the largest centres with >5000 outpatients reported that 25% and 50%, respectively do not have a dedicated dietitian or pharmacist. Low patient numbers on HTF and HPN of <5 annually are reported by 13% and 43% of centres, respectively. The survey shows clear differences and deficits in Clinical Nutrition training infrastructure, including staff and patient volumes, in European PGHN training centres, leading to large differences and limitations in training opportunities in Clinical Nutrition.

Training in pediatric hepatology across Europe: a survey of the National Societies Network (2016-2019) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition

BackgroundThe widely recognized burden of liver diseases makes training in pediatric hepatology (PH) imperative. The aim of this survey, which was part of a global survey on training in pediatric gastroenterology, hepatology and nutrition (PGHN) across Europe, was to assess the PH and liver transplantation (LT) infrastructure, staff and training programs in PGHN training centers.MethodStandardized questionnaires were collected from training centers via the presidents/representatives of the National Societies Network of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) from June 2016 to December 2019.ResultsA total of 100 PGHN training centers participated in the survey (14/100 were national referral centers in PH and/or LT). Dedicated PH clinics were available in 75%, but LT clinics in only 11%. Dedicated beds for PGHN inpatients were available in 47/95 (49%) centers. Full-time or part-time specialists for PH care were available in 31/45 (69%) and 11/36 (31%) centers, respectively. Liver biopsies (LB) were performed in 93% of centers by: a PGHN specialist (35%); an interventional radiologist (26%); a pediatric surgeon (4%); or a combination of them (35%). Dividing the annual number of LBs in the centers performing LBs by the number of trainees gave a median (range) of 10 (1-125) per trainee. Transient elastography was available in 60/92 (65%) of centers.ConclusionsThe survey highlighted the differences and shortcomings in PH training across Europe. ESPGHAN should take initiatives together with National Societies to ensure the acquisition of PH knowledge and skills according to the ESPGHAN curriculum.An infographic is available for this article at: http://www.annalsgastro.gr/files/journals/1/earlyview/2022/Infographic-Hepatology-training-paper.pdf

The contribution of family physicians to surgical capacity at district hospitals in South Africa

The World Health Organization states that essential, cost-effective surgical care should be delivered at district hospitals. In South Africa significant skills gap exist at district hospitals, particularly in the area of surgery and anaesthesia. These small to moderate sized hospitals are too small to support a range of full time specialists even if they could be recruited and were cost-effective. Family physicians (FPs) are trained in the clinical skills required for district hospitals and primary health care. Clinical associates have also been introduced to perform procedures at district hospitals. This report illustrates the contribution of a FP to surgical care at Zithulele Hospital in the Eastern Cape. Family physicians not only bring the necessary clinical skills set but also increase the confidence and capacity of the whole team. Outreach and support by surgeons, as well as continuing professional development, are important. Surgical and anaesthetic skills must be developed together. Family physicians also bring leadership and clinical governance skills that ensure the inputs to support surgery, such as equipment and information systems are available. The contribution of FPs to surgery and district hospitals is overlooked in both policy and practice. Human resources for health policy should recognise their contribution and increase the numbers available and FP posts at district hospitals. There is also a need to update the package of emergency and essential surgical procedures in policy.

Shell bead crafting at Greater Cahokia

Shell beads were important to Mississippians, and thousands of beads were found mostly associated with burials. Here I synthesize data on shell bead workshops from Greater Cahokia, along with crafting techniques. Different bead types required different tools, which, in conjunction with shell remains, allow the differentiation of columella versus disk bead workshops. Perishable drill tips were probably used. Bead size standardization is distinguished from craft specialization, and time spent on crafting indicates full-time specialists. Expeditions to get lightning whelk shells from the Gulf of Mexico were a part of the operational chain. The resources spent traveling to obtain shells, large workshop areas, time spent crafting beads, ethnohistoric accounts of shell barter, and the roles lightning whelk artifacts had/have in helping souls travel during liminal situations such as transitioning to death, all underscore the importance of Mississippian shell beads.

Robust breast cancer detection in mammography and digital breast tomosynthesis using an annotation-efficient deep learning approach.

Breast cancer remains a global challenge, causing over 600,000 deaths in 2018 (ref. 1). To achieve earlier cancer detection, health organizations worldwide recommend screening mammography, which is estimated to decrease breast cancer mortality by 20-40% (refs. 2,3). Despite the clear value of screening mammography, significant false positive and false negative rates along with non-uniformities in expert reader availability leave opportunities for improving quality and access4,5. To address these limitations, there has been much recent interest in applying deep learning to mammography6-18, and these efforts have highlighted two key difficulties: obtaining large amounts of annotated training data and ensuring generalization across populations, acquisition equipment and modalities. Here we present an annotation-efficient deep learning approach that (1) achieves state-of-the-art performance in mammogram classification, (2) successfully extends to digital breast tomosynthesis (DBT; '3D mammography'), (3) detects cancers in clinically negative prior mammograms of patients with cancer, (4) generalizes well to a population with low screening rates and (5) outperforms five out of five full-time breast-imaging specialists with an average increase in sensitivity of 14%. By creating new 'maximum suspicion projection' (MSP) images from DBT data, our progressively trained, multiple-instance learning approach effectively trains on DBT exams using only breast-level labels while maintaining localization-based interpretability. Altogether, our results demonstrate promise towards software that can improve the accuracy of and access to screening mammography worldwide.

Undergraduate endodontic clinical training in Malaysia: A National survey.

Online survey was conducted to investigate the state of undergraduate endodontic clinical training in Malaysian dental schools. An online questionnaire and a cover letter were emailed to the deans of 13 Malaysian dental schools. The questionnaire covers various aspects of endodontic clinical training including teaching methods, endodontic clinical procedures, minimum requirements, clinical sessions and teaching staff. The response rate was 69%. Similarities in teaching methods were observed in all responding schools. All schools taught contemporary root canal treatment procedures, including the utilisation of radiograph and electronic apex locator for working length determination, the crown-down approach for canal preparation and the cold lateral compaction for obturation. Sodium hypochlorite solution and non-setting calcium hydroxide medicament were used in most dental schools. Variations were observed in terms of the number of clinical requirements, supervisor: student ratio, and availability of endodontic specialists. The use of engine-driven instruments was observed mainly in government-funded dental schools. The majority of dental schools in Malaysia are adopting the European Society Endodontology recommendation for undergraduate endodontic training, particularly in relation to the surveyed aspects. Most of the government-funded dental schools have progressed towards engaging contemporary endodontics with their increasing application of engine-driven Ni-Ti instruments and 3D imaging techniques. Appointments of full-time endodontic specialists would further enhance the quality of endodontic teaching and permit the utilisation of contemporary endodontic materials.

Distance-Based Education for Nurses Caring for Children With Cancer in Sub-Saharan Africa.

Nursing specialization in the care of children with cancer provides the foundation for implementing successful childhood cancer and blood disorder treatment programs throughout the world. Excellence in nursing education is at the center of all that is needed to maximize cures for children with cancer in low- and middle-income countries (LMIC). While the burden of childhood cancer care is the highest in LMIC, opportunities for continuing nursing education and specialization are extremely limited. Capacity-building programs using distance-based learning opportunities have been successful in sub-Saharan Africa and provide insight into successful, continuing professional development. The Global Hematology-Oncology Pediatric Excellence (HOPE) program part of Texas Children's Hospital in Houston, Texas, has developed and implemented a distance-based training program designed for nurses working in sub-Saharan Africa. Following a needs assessment, Global HOPE developed a program using both the Moodle (modular object-oriented dynamic learning environment) distance-based learning platform and computer notebooks that hold the course content. The program teaches basic principles of nursing care for a child with cancer and has been implemented in Malawi, Uganda, and Botswana. Courses are taught using a modular approach and core competencies are established for each module. Frequent teaching sessions using Zoom and WhatsApp reinforce independent learning experiences. Formal course evaluation includes written pre- and posttests, self-competency assessments, and simulated checkoffs on essential pediatric oncology nursing competencies. The success of this distance-based learning program emphasizes the importance of formal training for nurses in LMIC to become full-time specialists in pediatric oncology nursing.

Improving Care for Children With Cancer in Sub-Saharan Africa Through Distance-Based Nursing Education

PURPOSE Nursing specialization in the care of children with cancer provides the foundation for implementing successful pediatric oncology treatment programs throughout the world. Whereas the burden of childhood cancer care is highest in low- and middle-income countries (LMICs), opportunities for continuing nursing specialization are extremely limited. The Global HOPE Initiative, part of Texas Children’s Hospital in Houston, TX, has developed and implemented a distance-based training program for nurses working in sub-Saharan Africa. METHODS After a needs assessment, the program was developed using the Internet-based, open-sourced education platform, MOODLE. MOODLE is an acronym for Modular Object-Oriented Dynamic Learning Environment, an online learning management system that provides custom learning environments. As Internet access can be difficult at the clinical sites, computer tablets are provided with all educational materials downloaded from the MOODLE learning site. Courses are taught using a modular approach and core competencies established for each module. Zoom and WhatsApp technologies are used for shared learning discussions. A Project ECHO (Extension for Community Healthcare Outcomes) for Global HOPE Nursing was implemented monthly to support the growth of the distance-based learning network. RESULTS This distance-based education program teaches the principles of nursing care for a child with cancer and has been implemented in Malawi, Uganda, and Botswana, where 35 nurses are now enrolled. Formal course evaluation includes written pre- and post-tests and simulated checkoffs on essential pediatric oncology nursing competencies, such as chemotherapy administration. Sixteen nurses have completed the program in the first year and significant improvement in knowledge, self-competency, and skills was found. CONCLUSION The success of this distance-based learning program emphasizes the importance of formal training for nurses in LMICs to become full-time specialists in pediatric oncology nursing. Education programs that build capacity to develop specialists in pediatric oncology nursing are essential to improve global cure rates for children with cancer in LMICs.

Evidence-based supported employment for people with psychiatric disabilities in Australia: Progress in the past 15 years.

This report summarizes the major developments in Australia since the first introduction of Individual Placement and Support (IPS) in 2005 in order to outline the current situation and discuss future challenges and opportunities. Using an informal snowball sampling method, all those known to be involved in IPS implementations in Australia in the last 5 years were contacted. The program has expanded from 2 full-time employment specialists in 2005 to 87.6 in 2018. The expansion has been most promising in youth mental health where an initial national 14-site trial of IPS was recently expanded to 24 sites. If the trial is successful, IPS may become a core component of a national youth mental health initiative. Expansion in the adult community mental health sector has been constrained by several factors including the low priority for rehabilitation in the public mental health system. On the positive side, the availability of independent technical support from Western Australia means that all new IPS sites can receive expert technical support for program implementation, continuing high-fidelity delivery, external fidelity assessment, outcome evaluation, and cohort-based outcome reporting. The expansion of IPS in the public funded adult mental health sector has not kept pace with progress in the youth mental health sector. There is an urgent need for adult mental health services to cease excluding vocational rehabilitation from treatment, care, and recovery plans. Disability Employment Service contract managers could increase disincentives for providers to adopt high caseloads and low intensity services, at the expense of more intensive evidence-based practices. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The behavior of specialist towards completeness of medical records

ABSTRACT This study aims to overview and identify how medical record is executed by specialists in undertaking their medical tasks. This study involves specialists at Dr. M. Soewandhie hospital. Based on the preliminary research, one of the problems in paper-based medical record is the incompleteness of medical record filling. The incompleteness is mostly caused by the specialists-in-charge who had not filled the form. Due to this, this study formulized a research problem on factors that influenced the compliance of specialist in completing the filling of paper-based medical records. This study applied a cross-sectional study with a descriptive analytic design. This study was conducted in patient units with the total of respondents of 35 full-time specialists along with 175 medical record files used as research data. This study resulted from 175 medical records, there are 97.1% completed medical records, and 0.029% incomplete medical records. It indirectly indicated a breach of specialist's duty to maintain complete medical records. This study concluded that voluntary and obligation factors were the two factors that affected the specialist to fill-in medical records completely, and it was tested by the regression test. Rather than out of a sense of responsibility, the medical records were actually the authority of the hospital director and monitoring-evaluation manager who has authority and high order for specialists to complete medical records.

Extent and nature of dual practice engagement among Iran medical specialists

BackgroundDual practice (DP) by medical specialists is a widespread issue across health systems. This study aims to determine the level of DP engagement among Iran’s specialists.MethodsA pre-structured form was developed to collect the data about medical specialists worked in all 925 Iran hospitals in 2016. The forms were sent to the hospitals via medical universities in each province. The data were merged at the national level and matched using medical council ID codes, national ID codes, and eventually a combination of the first name, surname, and father’s name.ResultsA total of 48 345 records were collected for 30 273 specialists from 858 (93%) hospitals out of total 925 hospitals. Sixteen thousand eight hundred forty-nine (69% of) specialists were non-faculty members and 6317 (26% of) specialists were employed on a contract basis. Eleven thousand six hundred and thirty-eight (47.7% of) specialists were engaged in DP on total. Female specialists had 0.78 times less DP chance; faculties compared to non-faculties had 0.65 times more DP chance and full-time geographic specialists compared to non-full-time specialists had 0.15 times more DP chance. DP was more frequent in specialists with higher age and more job experience and in provinces with more population, deprivation, and higher number of specialists per facility (P < 0.05).ConclusionsThe level of DP is relatively high among Iran medical specialists, especially in geographic full-time specialists. However, they are totally banned and they receive extra payment for being full-time; restrictive regulations and financial incentives without considering other factors might not eliminate DP in specialists and it should be addressed based on conditions of each country and regions inside the country.

Effect of dual practice on service delivery time by surgeons in the Islamic Republic of Iran: multi-level analysis of a national survey, 2016.

One of the work patterns which affects the supply of specialists is the phenomenon of dual practice (DP), i.e., working simultaneously in the public and private sectors. Uncontrolled DP in the surgery health workforce can have adverse effects on access to surgeons, efficiency, effectiveness and quality of surgery services. The aim of this article is to examine the impact of DP on service delivery time by surgeons. We used a prestructured form to collect data on surgery specialists in all 925 Iranian hospitals. National medical ID codes, council ID codes, first name, surname and father's name were used for data matching. Multilevel linear regression was used to assess the association between DP and study variables, which were recruitment type, faculty status, experience, sex and age. The 4642 surgery specialists in this study, representing 31.08% of the total number of surgeons identified, spent mean 1.09 (standard deviation 0.33) hours full-time equivalent (FTE) on health care service delivery. Specialists with DP had long service delivery time (β = 0.427). Female specialists (β = -0.049) and full-time specialists (β = -0.082) spent less time on health care service delivery. Permanent specialists had higher FTE (P < 0.001) and as the population increases, FTE increases (P < 0.05). Although DP had a direct impact on surgeons' working hours, it seems that a greater share of the difference in working time was used in the private sector services, leading to poor access to surgery services in the public sector. Therefore, it is necessary to develop a systems approach to regulate DP.

New Challenges for a Core Procedure: Development of a Faculty Workshop for Skills Maintenance for Abdominal Hysterectomy

To describe the development of a low-cost educational module for OB/GYN faculty skills maintenance for total abdominal hysterectomy (TAH), a low frequency core procedure in obstetrics and gynecology. After review of existing educational tools and utilization of a modified Delphi method to establish consensus regarding key procedural components for skills maintenance, a 2-hour workshop was developed to review knowledge and participate in a simulation focused on the critical steps in performing TAH. An expert in TAH delivered a lecture highlighting important surgical considerations. Participants then rotated through simulation stations for critical steps in TAH: dissecting the bladder, identifying the ureter, and closing the cuff. Knowledge gains were assessed with a written pre- and posttest. Consecutive focus groups were conducted with participants on effectiveness of the workshop, and suggestions for improvement. Ideas identified in the first focus group were incorporated into the second workshop. Massachusetts General Hospital, an academic tertiary care facility with a single Obstetrics and Gynecology faculty group, located in Boston, Massachusetts. Eligible participants were recruited via email from full time specialists in General Obstetrics and Gynecology at Massachusetts General Hospital. Of the 25 eligible gynecology faculty subjects, 22 participated (88%). On pre or post-test comparison, 70% of participants scored higher on the posttest, demonstrating an increase in knowledge of critical TAH surgical steps. Focus group analyses identified the need for increased review and training demonstrations of TAH, and recommended continued offering of the workshop. Based on focus group responses and pre or posttest comparisons, the workshop was deemed feasible and enhanced short-term learning. Future directions include utilizing more challenging anatomic models and simulation scenarios and optimizing integration of expert demonstration and individualized coaching, as well as identifying regionally tailored surgical workshop programming.

Organization of the soviet armed forces medical supply in 1970’s and 1980’s

The activity of the Soviet Army medical services on the troops medical equipment provision organization in the 1970-1980s is described. Principal schemes for medical equipment provision to the Soviet Army in accordance with the troopslogistical support principles in various conditions are also shown. General accumulation and summarization of the positiveexperience gathered during the local wars (Afghanistan), armed conflicts and in the liquidation of peacetime emergencysituations medical and sanitary consequences (Chernobyl, Armenia, etc.) is taking place in the medical supply system. Theresults of the military pharmacy legal framework development are presented. New progressive approaches to the guidancedocuments development have been established through the introduction of computer facilities based modeling processes fortroops medical equipment provision. The reasons for creating a separate discipline «Organization of military medical supply»and its role in the training of military pharmacists are considered. The role of the Military Medical Supply and PharmacyDepartment of the Military Medical Faculty at the Tomsk Medical Institute, where students of pharmaceutical faculties andpharmaceutical universities were called upon to study after finishing their third year, is exposed. The Military Medical Supplyand Pharmacy Department of the S.M. Kirov Military Medical Academy activity on the troops (forces) medical supply systemimprovement, on the administrative staff training in the resumption of two-year full-time specialists education in the troops(forces) medical supply organization sphere, including additional professional education programs is shown.